DIP Episode 335 - USMLE Step 2CK Rapid Review Series 63 (+ Upcoming Step 2CK/3 Course Reminder)

Okay, welcome. My name is Divine. This is episode 335 of the Divine Intervention Podcasts. And in this podcast I'll be continuing the Rapid Review series for the USMLS.2 CK exam. Although remember this Rapid Review series will also be like extremely helpful for presenting in a step 3 exam. For those of you that are taking the USMLS, the USMLS step 2 CK exam, any time soon. I know a lot of people are going to be taking the exams over the next two to three weeks so they can get their scores in time for your applications. I do have pretty comprehensive courses. It's in two flavors. One is the NBA Metasticking Strategy Scores. Again, that tons of people have taken, found to be extremely helpful. And then the review course. And again, the review course is for Step 2 CK Step 3. And I'll be having one next week on Wednesday. That'll be the Testicking Strategy Scores from 2 to 4 30 PM Pacific Standard Time. Then on Thursday, Friday and Saturday, I'll be having the NBA Review course for Step 2 CK Step 3 is going to be from each to noon and 1 to 5 PM Pacific Standard Time each of those three days. We're basically going to be covering Pediatrics, Surgery, Internal Medicine, OBGYN, Psych Neural, Ethics, Biostatistics, Communications, Professionalism, Multisystem Persises, and Disorders. And again, it's not going to be a stock lecture. It's going to be by case scenarios and by vNiets, almost exclusively. There's a lot of audience response questions, right?

To go over about 2000 USMLB concepts. And really, all we're going to be doing in that class is just going through those things in an NBA me format. So you have an idea because for me, I don't teach to the Cubanks. I teach to NBA me exams, right? So again, I've had many people take the courses and not long after the TIG exam, I'm being doing extremely well. So if that's something you're interested in, feel free to reach out to me through the contact button on the website. And I'll be glad to give you some more information. The course is held over soon. But I promise you, it is, it is well worth your while. I've not seen people attend the course I regret it. It is well worth your while. It is well worth your while. Yes, I mean, I've had like one or two people that said, I didn't really gain much from it, but I'm telling you from like the, probably almost a thousand people at this point that have taken the courses, a thousand or more that have taken the courses. Most of those people have done extremely well on the exams. So again, if that's something I'm interested in just shipping an email and I'll be happy to give you some more information. I've seen many people go from low scores and then they take the course and then they practice their scores, bummed by almost 30%. I mean, by like 30 points, right? So they have these really big score bumps. Okay. So let's get right into it. Right? So what if they give you a question about a rabid farmer that has really high fivers?

And then the teller that on physical exam, he has like a painful ulcer on his right grade toe. And he has like very prominent like superficial and went out in front of another thing. Right? So we see the fact that this is a rabid farmer. Right? So if you see something like this, I really hope you're saying, oh, divine. This sounds a lot like to Larimia. Right? So remember, what's the bug that causes to Larimia? Remember to Larimia is caused by the broad bug, Francis Celer to Lorenz's. Right? So one thing you may see sometimes, no, again, our friends at the NBME, this is like a classic time honor trick. They've been like, thing, they've been doing your recent times, right? And that thing they've been doing your recent times is to write derivative answers. So again, as you've probably heard me say this at the most of your podcasts, you're reading the question, you're like, hmm, I know exactly what this is. Then instead of putting exactly what you want as an answer choice, they put a word that you're less familiar with. It kind of sounds like what you know, but you're not very familiar with it. Again, that's why that is one of the primary causes of people having this feeling like they're guessing as they're going through the whole exam. Right? So this person has to Larimia. So what's the derivative answer they can put? If you notice, that has been like a big focus of my recent podcasts where I say, oh, this is what they love to say. This is what you expect.

