DIP Episode 246 - USMLE Derm Review (Part 2 of 3)

Okay, welcome. My name is Divine. This is episode 246 of the Divine intervention podcast. In this podcast, I'll be continuing the discussion we've been having on US Emily Demartology. So this will be the second party in the series of three. The first party in the series is episode 242. So I'll just continue today. You know, once I kind of hit like 30 minutes, I'll just go ahead and quite it shall. And again, as I mentioned, I do have a US Emily step 2 CK 10 hour class coming up on Saturday at 6 to 10 a.m. Pacific, or dig a 12 break 12 to 4 p.m. Pacific, 12 break, and then 6 to 3 p.m. Pacific. I will end up covering like 600 700 concepts from step 2 CK. Basically, we'll hit on the high yields of most specialties like Neuro, Psych, Obi Guy, Pied Surgery, Internal Medicine. Again, fast, majorly good that I've participated in this have even people that have taken the exam and got in scores back have given me a very good feedback on the course. And again, starting in August, I'm actually going to start time permittant. I'm actually going to consider starting a 2 D version where I do five hours a day prior and five hours the day after. So it will probably be something I'll try to do like biorecly in the month of August. So if you're interested in the five hour option, just go ahead and reach out to me. But again, tentatively, it would resume in August. Okay. So let's go ahead and jump right into it. So what if you give your question about like a 31 year old guy, right?

You know, they tell you that he was, you know, like active military, right? So again, remember the MBM is new focus on the military. Remember I've made podcasts for that stuff, right? So, you know, so that was like active military, right? And you know, just came back from Afghanistan or something like that, right? And then they tell you that on his arm, right? You can see like this all straight in like purple, like papi on his arm, right? And you know, let's say you did a lot of like ground combat or whatever, right? If you see this, right? I really hope you're thinking about Lishmanai SS, right? Remember Lishmania is a fluid of these things that they could use as a military question on your test, right? Remember, it's basically transmitted by the, you know, it's transmitted by the Sun fly, right? So if you see a question about a person in the military that's coming back from like Afghanistan or coming back from Iraq, right? Or coming back from Brazil or coming back from Saudi Arabia or even Peru. Those are classic countries that tend to, you know, have a pretty high, a pretty higher incidence of a Lishmania SS, right? And again, for the most part, the way we'll start is, you know, the person will say, oh, you know, and almost always is going to be on the upper extremities, right? So they'll tell you that, oh, on the face, in some cases, but usually it's on the upper extremities on NBM exams, right? So feel like this small red papi on, right? And it's painless.

And then, right? Usually what happened about like, you know, that's why you can be a person that's coming back from deployment because it takes about two to four weeks after the bike will you to get in hot water, right? And then over time, right? It begins to enlarge and large and large and large. So it goes from being red, right? And then it becomes like almost like a violet color, right? And many times it forms an ulcer on the test, right? And the way you actually make the diagnosis here is you actually go ahead and do a biopsy, right? You do a biopsy of the lesion, like a skin biopsy. You look at the, look at the organism, right? And then for the most part, these people you treat them with amphoteric in B, right? Or you can use a paramomizing on an NBM exam. Those are all ideal, right? And then one thing I guess I want to go ahead and say, like, this is something that people tend to tend to mix up on exams with HHV3, right? So like herpes number, yeah, I think it's herpes number three, yeah, herpes three, right? That's like very sad as those survivors. One thing that's actually kind of important, right? Obviously has a lot of dermatologic manifestations. That's what I'm talking about here. But one thing I would say is don't forget that if a person is over the age of, a person is over the age of like 50, right? There is actually now a recombinant zoster vaccine, right? That's actually available.

So if a person is over the age of 50, they can actually get the recombinant zoster vaccine. I mean, there is another one that's like the liva 10 with a vaccine, right? The liva 10 with a vaccine. In fact, let me just put it this way for you. You want to be able to parse this thing out as two different vaccine schedules, right? Again, they love to test this. And this recombinant vaccine, right? Because it's kind of like not liva 10 with it is something that the endemic has, you know, started caring about on these tests, right? So the thing is the recombinant zoster vaccine, right? It's something, so that's the one that is not liva 10 with it. You can start giving it as early as the age of 50, right? You can give it as early as the age of 50, right? And basically, right, she actually reduces the risk of like this post-hypetic neurology. And it actually really helps with just reducing the incidence of zoster infections, right? So it's a pretty good vaccine, right? Now, the other one, if you get a question, right, on the other one, right, like the liva 10 with a zoster vaccine, right? Basically, that one is only given to people that are over the age of 60. That's extremely important to know. It is only given to people that are over the age of 60. And that person has to be immunocompetent. If he's a person that's like 62 years old and has HIV, right, or has CLL, has some kind of immunodeficiency disease, it is not prudent to give those people the liva 10 with a zoster vaccine.

