DIP Episode 94 - USMLE Step 2CK Rapid Review Series 1 (Peds)

Okay, welcome. My name is Devine. I am a PGY1, a Transitional Year resident. It's ultimately going into radiology. So this is the 94th episode of the Devine Intervention Podcast. And like I said in prior episodes, I've gotten a lot of very positive feedback with with Rapid Review series. So I'm just going to keep making a bunch of them and then continue my mainstream like Mothorocom and Prehensive Reviews of Subjects. So in this episode, I'm going to be doing a Rapid Review, but this is more targeted towards the USML Step 2 CK exam. And I will spend more time on peeds. So basically I will give like a scenario, like a case scenario, and then we'll talk about it real quick. So what if you get a question about like, you know, like a human genome that kind of like sequester splitlets and this patient is thrombocytopenic. So what are you thinking about here? Right? So this is the Casa Batch Merit phenomenon, right? This pops up quite commonly on NV Me exams. Usually people get it wrong. Okay. Now what if you get a question about like bilateral conjunctivitis and this patient has like a rash on the palms and soles and they have like extremity edema. They have like a strawberry tongue or you'll check the CBC and the Appletale County super high. So they have like a severe thrombus like toses and they have like right upper quadrant pain potentially, right? And for this condition, you treat with like aspirin and IVIG. What are you thinking about here?

I really hope you're thinking about Kawasaki's disease, right? So the right upper quadrant pain, they are getting that because they have like gobladder hydrops. That's a classic association with Kawasaki's disease, right? And you give aspirin and IVIG. And remember, they usually have fever for more than like five days, right? And they can get like aneurysms of the coronary artery and they usually get like a unilateral, right? Versus a bilateral, a unilateral cervical infaninopathy, right? So that's Kawasaki's disease. Now what if you get a question about a child, you know, he's being treated for asthma and this child is tacky cardiac and has like hypochylemia on lapse. What drug therapy are you thinking about? Again, I really hope you're thinking about our beautiful, right? So remember our beautiful is a beta, beta to agonist, right? So remember, right? Yeah, it's purely a beta to agonist, but it also has some beta on activity. So it can cause tacky cardiac through that effect. And then remember, if a patient is hyperchalemic, you can give our beautiful or any other beta to agonist because that increases the activity of the sodium potassium ATP is pump. So remember that pump gets three sodiums out to potassium sin. So get two potassium sin to cells, right? So if you're actually on prolonged arbiter of therapy, that can actually trigger hypochylemia, okay? Now what if you get a question, right? And it's like a triad, right?

So let's say a patient has like a non thrombocytopenic pepper, right? So the afflictive count is not necessarily low, but you have like papyrus skin lesions and then they have like arthritis and they have like abdominal pain, right? What are you thinking about? I really hope you're thinking about HSB, right? So like Hinaka, Shunlein, a pepper, Henoxionline pepper, right? So that's the classic presentation. Although another thing you may see on the exams is, what is it called? Like a palpable pepper below the buttocks, right? But they don't always put that because they know everyone has memorized that crap for tests. So you don't really put that all the time. Now, and remember, right? HSB right is a risk factor for intersusception, right? And remember, they can give you a patient that recently had like an upper respiratory infection or GI infection, right? Remember, Henoxionline pepper is actually like a systemic manifestation of of hygiene and nephropathy, okay? So that's a high-yield thing you want to keep at the back of your mind for for tests. Now, what is the drug of choice in the treatment of like Lyme disease in a kid that is less than eight years old? I really hope you're thinking about amoxysyline, okay? That caught off age you want to remember is eight, right? If you're eight or less, right? You get amoxysyline. If you're greater than eight years old, you get doxycycline, right? You want to avoid doxycycline in kids because of the what is it called?