But then this is another word that may put on your test. Right? So they can put the term or sero glandular disease, right? Or sero glandular disease. And that will make sense because literally to Larimia causes an ulcer with big lymphatic apathy or sero glandular disease. Right? Now what's the book that transmits to Larimia? Well, remember, it's the Derma Center tick. Right? It's the Derma Center tick. And the way you're going to treat this is you're either going to give doxycycline. Right? Or you're going to give an amino glycoside, we're going to give superflexicin. Right? So you're either going to give doxycycline, an amino glycoside or superflexicin. Now one thing I found to be helpful for in B-Mexams is knowing situations where you should use superflexicin. Right? So it's actually very high yield to know that you can use superflexicin for pylonofridis on an Mbimexam. Superflexicin is one of the drugs classically besides tetriaxone that can be used to treat pylonofridis on Mbimexams. And then on Mbimex, we also use superflexicin to treat anthrax. When a person has infection with bacillus and threesis, the drug of choice on Mbimexams is superflexicin. Now, what if they give you a question about a, you know, a 32-year-old woman and they tell you that she just had her period or she just has had a mancy's like, she's been having mancy's for the last like three days. Right? And then they tell you that she presents with, you know, like a 12-hour history of really high fevers.

So they say temperature is like 104. And they tell you that a probable system of pressure is like 60, right? And she has like skin discrimination. She has alter mental status. Right? If you see something like this, what should you be thinking about? I would really hope you're saying, Oh, divine. This is probably toxic shock syndrome. Right? Again, we know that if people are having the appearance, maybe they're using super abs, so then tampons, right? Or you can give you a question about a person that has had nasal packing for a prolonged period of time for a few days, right? Or sometimes even a few hours, right? So this person has toxic shock syndrome. Right? Remember, toxic shock syndrome can be caused by one of two bugs on in being exempt. I mean, the other things that cost toxic shock syndrome, but they are these two, you need to know for your exams, right? You need to know strap pyrogenies. That's a group of these strap. I need to know stuff. Orius, right? Now, the thing is there is actually a difference in mortality between both bugs. When a person has toxic shock syndrome from strap pyrogenies, the risk of death is 50%. But if a person has toxic shock syndrome from staff, orius, the risk of death is 5%. Literally, you're 10 times more likely to die from strap pyrogenies, toxic shock syndrome than you are to die from staff, or your toxic shock syndrome. So toxic shock syndrome is something you need to pay attention to, right? It's also, you can just blow off.

These patients can die very rapidly. So what's the pathophysiology behind toxic shock syndrome? Remember, the way basically works is that you have like a super antigen, right? From these bugs, either stuff or you're just a strap pyrogenies is called TSS-T1, right? So toxic shock syndrome, toxic one, right? It binds to MEC to non-specifically. And then that just gives risk to a massive, massive, massive cytokine storm. And that massive cytokine storm can then cause the person to have just profound systemic effects. So the way you treat toxic shock syndrome, you're going to give these people fluids, right? You're going to do perform source control. You're going to get read, I mean, of the nasal packing or the superabsorbing tampon. That's causing all these problems, right? It can even be a person that just had an IUD placed. That's under classic scenario. You see an exam, president just recently had an IUD placed. And then it's that question I'm bringing from a sepsis perspective, right? So you're going to do source control, right? You're going to remove the source of infection. You're going to give those people fluids, normal settings usually find on exams. You're going to give those people a broad spectrum on antibiotics, right? And then you're going to put those people on pressers. The pressure of choice for people in toxic shock syndrome, like any other cause of septic shock, it's going to be neurobeenefreak. Right?

Remember neurobeenefreak is a first line pressure in septic shock. I remember the second line pressure in septic shock is visual pressing. And then the third line pressure in septic shock is epinefreak. If you want more information on pressers, listen to a belief episode 333, that was a podcast I made specifically on pressers for purposes of the of the US and the list of two CK Ns, step three exams. And then what if they give you a question about a 25 year old female? The telly that she presents with like a two days show of like, you know, really high fevers, sharpness of breath, malaise, my allergies, right? And then they tell you that, oh, you know, two weeks ago, she adopted a dog from an animal shelter. And then they give you some labs. And you notice that her LF Ts, so like a STL, TRL, elevated and she has like a high white count, this is like 15,000. And then they tell you that, oh, we can actually hear a new murmur at the left, the external border when you, when we listen to our heart. And then they tell you that, oh, on chest X three, they notice these bilateral, like noduline filtrates in the lungs. If you see something like this, what should you think about? Right? If you see this, you see a new murmur, you see fever, you see lucosytosis, right? You see a present that kind of works with animals. If you see this, this is a pretty classy presentation of Q fever. Okay? There's a pretty classy presentation of Q fever.

