DIP Episode 314 - USMLE Step 2CK Rapid Review Series 57 (+ 2CK/3 May Course Reminder)

Okay, welcome. My name is Divine. This is episode 314 of the Divine Intervention Podcast. And into this short podcast I'll be continuing the Rapid Review series for the USMLE Step 2 CK exam. If I'm not mistaken, in today's episode we're actually going to be going after Rapid Review series number 57. And again, as a reminder, I do offer in the combined Step 2 CK Step 3 class next week. Again, it's a super high-year class. Again, I've had many people take the class that I've done extremely well on the USMLE exams. It takes place next week from Wednesday to Saturday. So it's 5 hours each day. It's 11 a.m. to 4 p.m. Pacific Standard Time, which is the same for us 2 to 7 p.m. Eastern Standard Time. On all four days from Wednesday next week to Sunday, I mean to Saturday. And then on Tuesday, I'm holding an MBME Testicking Strategies class again from 2 to 4.30 p.m. Pacific Standard Time, which will be 5 to 7.30 p.m. Eastern Standard Time. Again, lots of people have taken these courses and they've done extremely extremely well on the exams. Again, I've had people that were doing polyon practice tests. They take the course, the two courses. And they take a practice test like a day or so afterwards and they've bumped by like 30 points. Again, if that's something you're interested in, shoot me an email and I'll be more than happy to give you some more information on the cost. The course is over zoom again. It's a very comprehensive course, very high level course.

We cover everything from peets to surgery to I am to OBGYN to psych to Neural to bio stats to ethics to the November 2020 changes. So you'll see how it's applied in the context of question because many times right it's not enough to just like no information right. It's also important to kind of know how to use that information. And also we cover the step one material that has slowly study making it to be an interceptive seeking. So again, slash step three. So if you're interested again, just shoot me an email and I'll give you some more information. Okay. So let's jump right into it. So what if they give you a question about a 25 year old male, you know, it comes in with flunk pain fevers. You check his urine, you see a lot of white blood cell casts, right. And then they tell you that, oh, he's given a safe triaxle, right? I've used a traxle, right? Because he has pilon of right is I feel like many times the more sending them exams. You're really in question, be like, oh, I know exactly what this is and do tell you exactly what it is. And then you're like, oh, what's this question that's coming next. So, right. So this person gets like I've used a traction for a pile of Friday's and they tell you that, you know, the do gramstain of the urine sample and they see like gram negative, gram negative rods, right? So they tell you that they give IV safe tracks. And then they say that two hours after the person gets IV safe tracks.

So the person starts having like riggers, starts having fevers, starts having chills, right? And the person's blood pressure is like 75 over 40, right? If you see that, what do you want to think about? I hope you're saying, huh, divine. This is potentially the Jarash Hicksheimer reaction, right? The Jarash Hicksheimer reaction. Again, I know some of you may be like divine. This does not look like syphilis, right? So that's the point behind this question. So your friends at the MBM, they get really smart. So these are these are things about the Jarash Hicksheimer reaction. Again, the MBM is still testing the same pathologies. They're just testing those things in different ways, right? So remember Jarash Hicksheimer reaction in general on MBM exams, you can see it in Spyro Kits, right? So like if a person is getting antibiotics for any spyro Kitting infection, like Lyme disease, like syphilis, remember Lyme disease is caused by Borrelia Boudoufri, which is a spyro Kit, or syphilis, right? Try Ponyma Palidam, which is a spyro Kit, or leptosperosis, which is caused by leptospiring terror guns, which is also a spyro Kit, right? Those things, if you're treating those infections with antibiotics, right? As those bugs are being laced, the self-subkindness spills into the surroundings, and those things can cause major, major issues for an individual, right? Kind of like the same thing with gram negatives as well. Gram negatives can actually also incite the Jarash Hicksheimer reaction.