Because of the tooth discoloration that may arise through that. And remember that Lyme disease is caused by Borrelia Borgophria, right? And don't forget that it's carried by the exodistate. So it's a tick-borne illness, okay? But Borrelia Borgophria itself is a spirochete, okay? You may say, hmm, divine, why you mention all this spirochete, tick, whatever. Do you think it's loyal for step two? It's not. I promise you, if you've gone through a third year in any way shape or form or you're about to take step two CK, you'll potentially get a few questions wrong if you don't know these are specific pieces of information. Now, what if you get a question about a patient that has like U Vitis and they are any positive and they have like, like, you can they say they have like joint pain and there's like four or less joints involved. What kind of JIA are you thinking about? Well, I hope you're thinking about oligua-ticular JIA, right? Remember that these people usually have like U Vitis, especially for the oligua-ticular kind and for that you need to do like routine slit lump except. So, okay, that's another classic thing. They could test on an NV Me except. Now, what if a patient, right? Has JIA and it's like rheumatoid factor, like positive? I mean, it could also be negative in this and they have like more than four joints involved and usually if he shows up in a guy, right?

So, like in a milk kit, usually shows up at an age greater than 10 and it can actually present as an ankylose-inspondelitis like picture. What kind of JIA is this? Right? So, this is the poly-articular JIA, right? And then if you give your JIA that sort of involves like spiking fevers, right? So, like I like to call them like picket fence fevers where the February at night, the better in the morning, February at night, better in the morning, or February in the morning, better at night. So, the fevers keep going up and down and then another boss phrase is like the evanescent salmon-colored rash. So, the rash tends to come along with the fevers. If you see that you want to think about stills disease, right? That's like the systemic onset of JIA. Now, what is the most common cause of osteomyelitis and a young child with like sickle cell disease? Right? That'll be some one, right? What will be the most common cause of osteomyelitis in a neonate? So, note, this is a neonate, right? So, the first 28 days of life, I really hope you're thinking about group E-strap, right? So, like, strapping Galactic. It may not necessarily be the most common cause, but on MBME exams, if you see like any notable infection in a kid that is from zero days to 28 days old, I really want to think about group E-strap. The only time you will not be group E-strap is if they give you a clear indication of another bug, right? So, usually they will give you like gram stain results, right?

So, if obviously if you get like a question about like a 14-beauty kid that has like a serious infection, let's say like a respiratory infection or whatever, and then you obtain gram stain of whatever like body fluid you decide to get and you're seeing like gram negative or odds, right? You're thinking more about E-coli, right? But, yeah, if you don't give you any clear indication, it's like a non-specific question. You really want to go after group E-strap, to caucus or strapping Galactic. Okay, now what if you get this question, what if you, you know, you get a question about a patient that has like a, and actually let me not forget this, you know what I'll talk about in a later. Okay, so what if you get a question about a patient that, you know, they have like a recent like upper respiratory infection or like otitis media, and then they have like hip pain and they have like a normal white blood cell count, and then they have like ESR CRP that is like a tinged, like literally like borderline elevated, and they have like four-inch of motion of the affected extremity, like very mild pain, what are you thinking about here, right? This is transient sign ofitis, right? So basically it's like recent like upper respiratory like viral syndrome, and then this child now has like hip pain, but they have like four-inch of motion, doesn't hurt as much, this is transient sign ofitis of the hip, right? And really the way you treat this is by giving in-sits.

Now, what if you get a question about like a child that is kind of like asymptomatic during the day, the child is okay playing with their friends during the day, and then they have like a super normal physical exam, and then they tell you that man at night, this child's like calf and thigh hurts a lot, right? If you see that, I really hope you're thinking about like green pains, right? That's a classic, classic thing that's tested on the ex-apps. Now, what if you get a question about a kid that has like a pop-up or click, or I guess pop-up or clunk on exam, and it's a new niche, right? What is that, right? That's developmental dysplasia of the head, right? Now, what if you get a question about like hip pain in a kid that is like less than nine years old, so this is not a new niche, right? This is like a kid that's like less than nine years old, and you have like hip pain on an NV Me exam, I really hope you're thinking about like leg, calf, a perth, these disease, right? Remember, that's like an avascular necrosis of the hip. Now, what if you get a question about a kid that is you know, greater than nine years old, so like at 11, 12, 13 year old kid, and the obese, or they are going through like a recent growth spurt, and they have hip pain. I really hope you're thinking about a skinny, right? So let me see to find how do I remember which is which, right? The thing is just sort of going the other of the alphabet, right?