I remember Q fever is caused by Coxiella Bonediye, right? Coxiella Bonediye. It's one of those things that these, these causes a culture negative endocraditis. Really, this person ultimately, after all is said and done, has infectious endocraditis, right? So how do, how do we treat a Coxiella? Well, we're going to treat it with doxycycline. Again, remember, all these weird infections usually respond to doxycycline pretty well, right? And really, the way you're going to make this diagnosis is by pretty much identifying the antibodies in the serum, right? Just find the antibodies in the serum. And that way you'd be able to make, make the diagnosis. Now, what if they give you a question about like a 30 year old, like army engineer or Coast Guard, whatever, right? And then they tell you that this person has a past history of like diabetes, and they bring him to the emergency room because you know, for the last like two, three days, he's been having like really high fever, shortness of breath, altered mental status, right? And they tell you that, oh, he just returned from some kind of relief mission, right? Where he worked with teams that rebuilt homes that we have flooded, right? Or they can even tell you that, oh, you know, there was a hurricane, you can give it like a hurricane, Katrina kind of question, right? And they tell you that all this person worked during hurricane Katrina, and then the person, or you know, some sort of some sort, right?

So they were exposed to like, soil and water. And then they tell you that, well, this person for like the last two, three days, persons crashing on burning, and you notice that this person's white count is really low. This person's local panic, right? And the upload pressure is really high. And then you start seeing all these fluid collections in their brains, fluid collections in the elevators, right? So these are one of those weird bugs that the presentation is pretty unique, but it's pretty rare to encounter resources, but it's pretty high, you know, for exams. Kind of see all those statements I said, it's pretty unique. It's pretty rare. And resources that exist out there, but it's pretty high, you also know for exams. This person has Bacodaria Sudo Malai, right? Bacodaria Sudo Malai. Bacodaria Sudo Malai is the bug that causes Meliodosis. Meliodosis is spelled M-E-L-I-O-I-O-D-O-S-I-S, right? It's caused by Bacodaria Sudo Malai. Basically, let me tell you the big things you're going to see on your exam. It's going to be a person that is a diabetic. That is a very the biggest risk factor for Meliodosis, right? It's a person that's going to be a diabetic, for sure, right? And then you're going to see exposure to soil and water. That's kind of like a big, big, high old combination to know there. You'll see exposure to soil and water, soil and water, right?

And then you'll notice that these people don't really have like abscesses, fluid collections like in their brains and their levers. If you see something like this, I want you to think of Meliodosis is caused by one of the Bacodaria species, right? Bacodaria Sudo Malai. Bacodaria is spelled B-U-R-K-H-O-L-D-E-R-I-A Bacodaria. And then Sudo Malai is spelled as Sudo P-S-E-U-D-O and then M-E-W-L-E-I Sudo Malai, right? Bacodaria Sudo Malai, Bacodaria Sudo Malai, right? And the thing is again, the way you're going to diagnose these, you're going to get blood cultures and really, we are going to treat it as you're going to give the person like Ivey Svetazidim. Remember, Svetazidim is one of those third-gen cephalosporines that actually has the ability to cover through the monos, right? And then you're going to give these people like Bacodaria, like try to prevent the problem from the foxes all for many, many, many, many months, right? So again, it's very high yield to kind of know those, know those stints for, for exams, very, very high yield to know those stints for exams. Now, what if they give you a question about us nine year, like a seven year old male, just to make this more, we're more interested. Would they give you a question about like a seven year old male? And they tell you that for the last three days, he has had like a fever and a rash, right? And that, you know, he'll all kind of started with like pt.k.o bleeding on his wrists and on his ankles.