In fact, many resources may lead you to believe that it's Spyro Kit, or infections that are the most common cause of the Jarash Hicksheimer reaction. It's actually gram negatives, right? So this person, the hospital of Friday as well, okay, you tell me about the most common cause of Pylon of Friday. It's going to be E. coli, right? E. coli is a gram negative organism, right? So Jarash Hicksheimer reaction again comes. Basically, the key thing is you see a person that just recently started antibiotics for some kind of either gram negative or Spyro Kit, or infection. And then you notice that within a few hours, minutes to hours after they get the antibiotic, everything just gets really bad. I'll see more hours, because if you see it within minutes, you're thinking more along the lines of some kind of an aphylactic reaction, right? Like a allergic reaction of some sort, right? Which is not a point of this question, right? So this is the Jarash Hicksheimer reaction, right? And again, essentially the pathophys is like, especially with these gram negatives, right? When their cell walls are liced, their release are lipopolisaccharide, probably remember studying that from step one. And then that LPS, right? Another molecule incite like a big, big, big cytokine reaction, right? For the most part, you don't need to stop the antibiotic therapy. All you really need to do is just give NSAI Ds, so what if care, maybe give them some fluids and they'll be fine.

Stereoids will actually be the wrong answer on your NV Me exam. If you select steroids for the treatment of the Jarash Hicksheimer reaction, it can pretty much guarantee you're going to get the question wrong. Okay, so what if you get a question about like a 24-year-old male, excuse me, 24-year-old male, his parents bring him to the emergency room, you know, they tell you that, oh, he collapsed at home. And then they tell you that, you know, over the last three days, the assonance can be an out of it. And they tell you that, oh, he ran out of his prescription six days ago, right? And they say, he's parents say, you know, he needs to, he plans to get a refill soon. And then they tell you that, oh, in the question that this child has severe persistent asthma, takes oral, daily oral pregnancy, right? And let's say he also takes like a bitter role, and he pretropium, remember, a bitter role is a bitter to agonist. Epertropium is a most chronic antagonist, right? So and then they tell you that he also takes like oral for motor role. Remember, our bitter role is a short-acting bitter to agonist for motor role and some metter role are long-acting bitter to agonist, right? They allow us. And they tell you that physical exam shows like decrease responsiveness, patient is some length, and then you notice the patient blood pressure is like 60 over 40. And then they tell you that, oh, they give a letter of crystal oil, right?

Again, crystal oil is just mbme fancy terminology for normal ceiling, right? For normal ceiling. So they give crystal oil, although a lactator ringer is technically is an example of a crystal oil solution. Hopefully when I have time in the future, I'll make a podcast on fluids, right? Because I think I think I think I'm gonna mess this people up a lot on exams and also just clinically, although again, this podcast is for exams, right? Not for clinical management. Okay. So they tell you that they give him a little crystal oil and his blood pressure only increases to like 61 over 41. So basically it's only blood pressure went up by one. Is that the stomach blood pressure went up by went up by one. So if you see stuff like that, what are you thinking about? Well, I really hope you're saying all the vine sounds like this kid has potentially like a HPA access crisis, right? Almost like an Adyssonian crisis in a sense, right? So this child pretty much stopped sticking steroids abruptly, right? Well, remember, if you've been taking steroids for a long period of time, right? Your hypothalamus B-3rdrional axis will essentially atrophy from chronic suppression, right? Remember steroids, they work at the genetic level, right? Steroid hormones just in general work at the genetic level. So the pressing HPA access has actually been suppressed has actually gone into atrophy, right? So this person essentially was taking his medications and then run out, right?

So when you run out of your medications, well, you are no longer taking that exogenous steroid. If you're not taking that exogenous steroid, well, there's no place for steroids to come from in this individual, right? So essentially this person is going to have a general crisis, right? So they will have high puny trimia because they have an outdoor strewn deficiency. Remember, our Adyssonian's job is to help you reabsorb sodium in the principle cell of the collecting duct and people potassium as well. And it also helps you pee protons, right? So if you remember these three tasks, you're being great shape. Adysson helps you reabsorb sodium, people potassium and pee protons, right? So reabsorb sodium, people potassium, pee protons. So if you're not able to reabsorb sodium, you're going to have high puny trimming. If you remember that in a channel, that's kind of like the channel that our dostorial operolids in the principle cell of the collecting ducts to help you collect sodium from your urine, right? So you get high puny trimia, you get hyperkelimia, right? And you get a normal anion gap metabolic acidosis, right? You get a normal anion gap metabolic acidosis. And in fact, if you want to be more specific again, because it's a luar dostorium state, you're going to be getting a typhoid RTA. Remember, a typhoid RTA is the hyperkelimica RTA, right?