So D comes before L in the alphabet, and then L comes before S in the alphabet, and then remember that the D is in a new niche. The L is in kids that are like between like I like three to 10 years old, and then the S is in kids that like more than 10 years old and obese, then you remember like developmental dysplasia of the hip versus leg, calf, a perth, these disease, versus a slipped capital, femoral epiphysis, right? Or skinny, right? I remember a skinny, classically, right? You have like this ice cream falling off a corner appearance on an X-ray. Although like I said, you usually do not need the picture to get the question correct on NV Me's. There is probably like, I will say my entire career as a test teacher, I've probably only seen like, I will say it at least it's less than 10 questions that absolutely require the picture or the image they put in front of you, or histology, whatever, to like get the question right. Like many times the question, the picture is not even a consideration for me. In initially selecting my answer, I just sort of use it to like feel good about myself like, oh yeah, okay, yeah, this is definitely the right answer, I just I just selected. Okay, now what if you get a question about a kid that's like a hyperfunctioning athlete, and then they have like pain on the TBO tubercle? What are you thinking about? I really hope you're thinking about Osgoch slaughter disease, right?

Remember, a boss phrase you want to associate with a Osgoch slaughter disease is something known as attraction, a prophesitis. That's a classic association that's usually tested on the exams. They think they sort of tested as a mechanism behind the clinical findings. Now, what if you get a question about a child, you know, that has like joint pain, has like many bleeding episodes as a kid, and their PTT is elevated. What disease are you thinking about? Well, I hope you're thinking about like hemophilia A or B, right? Remember, it's like a hematrosis, right? So remember, hemophilia A is a factor eight deficiency, right? So A sounds like eight, and then hemophilia B is a factor nine deficiency, right? So like B9, B9, okay? So that's a way to kind of remember that. Remember, those people can get hematrosis so they can get like early onset arthritis. Now, what if you get a question about like, you know, like a program of like upper respiratory symptoms, like an respiratory strider, like a barky cell like cough? What are you thinking about? I really hope you're thinking about CROPE, right? Remember, I know that name for CROPE because again, your friends at the NBA me, right? There's only so many ways you can test a particular concept, right? So if they notice that, man, a lot of people are getting the same right. The thing they do is they just basically tell you the same thing you know, but they just use different words, right?

So, uh, well, example I love to give because it's like a classic example that they still put on exams is instead of referring to some homo bodies, they refer to laminated calcifications, right? Same thing occurs here. Uh, basically, like this kid has CROPE, right? But another way they can test CROPE on the exam is instead of writing the word CROPE, they can write laryngo tricubron chitis, okay? So that's just something you kind of want to keep at the back of your mind with CROPE. Remember, if a person has CROPE on X-ray, you see like a steeple sign, right? A steeple sign is pathonomonic, at least on NBA me's for CROPE. And remember, right? You can sort of treat with like a re-semicapin efframe, you can also give steroids. And remember, I did usually cause by like the power influence of virus, although they actually are the things that can cause CROPE, but usually on M, I'll say, and I probably shouldn't say always, but I'll say like 99.9999% of the time on NBA me's, you really want to go after a power influence as an exciting agent. And remember, but that it's a problem below the glottis, right? So it's a sub-glottic laryngeitis, okay? You may say, the vine, that is low yield. I promise you, it is not low yield. I know I'm saying it, but I promise you, it is absolutely positively not low yield, right? And again, because it's an operate-way problem, this kid will have like inspiratory strider versus lower-errory problems that present with like expiratory whizit.