So again, the recombinant vaccine, you can start over the age of 50, the liva 10 with a vaccine is then started over the age of 60, right? And again, remember, the weaselster presents an example, right? You know, pain, rash, dermatomodistribution, the works, right? And one thing you should kind of watch out for, right? If you notice a person has like just this very pervasive outbreak of like zoster, right? You want to go ahead and test that person for HIV, right? So if you notice that like me and this person just boom, like they almost have like this zoster explosion in their bodies, you absolutely, absolutely on your test. I want to think about, I want to think about like HIV, go ahead and screen those people for HIV. Another classic way to test that go ahead and screen those people for HIV is if a person has, if a person has like this sudden outbreak of monoscomcom contingency, you also go, you need to go ahead and screen those people for HIV. And all the sudden outbreak, bizarre scenario you see on your test is if a person has like, prefer cutinia, tarda, right? You need to screen those people for HIV, right? These are all high-yield things enough to test on exams, right? Now one thing you should keep at the back of your mind with zoster, right?

Is if you notice that a person has like this, again, like these these are vesicular rash in their dermatomodistribution, if you notice it like in the distribution of like the trigeminal nerve, like the first branch of the trigeminal, if I'm remembering correctly, that's the ophthalmic nerve, remember trigeminal has three branches, there's ophthalmic, there's a, there's the ophthalmic nerve, that's V1, there's the maxillary nerve, that's V2, and there's the mandibolone nerve, that's V3, right? So if you have any problems along like the first division of the trigeminal nerve, right? Let's say like they have lesions on the tip of their nose or like just above the eye, you need to go ahead and you know, treat those people, but you also need to refer them urgently to an ophthalmologist, right? Because they have something that's known as zoster ophthalmicus, right? Zoster ophthalmicus, that's an emergency, that's an ENT, that's an ophthalmological emergency, right? And then if for example they tell you that, oh, you notice this is a way like they usually throw these on neuro questions, right? These are really into rigderm with neuro, on endemic exams.

But the thing is, if for example they tell you that all this person has like vesicles in the ears or they are, they are specialty sensation for the anterior to the third of the tongue is gone, or the person is like paralyzed on one side of the face like the upper hand, like it's almost like the person almost has like a bell spousing as things, but you see it in the setting of a, basically you're seeing a little cranial seven problems, right? Like vesicles in the ears, right? But again, teeth, not the general sensation of teeth, the special sensation of teeth on the anterior to the third of the tongue, the paralyzed upper and lower face, you want to think about something known as a Ramsey Hunt syndrome, right? So Ramsey, MR, no, R-A-M-S-E-Y, H-U-N-T, Ramsey Hunt syndrome, that's something you want to keep at the back of your mind, for example, right? Again, for the most part, for a person has zoster, right? You treat those people like e-cyclover, they want to be mean on your test, you know, they can put like valley cyclover, they can put fun cyclover, that's absolutely fine. So it's not a huge deal on exams. And if a person has like post-operative neurology, you need to treat them with like an neuropathic agent, right? So you want to treat them with like gabapentin, or you can give them a tricyclic and tidy present like emetripe, tilin, nortripe, tilin. I remember you want to think twice, right?

Again, the elderly, those things can trigger anti-colonergic symptoms and add delirium, right? You can give a pregabaline, right? So like gabapentin, pregabaline, tricyclics, those are absolutely fine, right? And again, please, I know this is something that many people mix up, but please don't mix this up. The recombinant, VZV vaccine, you started the age of 50, regardless of if you've been infected before, if you've gotten a vaccine before it does not matter, basically once you hit 50, regardless of your vaccination status in the past, no one cares, you're eligible for the Zoster vaccine, right? You're eligible for the Zoster vaccine. And one classic thing that you may see on exams that one condition that people may occasionally succumb to is they may try to treat like, like herpes Zoster, like steroids, do not give steroids for herpes Zoster. I mean, if you want to make it disseminated in the patient and kill them, then you can give them glucocorticoids, right? So that's not something prudent you want to do, you want to do on the test, right? So again, group vesicles, their motor distribution, that's herpes Zoster, right? That's herpes Zoster, right?