It's the kind of RTA you get when you have a luar dostorium state, say for example, if you have like 21 hydroxylase deficiency, or you have a water house phyrzoxin syndrome from meningococcal infection, or you have Adysson's disease, right? Or you have just again, anything that causes a primary adrenal insufficiency. And then, you know, if a person has been on steroids for a long enough period of time, right? And you're like, okay, we need to take you off steroids. What are you going to do? Are you going to stop it abruptly? No, you're not going to do that. If not, you'll throw the patient into the exact same situation that is bringing this patient of ours into the ED, right? Essentially, you need to taper it over weeks, especially when you're taking it for like a long period of time like this, like this guy, right? You need to taper over weeks, right? So, one thing that is becoming more important on step 2, see he's step 3, again, especially with step 1 becoming pass fail, is the beginning to import stuff from step 1 to step 2, see he's step 3, right? So what is one big thing that they love, love, love to test these things, right? Again, pharmacology. That's like easy pecans for them, right? So let's talk about how prednisone works, right? Let's kind of talk about some high-youth things that your friends at the NBM want you to know about steroids. So you don't get them wrong on your test, right? So remember, prednisone, for example, it actually is like a pro-drug, right?

So it goes when you take it orally, it goes to the lever, the lever, right? It's a very big time metabolic organ. It's going to convert that prednisone to prednisolone, right? It uses this enzyme called 11-beta-hSD, 11-beta-hydroxy-steready-hydrogenase, right? You probably don't need to know that, right? And then, so that prednisone is converted to prednisolone, and then that prednisolone will then act on intracellular, glucocorticoid receptors, right? It will affect gene transcription and all those things, right? Now, do you want to give steroids to a person that has a history of diabetes? Probably not, right? Because remember steroids, they can work in hyperglycemia, right? Remember steroids, they have diabetogenic hormones, right? So they can potentially worsen a person's hyperglycemia, right? In fact, what are the other diabetogenic hormones you want to know for an exam? Well besides steroids, remember you want to also know that if a person has a glucogonoma, right? Glucogon is a counter-agglutory hormone, right? So you can cause a- it can worsen a person's diabetes, right? So that's why typically people that have glucogonomas, they have that necrolitic migratoryorythema, right? That they have diabetes. Remember that growth hormone is also a diabetogenic hormone, right? So people that are taking exogenous growth hormone, right? They are a very, very high risk of getting diabetes, right?

And then another diabetogenic hormone, especially like in OB-GYN country, on MBM exams, is human placenta-lactogen, right? So human placenta-lactogen is released by the placenta. It causes a mild insulin resistance and mom, right? So that mom's blood glucose levels are higher than normal, right? Which is almost like an adaptive measure so that there's more glucose and energy available to the philates, right? So that's something to keep in mind for, for exams, right? And then remember, what is the gastric side effect associated with cortical steroids? But I hope you're saying, oh, divine, potentially steroids can cause a peptic ulcer disease. In fact, this is a classic MBM exam question. You'll give your question about a person that is being studied on chronic therapy for some bad rheumatologic things. Bad rheumatologic things, right? Or really bad asthma, right? Those people need to be placed on two prophylactic things. One, they need to be placed on prophylactic PPI's, right? They need to be placed on prophylactic and proton pump inhibitors, especially if you're taking steroids for like three months or more. But I think those people need to be placed on is a prophylactic bisphosphonids, right? Because remember, bisphosphonids, they can absolutely, absolutely, absolutely cause a decrease in a person's bone mineral density, right? In fact, they can give you a question about a person that has been in like oral steroids for some disorder for a long period of time.

And then they tell you that the person starts having like low back pain or like right hip pain or something like that. If you see that, especially if you see like in the hip, I want you to think about evasculomy crosses, right? I want you to think about evasculomy crosses of the hip, right? I definitely want you to think about evasculomy crosses of the hip. Now, what if they give you a question about like a 39-year-old male, again, still talking about steroids? So 39-year-old male, he's been on prolonged sterile therapy for the last like three, six months, right? And then they tell you that, oh, he has been noted to have this decrease in executive function, right? They tell you that he has forgotten to turn off the stove multiple times at home. And then they tell you that, oh, you know, maybe he's in some like PhD program and he's struggling academically, right? If you see that, I really want you to think of something called a steroid dementia syndrome, right? And then what you want you to think about steroid dementia syndrome is one of these things, you pretty much won't find in any resource, but it's something that's floridly high yield to know for your USML exams, right? So steroid dementia syndrome, essentially the thing that happens is, or if you're trying to kind of like say, oh, divine, how, why would this happen? Well, essentially, it happens because you have down regulation of local quadicoid receptors in the hippocampus.