Okay, now, what if you get a question about a child that is, you know, like toxic appearing, okay? And this child is drooling and has this phasor and has like tri-bodan. What are you thinking about? I really hope you're thinking about epiglottitis, right? So remember, epiglottitis, right? So these people, right, classically, it's caused by H-flu, although it's no, H-flu is probably not the most common cause anymore, because hopefully you know that there is such a thing as the H-flu vaccine. And again, my public service announcement, vaccines do not cause autism, right? That's just awful, awful, awful, awful, again, I just not backed by science, right? So just, I'll just leave it at that before I go off on, go off on my, I guess, around or anything like that. But yes, right? So that is epiglottitis. The next step in money event is always to intubate, right? So here the early before doing any other thing. And remember, right, on X-ray, right, you see like the classic thumb print sign. The thumb print sign on X-ray is classic for for epiglottitis, right? And remember that epiglottitis, because it's again also an upper-error problem, these kids will have inspiratory strider, right? They won't have whizzing on the NBME, right? So there is an I'm saying all these things, right? The thing is most other subject theorists on the NBME, if you just read the question, you know exactly what they're going after.

What the thing is, your friends at the NBME that write pediatric questions for whatever bizarre reason, they try to give you as few clues as possible. Like, kids questions are usually very non-special. You'll be like, wait, this can be caused by like any of these answers, right? So that's what I'm sort of pointing out, like certain key terms you should look for. If a patient has like inspiratory strider on an NBME exam, you probably don't want to pick pneumonia as an answer choice. Because pneumonia is a lower-error problem. If you have a lower-error problem, classically on NBME exams, you have an expiratory whizz, okay? Whizzing is pathonomonic on NBM Es for lower-error problems. Strider is pathonomonic on NBME exams for upper-error problems. And strider is an inspiratory sound on NBM Es. Whizzing is an inspiratory, so sorry, strider is an inspiratory sound on NBM Es. Whizzing is an expiratory sound on NBM Es. Now, is that always true? No. What is that usually true on NBM Es? Absolutely, okay? So that's something I definitely keep in mind if I were you. And one thing I also want you to not forget is that epiglottitis is actually an example of a super-glotic laryngeitis. Remember I talked about group and I said, group is a sub-glotic laryngeitis. Epiglottitis is a super-glotic, right? So epi to the glotis, right? So it's above the glotis. It's a kind of super-glotic laryngeitis. So that is epiglottitis. Okay, now, what if you get a question about a child?

Let's say this is the first 20 days of life. So let's say it's a neonate and this kid has, how do I put this? Let's say this kid has like a whiz and they've been on an event for the first 20 days of their lives, right? I really hope you're thinking about like a bronchopulmonary dysplasia. Remember, that's one of the consequences of like oxygen therapy and like premature kids, right? Classically in the setting of our respiratory distress syndrome, right? So like NRDS. And remember that that classically arises in the setting of so-fact and deficiency, right? In a premature kid. Okay, now what would be the most common cause of the money in a child that is like less than one to two years old? Right? That'll be RSV, right? Now, what if you get a question about like, experiment? Let's say you have a kid, you know, this kid has like a respiratory whiz and they have a cough and the kid is not like super toxic, but the kid is like whiz and they have a cough. I really, all you do for this problem is supportive care. What are you thinking about? I really hope you're thinking about broncholitis, right? I remember broncholitis, right? It's classically caused by RSV, right? So if you notice, I was very careful here because you can see divine. How do I differentiate between broncholitis and epiglotitis and croup? I give you the magic words. Epiglotitis, croup, strider on NV Me's. Bruncholitis, whiz in on NV Me's. Bruncholitis, right? It's a bronchola problem.

Your broncholitis consists of a part of your lower ear weight, okay? So it's kind of high yield to, again, pay attention to the words on exams. You may think I'm full of it. I promise you just take NV Me exam, pay attention to these words or I guess not pay attention to them and you sort of see what the results are look like. Okay, so, so, um, so, respiratory whiz in in a kid, think more about broncholitis and again, it's usually like a pretty like, young kid, right? So like a year or less than two years old stuff like that, okay? So think about broncholitis. Remember that, uh, really, it's usually caused by RSV, right? Um, and really, again, so what if here is all you do steroids don't do squat for this condition? Bruncholitis don't do squat. You can use like, homidified, like, air or oxygen or whatever, but really the steroids broncholitis, they really don't help. Um, I mean, if a kid is super high risk, you can consider ribo-viring, but basically no one does that in the real world. Um, and if a kid, right, is, let's see, a kid has a history of like cystic fibrosis or they have like an immunodeficiency problem that sort of puts them at high risk of like respiratory failure. If they get like broncholitis from RSV, you can actually sort of like pre-profilax those kids with a palevizumap, right? So, um, you can pre-profilax them with, uh, with a palevizumap, palevizumap, uh, soda, tax, uh, RSV.