And then they tell you that these pt.k.o bleeds are now spreading towards his abdomen, right? And they tell you that, oh, he just, you know, went on a field trip to, to, uh, El Paso, right? With some classmates, right? With some classmates for like a geography class, right? They were, you know, exploring mountains, checking our rock formations, right? And then they tell you that, oh, they obtained some labs. And he noticed that his white count is 2000. So he has a local opinion, right? And he split their counties, like 55,000. So he has a thrombocytopenia. And his sodium is like 125, right? So he has hyponitremia. And in detail, he's LF Ts, they love it. Right? When they see something like this, right? Notice what I did here. Again, I'm using a derivative question. He's not saying, oh, he has a rash on the palms and so's that are spreading inwards. I just said pt.k.o bleeding on the wrists and ankles that are spreading towards the abdomen. Again, that's a classic presentation of Rocky Mountain Spotted Fever, right? Rocky Mountain Spotted Fever. Remember Rocky Mountain Spotted Fever is caused by Riketsia Riketsai, right? Riketsia Riketsai, right? Riketsia Riketsai. And this is also a bug that's carried by the Dermacentr Tick. Right? Remember, there are two Dermacentr Tick organisms that we've talked about today. We've talked about Tularemia from Francis Eletolarynsis. Remember, that has a rabid association. But again, the Dermacentr Tick is what carries the infection.

And then Rocky Mountain Spotted Fever, right? From Riketsia Riketsai, right? Again, also carried by the Dermacentr Tick. So I know some of you may be like, but divine. I'm used to MBME questions where a person has Rocky Mountain Spotted Fever from like North Carolina, South Carolina, you know, those parts of the country, right? If you notice, most of the question talked about Rocky Mountain Spotted Fever, but the geographical association didn't make sense, right? Remember, you always want to go with what most of the question is saying in selecting a not just one tiny part, right? So you just kind of want to be careful. That's a pretty classic thing, the MBME dose to people on exams, right? So this person has Rocky Mountain Spotted Fever. It's carried by the Dermacentr Tick, right? And really, the way you're going to treat this is you're going to give the Doxycycling to everybody, right? That's why I put a seven-year-old because I know some people may say, hmm, okay, well, all this person is less than eight. They're not getting Doxycycling. Well, the thing is you make an exception in Rocky Mountain Spotted Fever. Rocky Mountain Spotted Fever, everybody, doesn't matter who you are, less than eight years old, greater than eight years old, even pregnant, you're going to get Doxycycling, right? You're going to get Doxycycling. It is first line for everybody, including people that are pregnant, right?

The thing is, if it's a pregnant woman question, you don't see Doxycycling as an answer. The one answer you can go with is, is Clarem Fennecoll, right? One answer you can go with is, is Clarem Fennecoll, right? So remember Clarem Fennecoll is like a second line agent for treating Rocky Mountain Spotted Fever in pregnant women, right? Now remember when people have been treated with Clarem Fennecoll, you've got to watch their white count because Clarem Fennecoll can cause igrenolousitis, right? So you need to monitor the person's white count when you own Clarem Fennecoll. Clarem Fennecoll does probably like one of the only uses you've ever seen for, on NBM exams in the US, right? Because I remember back in the day in my year, people used to take Clarem Fennecoll quite quite frequently actually, right? And remember that Clarem Fennecoll can cause gree baby syndrome, that's very high up to them, right? So they'll give you a question about a newborn that has like an ashen gree complexion, and this newborn also has like cardiovascular collapse. So when you see something like that, I really want you to think of gree baby syndrome. Although one way they can test gree baby syndrome on the USML exams is they can give you a question about a patient that just immigrated to the US a few weeks ago from like an African country. And you'll tell you that, oh, how only pass medical history is that she has had many anxieties. She had many anxieties earlier in pregnancy, right?