Now, what if they give you a question about like a young kid, you know, or like a homeless person, person's birth to the emergency room, or comes to the physician's office, or like the department of health, because he says that he has like this itchy rash, like between the finger webs on his penis, on his scrotum, stuff like that. If you see that, right, you want to think about skibis, remember skibis is caused by the bug, syracoptis skibi. So S-A-R, I hope I'm saying this, right? S-A-R-C-O-P-T-E-S syracoptis, and then skibi is S-C-A-B-I-E-I, that kind of sounds right. So, anyway, so, so this person, right, you know, pretty much has skibis, right? For the most part, you'll see like burrows where the person has the infection, right? And remember that if a person is immunocompromised, they can actually have like, almost like this thing called like the semi-fid skibis, right? So people that have like HIV-A, right, they can have the semi-fid skibis, I mean, HIV is just not an ideal thing for any person to ever have ever, right? And really, the way you make the diagnosis is, you know, you basically like swap the tissue that has the problem, right? And you will find like the mites, you find the eggs on like a kill-hitch, like a kill-hitch prep, right? That's pretty much the way you make the diagnosis of skibis. And remember that the way you treat skibis on MBM exams, right? Like, you can treat it with like a topical agent, right? You can treat like per me-3.

And remember, if you don't just treat the patient, you have to treat the patient, treat all the family members, treat all the people that have contacted the patient, you know, people that have had sleepovers and all that stuff, they kind of need to, you know, get treated. And for the most part, these people, right, they can make this like a preventive medicine question. Pretty much remember, these people like clolin, like the atals, everything, right? You need to wash it in hot water and at high heat for a very long time, right? For this thing to kind of go away. If you don't see per me-3 as an answer, one drug you could potentially use is something known as Ivermectin, IVER, NEC-TIN, right? So you can use Ivermectin, right? But again, remember, for a person is a kid, like a very little kid, or you see like a person that's pregnant or breastfeeding, they cannot get Ivermectin, right? They cannot get Ivermectin. That's very important to know. So again, skibis again, remember, you see like, again, these like red, they almost like red shiny papules, right? Again, just look up pictures of this, just look up pictures of this, I think that will help you out. Just look up it because these dermatologic disorders, right? You know, it's kind of like reasonable to try to be able to identify that, right? So, you know, it will look like red, again, they'll be like papules, erotions, you see all these burrows, and again, usually they are within between the fingerweb, right?

That's pretty classic for skibis. Now, the thing is, I guess one thing I should go ahead and mention is, if you notice that a person has skibis and they put one of the answer choices as like lindane for treatment, don't give lindane these to do it back in the day, but no one does it anymore, right? Because that thing causes like seizures in kids. It won't be ideal to give kids seizures, right? So, you probably go ahead and avoid that on a test, right? So, we don't use lindane anymore, right? It's new. Sometimes they may just put seizures as the answer, like the toxicity of lindane, or they may put like a neurotoxic, right? So, just stuff to watch out for on exams, right? Now, what if they give you a question about a patient and they tell you that, oh, this patient, you know, has been having like this itchy lesion in the skin, right? And then they tell you that, oh, on exam, right? You notice like grouped like papules, right? They are very itchy, right? In fact, sometimes the dermatologist refer to this as breakfast, lunch, and dinner. Basically, you know, you have like, again, these like red, just red circles, they're in very close proximity to each other and each at home. If you see that, you want to think about bedbugs, right? You want to think about bedbugs. That's why it's called because they include configuration. That's why they are called like the breakfast, lunch, and dinner lesions, right?

And again, usually the person will have like this itchy, itchy in the morning, right? Because when do bedbugs have dinner, right? I mean bedbugs, right? They have bugs for the bed. They have dinner at night when you're sleeping, right? And really like, there's no real treatment. I mean, all you can do is you can do like topical steroids or you can give them an antihistamine, but really they need to kind of take you out of the bedbugs. And as you know, bedbugs are pinning the butt to get rid of. Now, what if they give you a question about a patient, right? And they tell you that, oh, this patient has a history of HIV. And then they tell you that, oh, on his skin, you know, they're these like brown, right? So this is actually a color you want to remember, right? They tell you that, oh, this thing looks brown and it looks like a tan, right? And it's like well demarcated. And they tell you that, oh, they're like poppules, or they're like plaques. And they tell you that they have a stock on. That's the buzzword. They have a stock on appearance. If you see this, right? You want to think about similar characteristics, it's pretty classic again. For the most part, you actually don't need to treat this. But if they are trying to get you to treat this on a test, right? You can do like an excision, you can just excise the lesion, or you can use like liquid nitrogen, right? You can use liquid nitrogen. That actually takes care of a seborrheika keratosis.