And also in this part of the brain called a prefrontal cortex, right? So think about it, right? If I just kind of think of it this way, right? So say for example, you love bread, right? Let's say you're like, oh, man, I really love bread, right? And then you eat bread morning afternoon evening, morning afternoon evening, breakfast, lunch dinner for like three weeks, right? After a while, you kind of get out of that bread. And when they give you bread, even if it's like the choice as bread, let's say like something like a super, super, super sweet bread, right? And then you probably turn it down after a while, right? Because again, you've been overexposed to that bread. So you're like, you know what? I'm tired of this. Get this out of my face, right? So the thing is, if a person is taking chronic steroid therapy, and this disorder usually happens in people that have taken stairs for a long period of time, right? The thing that's unfortunately going to happen is, you're going to begin to downregulate those global quadicoid receptors in key parts of the central nervous system, like the hippocampus and the prefrontal cortex, right? And if you downregulate those receptors, unfortunately, that person can begin to have some dementiva symptoms, right? And again, whenever a disorder has a neuroanatomic ulta association on exams, it's absolutely necessary to know those things for MBA meetings, right?

So again, you want to make sure that you understand that these people, right, it's associated with downregulation of local quadicoid receptors in the prefrontal cortex and in the hippocampus, right? And the thing is, this is actually not permanent, right? So the thing is, if the person stops taking those quadicoid steroids, we don't have a few months to a year, their memory will come right back, right? Okay, what if a person has been on a quadicoid therapy, right? And they tell you that, oh, this person has been having like proximal shoulder and heat pain for the last two weeks, and they tell you that the creatine falls for kinases within normal limits. But if you see that, I would hope you're saying, oh, divine, this is potentially like a steric induced myopathy, right? Remember, whenever you have an endocrine cause of a myopathy, that's classically associated with a normal creatine forceful kinase level, right? So when people have like steric induced myopathy or people have like hypothyroid associated myopathy, those tend to be associated with normal levels of creatine forceful kinase, right? What if the tell your person has been on steris for a long period of time? And then they begin to have like worst-name vision at night while they are driving, right? If you're seeing that, I'd really hope you're saying, oh, divine, this person potentially has cataracts, right? This person potentially has cataracts, right?

Or let's say they give you a question about a person, cause remember steris associated with a lensopacification, right? Okay, what if they give you a question about like a 39 year old male, they tell you that he's on prolonged sterotherapy, and you know, he requires like pelvic surgery because he's been in like a major motor vehicle accident. And then they tell you that during the procedure, he's like super hypotensive, and they're giving him all these fluids, but his blood pressure doesn't seem to be responding. If you see that, I really want you to say, oh, divine, this person potentially needs a stress dose of steris, right? Again, this person has like an adrenal crisis, right? So this person is on the goin-ness stressful event of some sort, so he'll need more than his regular dose of steris, right, to help. And again, you may be like, oh, divine can't he's HPA access help? Well, it cannot. Why? Because again, if you are taking chronic exogenous steroid, that's going to suppress cause atrophy, right? Atrophy of your HPA access, right? So if you atrophy your HPA access, you cannot meet extra demand, right? Because again, surgery is very stressful on the body, right? So again, that's why this person requires a stress dose of steris. Many times on MBM exams, you're going to give any steroid for some reason, because it's going to be really low hydrochlorousone. Hydrochlorousone is a corticosteric that also has some pretty amazing mineralocorticoida activity.

Now, what if the, in fact, you know what, I'm just going to keep talking about all the steris things that come to mind, and then that'll be the end of this podcast, right? Because again, steris are one of those things you know as you're taking your exam. You're going to see a bunch of questions that kind of goes over those things, right? So what if they give you a question about a patient? They tell you that this patient again has been using in Hild Flutica zone for allergic rhinitis, right? And then they tell you that, oh, this person is using it for months, and then now this patient presents with like what dynofisia. If you see this, I really hope you're saying, oh, divine, this sounds a lot like a suffrageocandidasis, right? Because again, steroids, they are very good, right? Especially if you're not using it right, right? They can be collecting to your esophagus, right? They can immunosuppress the local environment around your esophagus, and the person can get candidises, right? And typically for presidiasis, or for geocandidasis, what are you going to do for them on exams? I hope you're saying, oh, divine, we're going to go ahead and do the nice starting swish and swallow, right? You do the nice starting swish and swallow, right? Or you can even give those people like an oral easel on an in-beam. Okay, now what if they give you a question about a patient?