And she was treated in this foreign country, right? Well, one common way of treating meningitis in developing countries is with Clarem Fennecoll, right? Because it actually has good blood-brain biopinitration, right? So, and then they tell you that she delivers this newborn that is crushing on burden from a cardiovascular perspective and has like this ashen gree color. If you see that, I really want you to think about a, I really, really want you thinking about a gree baby syndrome, right? I really want you to think about gree baby syndrome. So again, those are all, you know, high up things to know, know for exams, right? So now the final thing I want to talk about today, right? So what if they give you a question about a, you know, a person that has a mononucleosis like syndrome, right? And they have a negative monospot test. Well, if you see that, I'll re-opulate them about CMV, right? We'll re-opulate them about CMV. Now, for CMV, remember, you need to know that on, on, on, on those copy, I mean on, on histology, you're going to find out all eye nucleus, right? Many times on exams, they're going to say that, oh, you see intra-nuclear inclusions, right? So how do we treat CMV? Remember, we're going to treat CMV with GAN-cyclover, right? Which treat CMV with the drug GAN-cyclover. Remember, GAN-cycl, you can use that GAN-cyclover or Val GAN-cyclover, right?

So the thing is, this drug actually, you do need to know a little more than, a little more than is average about it, right? So remember GAN-cyclover basically is a DNA polymerase inhibitor, right? And for it to work, you need to activate it first with an enzyme called the UL97 kinase. When it's activated by the UL97 kinase, you'll then go ahead and inhibit DNA polymerase and it'll shut down DNA synthesis, right? So many times though, if a person is going to be resistant to GAN-cyclover, obviously, it would make sense that the mutation should be in the enzyme that activates it. In this case, again, UL97 kinase. So if there's a mutation, UL97 kinase, then you won't be able to activate GAN-cyclover, you won't get any effect from that. So obviously, in those circumstances, you want to use the drug force-carnate, right? You want to use the drug force-carnate. Remember, force-carnate is a pyrophosphate analog. Force-carnate is a pyrophosphate analog that can be used, right? It's look at it pyrophosphate. So it's already activated. It doesn't need activation by some like weird kinase for it to start working, right? And remember, if a newborn has CMV, what's the classic thing you're going to see? Remember classically, if you get like brain imaging, you're going to find periventricular calcifications, right? You're going to find calcifications all around, I mean, around the ventricles, right? Calcifications are around the ventricles.

That's how you differentiate that from toxoplasmosis, remembering toxoplasmosis. They have calcifications, but it'll be pretty much everywhere in the brain. It'll be all around the cerebral cortex, right? And they remember, these kids that have a congenital CMV, right? They're going to have microcephaly, right? They're going to have microcephaly. So their heads are going to be small. So they can tell you that, oh, because the new habit that our friends at the Amy and I have is, is not saying that, oh, they have microcephaly. They will see that, oh, the child's head is like in the second percentile for heads and conference, right? So kids that have CMV, their heads are going to be small. But kids that have toxop, their heads tend to be big, right? Remember, toxoplas this triad of choreoridmitis, hydrocephalus, right? And intra cranial calcifications, right? So I've talked about how you differentiate CMV from toxopythe calcification pattern, but in the way you can differentiate is by the size of the head. Kids that have CMV almost always have small heads. Kids that have toxoplasmosis have big heads because they have hydrocephalus, right? So they can be like in the 99 percentile for heads or conference. That's a nice way to differentiate those things. And then remember kids that have CMV, they can also have a sensory neuron here and loss, right? They can also have a sensory neuron here and loss. They can have the blueberry muffin rash.