Now one thing I think I'd really like to mention is, if you notice that a person has like this just like all of a sudden, right? They just develop like this huge breakout on their skin, like just tons and tons and tons of these stock on lesions. You want to go ahead and screen those people for like a, some kind of gem, a lignancy, right? So you want to pick an answer that involves doing like a colonoscopy or an EGD, because many times right, people can have like a gastric or like a colonic or a small bowel, or a synoma, right? That's actually just like just this big breakout of a seborrheika keratosis. Now, what did they give you a question about a patient, right? You know, to tell you that, you know, she's like a 17 year old female, right? She's not sexually active. And then they tell you that, oh, she has like these, she has like these, oh, you know what, this one is something that most people I feel like I recognize on a test. They usually show you a picture, right? But if nursing has words, right? Like general words, right? Again, remember that those are the things that I know as condiloma acominata. Don't scrub condiloma acominata. Don't try to mess it up by confusing condiloma a lot. Condiloma a lot is something finding secondary syphilis. Condiloma acominata is something that is caused by again, like something finding like general words. And remember that the HPV is remember HPV one and six, those things cause plantar awards, right?

But HPV six and eleven are the ones that cause general words, right? Again, that's what's known as condiloma acominata, right? And then HPV 16, 18, those in the 30s, right? Those ones cause a cancer, right? So, for the most part, again, there will be like these flesh-colored, like papioles, nodules, and you see on a test. And for the most part, you can use many treatments on the exams for this, right? But what are the buzzwords you want to remember, right? You can actually use like many topical agents, right? So you can use this thing called salicellic acid. You can use topical salicellic acid. Remember, that's one of the things you can use to treat acne, right? Or you can do cryotherapy on your test, right? You can do cryotherapy on your test. And then one of the thing you may see on an exam, right, is something known as putofiling, right? Putofiling is probably the most commonly used thing on NBM exams to treat general words, right? It's spelled as PODO PHY-DOL-L-I-N, right? So putofiling, right? You can use putofiling for that. Now, one classic question, again, one of these bizarre questions you may see on these newer NB Ms, they may say, oh, which of the following represents the most likely outcome of a person having like general words? The answer is actually like just spontaneous resolution. Most times, people just recover from this, right?

Another classic scenario where they may throw in that kind of question is if a person has a tini-caratosis, which is actually the next topic I'm going to talk about actually, the most likely outcome of a tini-caratosis is actually just spontaneous resolution. So that's something you'd want to keep at the back of your mind on the exam. So how do these at tini-caratosis present, right? Again, you'll have like this sun-beeper appearance, right? And again, for the most part, it'll be a part of the skin that has like sonic exposure, right? It'll be a part of skin that has sonic exposure, right? So it'll be like the face, right? It can be like the back stuff like that, right? And again, it'll be red and you'll have like this sun-beeper like a texture, right? It'll almost be like the presence like this butter of spot, right? And remember that tini-caratosis, right? It's basically like a precursor to a person potentially having a scrimous cell cross-anoma of the skin. And how do we treat treat this condition? For the most part, you can use a topical agent, you can use like topical five-flerior cell or you can use this other drug that's known as in make-way mode, right? So I am I cue you I am O D in make-way mode, right? In make-way mode, right? So that's really how you treat that tini-caratosis. And I mean, as you can see, I'm probably beginning to dovetail into the world of like skin cancer. Remember, right? What is the biggest risk factor for any kind of skin cancer, right?

It's sonic exposure, right? It's sonic exposure. And remember, if you're comparing UV and UVB lights, the one that really increases your risk of skin cancer is UVB light, right? And remember, one of the things that can happen is a person can have like this time, medium, fine, medium, dimers form, right? Which can ultimately place the patient in trouble. Now, let me go ahead and tell you this. This is actually florida high you to know. On MDM exams, the primary preventive strategy so that a person doesn't get skin cancer, let's say the person is being exposed to the sun and all that stuff is actually to use like actual clothes that will protect you from the sun, right? It's used atro clothes that will protect you from the sun. You just avoid the sun altogether, right? So it's just one of those things that sounds simple, sounds obvious when I see it. But in the heat of an exam, people can mess this up, right? So they may try to trick you into saying that, oh, you know, you can go ahead and use sunscreen in the world. I'm not saying you should only use sunscreen, but that is not your primary preventive strategy. The only time you should ever pick sunscreen on your exam is if you don't see an answer choice that involves wearing clothes that protect from the sun. Again, I know you may be like, the way I'm going to big force about this, I promise you, I'm going to big force for a big reason. This is super high you to know for your exams, right?