So it's not something you'll give like during the acute phase while you're having the broncholitis, right? And it's like when you have the infection, you've got the infection, you're screwed already, right? Before they get it, you can place them on, uh, on palevizumap. Now, what will the drug of choice be in treating a patient, you know, that has like asthma symptoms like, you know, less than twice a week, um, and they very rarely have symptoms at night, right? This will be like, as needed, albuterol, right? Now, what will the drug of choice be in a patient that, you know, has asthma symptoms like more than twice a week? Um, and the night, I mean, they don't have symptoms every night, but the symptoms are, you know, sort of kind of relatively frequent at night, right? Uh, if you notice I'm basically teaching you the asthma algorithm, right? So these people, you put them on like as needed albuterol, but you also kind of start with like, you basically add on, um, in health cortical steroids. And remember, these are daily medications, right? So the cortical steroids are daily meds, the, so the in health cortical steroids, the, albuterol is not a daily med. You don't take albuterol every day, right? Albuterol is something you use when you have symptoms. It's a rescue inhaler, okay? It's not like a daily like, oh, you got to take it every day. No, that's not the way albuterol is used for. Kind of like the same concept with like migraines.

If you're about to have a migraine, you take a triptan, but a triptan is not a daily med. If you give your patients delis, like, so much triptan, you have strongly increasing the risk of like strokes, amides, or that crap, right? So you don't do that. A triptan is a rescue migraine med, but the meds you can take on a daily basis to decrease your, like, your incidence of migraines is like a beta blocker, like, perpranolol, or you can use a topyramid, right? Okay, so for this patient, right? You add in health cortical steroids. One, if you don't see an in health cortical steroid as an answer choice on your exam, one thing you may actually consider adding is a luchotrain receptor antagonist, right? So like Monte-Lucast or like Zafere-Lucast or like Zyluton, although remember, people don't usually use Zyluton much anymore because it kind of explodes your liver, right? So this is usually not a, not a great idea. Remember Monte-Lucast and Zafere-Lucast, they have the luchotrain receptor antagonists. Remember, the luchotrain receptor is the cis-LT1 receptor versus Zyluton that is an actual inhibitor of lipoxygenase. So Zyluton inhibits the enzyme that makes luchotraines and then Monte-Lucast and Zafere-Lucast, I mean, if you've heard of single layer, single layer is Monte-Lucast. Those inhibits the actual receptor that those luchotraines are okay. But if they give you like a little more severe symptoms again, one other thing you can add is like a laba, right?

So a long-actin beta antagonist like some metrolophonodrol, although remember the classic warning, those laba, so you don't want to use them as monotherapy because those increase the risk of death, right? In asthma, if you use them as monotherapy, okay? So basically, the progression is as needed, I'll be right wrong. You can add on an inhaled corticosteroid, after that you can add a laba or you can add a luchotraine receptor blocker like Monte-Lucast or Zafere-Lucast. Okay, now because I want to keep this relatively short because it's supposed to be a rapid review in the first place. What if a patient, you know, a kid has asthma and they have like continuous like daily symptoms, nightly symptoms, they get out of bed, they become short of breath. Basically, this kid needs to be on all of the above that I just mentioned before, so like as needed, I'll be right wrong. And instead of low dose inhaled corticosteroids, they actually need high dose inhaled corticosteroids and then they need a laba as well or you can sub a laba for like luchotraine receptor antagonist and then in addition to that, they need oral steroids, okay? They need oral steroids.