Although remember that blueberry muffin rash is not specific only for CMV. And then remember in HIV patients, or patients that are immunocompromised, when they have CMV, they tend to have a CMV rednidus, right? So if you see a retinal infection and eye infection in a patient that has HIV, don't you think of CMV rednidus? Then the post-transplant patient, especially like a few days after the transplant or a few weeks after the transplant, think of CMV colitis, right? Many times you'll probably present as like just bloody diarrhea, right? In the patient, right? Presidents bloody diarrhea in the patient, who presents as bloody diarrhea, right? Sometimes it can also be a watery diarrhea, right? But if you see like big, big bad diarrhea, you know, present that just got a transplant, right? You see that temporal association on the recent transplant, don't you think of of CMV colitis? Okay? And again, you treated the exactly we treat normal CMV. So I'm going to go ahead and pause here. Again, as I do at the end of a report cast, I do for one or one two or for many exams, step one, step two, see case, step three, preclinical medical exams, third year shelf exams. And again, for ERAS applications, I do help people with ERAS applications, personal statements, recommendation letters, editing your ERAS applications. Can I do these things that fix straight? So just should be an email through the website. And I'll give you some more information.

And then, you know, these podcasts on Google podcasts, Apple podcasts on Spotify. So I'd encourage you to subscribe to those and you will see the most recent 150 podcasts. It's a Word Press rule. If you want everything from episode one, all the way to this great episode, then you want to go on the website, divineinterventionpodcast.com. And by doing that, you can subscribe. And whenever I actually make a new podcast, you'll get an email notification. And then I also have a You Tube channel, divine intervention, USML podcast and videos on that resource, you know, that's where I put all my videos. Please subscribe to the You Tube website. That certainly helps. And then again, I know many of you love the, I've got in tons of countless emails on like my life lessons, right? Like, oh, people love the life lessons I talk about. So, you know, I still put life lessons every now and then with these episodes, but I also have a new website, score, divine intervention, life lessons.com. And in that, you know, website that you have been making life lessons or podcasts, they're all less than 10 minutes long, you know, it's just Bible-based teaching or like a key thing that is necessary for life. So if you're interested in that, just go on that. I also have the actually that podcast as well, score, divine intervention, life lessons podcast. It's an Apple podcast, right? So you can subscribe to that as well. They are very short.

My goal is to make a couple every week that you can kind of use as a devotional or something. I used to just learn something from the Bible. So thank you for listening to me. I'll see you next time. If you're interested in the course again, shoot me an email and I'll give you some information on payments and reserving your spot. Thank you for listening to me. God bless you. I'll see you next time. Thank you.

Burkholderia pseudomallei.

Diabetes Mellitus and exposure to contaminated soil/water.

Doxycycline (or tetracyclines).

CMV typically causes periventricular calcifications and microcephaly; Toxoplasmosis often involves diffuse cortical calcifications and can cause hydrocephalus.

Norepinephrine (Levophed).

Fever, new murmur/carditis, elevated LF Ts, and bilateral nodular infiltrates on chest X-ray.

Francisella tularensis; transmitted by the Dermacentr tick (and rabbits).

Doxycycline, an aminoglycoside (e.g., gentamicin), or Sulfhexicin.

1st line: Norepinephrine $\rightarrow$ 2nd line: Vasopressin $\rightarrow$ 3rd line: Epinephrine.

Intra-nuclear inclusions (or periventricular calcifications in the brain).

Thrombocytopenia/low white count (Clindamycin can cause agranulocytosis or thrombocytopenia).

CMV usually causes microcephaly (small head); Toxoplasmosis often leads to hydrocephalus, resulting in a larger head.

Ganciclovir; DNA polymerase inhibitor.

Francisella tularensis; transmitted by the Dermacentr tick (and rabbits).

Doxycycline, an aminoglycoside (e.g., gentamicin), or Sulfhexicin.

1st line: Norepinephrine $\rightarrow$ 2nd line: Vasopressin $\rightarrow$ 3rd line: Epinephrine.

Intra-nuclear inclusions (or periventricular calcifications in the brain).

Thrombocytopenia/low white count (Clindamycin can cause agranulocytosis or thrombocytopenia).

CMV usually causes microcephaly (small head); Toxoplasmosis often leads to hydrocephalus, resulting in a larger head.

Ganciclovir; DNA polymerase inhibitor.