You know, basically this patient has a history of multiple sclerosis, and this patient right now is having like sodium onset, painful vision loss, right? So they bring the person to the neurology I see you. And they tell you that, oh, they start this patient on like 100 milligrams of, you know, IV prednis on every day, too, you know, kind of help with that optic neuritis, right? And then let's say like two days after this person starts therapy, they tell you that this person starts pulling out IV lines, you have to restrain this patient, the patient is saying that their voices that are coming out over stomach, telling him, saying, oh, these doctors want to kill me, kind of deal, right? You see this? I will hope you're saying that this person has steroid induced psychosis, right? They will try to trick you and they'll put your psychotic disorder and whatever crap as an answer. Remember, whenever there is a potential substance that's causing a person's like psych problems, that you cannot diagnose that psych problem, right? You need to seek psych problem due to XYZ substance, right? That's like a classic thing that pops up a lot on in-beam examples, it's really like psychsholver exams. Now what if you see like Ciggy Capsum thumbs, right? You see like a poor sleep, low energy, concentration, gale, you know, psychomotoric tradition, you know, the works, right?

In like some 42-year-old guy, and they tell you that he was placed on oral prednisone therapy for, like severe persistent asthma, right? Like 90s ago. Again, this person has, again, they'll put me into the press, if I let him not see 90s ago, 23 days ago, right? Again, they'll put me into the press, the disorder has an answer. Don't pick that, you get that wrong, right? Again, the thing you want to pick is this person has like a substance induced mood, disorder, right? Substance induced mood disorder, right? Substance induced mood disorder. So again, whenever there's a substance you're taking like a little blocker or steroid, right? Or interferon, right? That's potentially causing the presence of depressive symptoms. You cannot diagnose those people and measure the presence of the disorder, right? You need to pick the answer that talks about like the substance induced mood disorder in those circumstances. So I guess let me go ahead and stop here. Again, as I do at the end of every podcast, I draw a throw one or one tutoring for many exams. Step one, step two, see case step three, pre-cleaned comments call exams, 30-ish-elf exams. If you're a medicine resident, I tutor for the medicine, treating exam and the medicine boards. So if you're interested in that, just ship me an email and I'll give you some more information. And then I also work with people on various applications.

Again, I've worked with tons of people that have matched in many different disciplines, like germ, psych, pathology, EMT, ortho, neurosurgery, cardiac, like those are cardiac thoracic surgery, right? So I've worked with tons of people that have matched in pretty much every specialty, right? Again, people that have tricky applications, red flags, graduated from med school many years ago kind of deal, right? So again, if you're interested, just ship me an email through the website and I'll give you some more information. So thank you for listening to me today. I'll see you in the next episode, have a wonderful, wonderful, wonderful day. And God bless you and please pray for the makers that we win against the Goddings Day Warriors today. Okay, thank you. Bye.

Fever/rigors appearing hours after starting antibiotics for spirochetal or gram-negative infections.

Hyponatremia, hyperkalemia, and normal anion gap metabolic acidosis (Type IV RTA).

Taper slowly over weeks; never stop abruptly.

E. coli (a gram-negative organism).

Proton Pump Inhibitors (PP Is) and/or H2 blockers.

Downregulation of glucocorticoid receptors in the hippocampus and prefrontal cortex.

Hyponatremia, hyperkalemia, metabolic acidosis (Type IV RTA).

It is a prodrug converted to prednisolone by 11-$\beta$-HSD in the liver.

Bisphosphonates (or calcium/Vitamin D supplementation).

Human Placental Lactogen (HPL).

Swish and swallow of an antifungal solution (e.g., Nystatin).

Steroid-induced myopathy or Hypothyroid myopathy.

Hyponatremia, hyperkalemia, metabolic acidosis (Type IV RTA).

It is a prodrug converted to prednisolone by 11-$\beta$-HSD in the liver.

Bisphosphonates (or calcium/Vitamin D supplementation).

Human Placental Lactogen (HPL).

Swish and swallow of an antifungal solution (e.g., Nystatin).

Steroid-induced myopathy or Hypothyroid myopathy.