So I think that's where I'm going to stop, but I hope you get something from this podcast and as I always mention at the end, I do offer one on one tutoring for the USMLS step one, two CK, two CSN three exams and also like pre-clinical med school exams and 30-ish-off exams and teach a bunch of college subjects where I saw like physics, Gen CAM, Okam, I teach all those biochemistry, I teach that as well. And then if you're a med student applying for residency, so like an ERAS application or you're a college student applying for med school, so an ANCA application, I do offer like application advice and interview prep, I prepare personal statements and all that stuff, so just reach out to me through the website, so divineinterventionpodcasts.com and I'll be happy to point you in the right direction. And then something I'm also offering is like a 12-day USMLS course for either step one, two CK or step three. Basically in 12 days you learn everything you need to know for those exams, it's an in-person course, small group like five to seven people, and then you also learn a bunch of very high-yout, very useful test-taking strategies. I believe my next iteration will likely be in June, I'll probably hold it over like a two-week period in June, like probably like this mid first week of June to like middle of June sort of deal.

But yeah, if you're interested in any of those things again, just reach out to me through the website, if you have a group of people that may be interested, reach out to me through the website. And I'll be again happy to provide some more information and there's also an online option that I can make available, again small group, the online option that I can probably hold at any time of the year, but it's something that will probably take a longer period of time than two weeks, you'll probably be more like you know like three or four weeks, but basically over that four-week period will review all the content you need to know for those exams, we will review high-youtesticking strategy, and we'll review those test-taking strategies specifically with NBM exam questions, okay? So you basically sort of get like a complete exam prep with that. So if you're interested in any of that, feel free to reach out anytime, have a wonderful rest of the day and to all my nurses out there, just making sure that we support you as physicians, you guys are not, you guys are gals, or not you don't spend your deep-playing cards, okay? You're the lifeblood of any hospital, really a hospital will collapse without its nurses. So if you see a nurse that works with you today, I appreciate them, right?

That statement that came out in the news, again I'm not a political person, I'm not gonna start an inflammatory conversation here, but that statement about people, nurses spending their time playing cards, that is just kind of off-putting, right? So reach out to your nurses, you know, touch me with them, show them you appreciate them, and I'll see you in the next podcast. So have a wonderful day, happy Easter, God bless you, I'll see you next time.

Croup causes a "steeple sign" (sub-glottic narrowing), while Epiglottitis presents with a classic "thumbprint sign" (swollen epiglottis).

Amoxicillin is preferred for children $\le 8$ years old; Doxycycline is used for older children/adults to avoid tooth discoloration.

Non-thrombocytopenic palpable purpura, arthritis, and abdominal pain.

Oligoarticular JIA.

Bronchiolitis presents with wheezing (lower airway problem); Epiglottitis causes stridor (upper airway problem).

Group E Streptococcus (GSE) or Streptococcus agalactiae.

Fever $\ge 5$ days, conjunctivitis, rash on palms/soles, extremity edema, and mucosal changes (e.g., strawberry tongue).

Still's Disease (Systemic onset JIA).

Hemophilia A = Factor VIII deficiency; Hemophilia B = Factor IX deficiency.

Legg-Calvé-Perthes Disease (LCPD); avascular necrosis of the femoral head.

DDH (newborn/infancy), LCPD ($3-8$ years old), SCFE ($\ge 10$ years old, obese).

As needed SABA (Short-Acting Beta Agonist) inhaler.

Upper airway obstruction (e.g., Epiglottitis or Croup).

Fever $\ge 5$ days, conjunctivitis, rash on palms/soles, extremity edema, and mucosal changes (e.g., strawberry tongue).

Still's Disease (Systemic onset JIA).

Hemophilia A = Factor VIII deficiency; Hemophilia B = Factor IX deficiency.

Legg-Calvé-Perthes Disease (LCPD); avascular necrosis of the femoral head.

DDH (newborn/infancy), LCPD ($3-8$ years old), SCFE ($\ge 10$ years old, obese).

As needed SABA (Short-Acting Beta Agonist) inhaler.

Upper airway obstruction (e.g., Epiglottitis or Croup).