So the primary prevention of skin cancer, if you're going to be exposed to sun, it's where clothes that literally protect you from the sun. The only time you should ever pick sunscreen on your test is if there is no answer that says to wear like sun protective clothing, right? Or like sun avoidance. Again, just things you want to keep at the back of your mind on exams, right? So sunscreens are things you use after you've applied, like you know, you've actually like dressed up for change. And remember if a kid is less than six months old, those kids cannot get sunscreen. Sunscreen is actually for the most part of NBM exams, contraindicated in kids that are less than six months old. So let's talk about these skin cancers, right? So what if they give you a question about like, you know, like some guy, you know, he was like, you know, fire, he was rescued from a fire, he's had like multiple burns, you know, that have, you know, healed little by little, he's gone through a lot of plastic surgeries over the years. And then they tell you that, oh, that, you know, on his, on his scalp, he has like this lesion, like this ulcer that doesn't seem to have like resolved or anything like that, right? And you know, over time, it has like been slowly evolving, has all these erosions, you know, they'll use all these dermatology buzzwords, right? Buzzwords.

If you see that, where you want to go ahead and think about a scum of cell cancer, although remember typically, scum of cell cancer shows up below the lower lip on MBM exams. But the friends at the MBM have kind of put up to that. So remember, you can technically get it pretty much anywhere, right? But for the most part, you can get it like on the scalp, you can get it on the ears, on MB Ms, right? You can get it on the neck, right? Those out, I mean, the ears technically are both the lips, you know, in most people, right? But again, you can get scum of cell cancer on those regions, right? And there's actually a relatively special type of scum of cell cancer that I occasionally miss you on tests. Many people get this wrong because, they just always, you know, almost forget this on exams. But basically, they tell you that all, like a person has like this, this, this module, right? That has, you know, just growing, growing, growing, growing on their skin, right? And they tell you that it looks like a volcano, right? Or you may say that it has a volcanic form appearance, right? Like you basically see like it's a module. And then in the center, it almost looks like there's a lot of keratin. Remember, scum of malignancies of anywhere in the body tend to contain a ton of keratin. In fact, if they tell you that they do biopsy of malignancy, and you see keratin perots, that's, that's pretty much a scum of cell cancer wherever, wherever it is in the body, right?

So if you ever see stuff like that, right? You want to think about this thing called a keratoceratoma, a keratoceratoma, right? It's basically a form of scum of cell cancer. But again, it's red. It grows very quickly. It's a nodule. And in the center, you see all this debris and it will be white. It's almost like, oh, the center is about to erupt, right? I will encourage you to look at a picture of this when you look it up. It's something that's very memorable, right? So again, scum of cell cancer is usually ulcerate on end-baving exams, right? And for the most part, you go ahead and excise the lesion, and the patient should hopefully be fine as long as it has not metastasized, right? And then if you contrast that presentation with, oh, they tell you that, oh, you see like this pink pearly translucent lesion with telangeptages, you know, like on a person's face, above the lips, if you see that, above the upper lip, if you see that, where you want to think about a bizzle cell cancer. So again, don't forget the buzzwords, pink pearly translucent, right? Lot of telangeptages, road borders, right? If you see stuff like that, you want to think about a bizzle cell carcinoma, right? And the thing is, bizzle cell carcinoma is usually pretty locally invasive, right? So it loves to spread radially, right? Like horizontally, it doesn't really invade into like deeper structures, which is good from a prognostic perspective.

The only problem is it can be very rapidly destructive in like certain phases of the disease. And again, you go ahead and reset. Now, there's one small snuffle here. If a person has bizzle cell cancer, right? And let's say it's like on the person's face, on the hands, on tests, you want to go ahead and do like the visa, most surgery. Sometimes MOHS, right? So it's like this fine surgery. Sometimes you don't want to mess with your head on the test. It's of clean most surgery, the of quality of micrographic surgery. If you see that, you want to, again, keep that at the back of your mind on exams. And let's, I guess maybe, yeah, let's maybe think of wrapping this up sooner rather than later. Let's, because I'm almost getting to 30, again, I don't want these things to be long, because I want people to actually really understand what's going on here, right? So let's assume that they give you a question about a person, you know, they show you like a, usually they love to show this as a picture, right? And you notice that, you know, it's a lesion on the skin, has like many different colors, like some parts of brown, some parts of black, right? And you notice that it's not like a lesion that is round or oval, right? It's kind of like you're regularly shaped. If you see this, right, in the right patient, what should you be thinking about here? I really hope that you're thinking about a melanoma, right? I will really hope you're thinking about a melanoma on your test, right?

And remember, there are certain criteria on MDM exams, right? That's you should hopefully have memorized for how melanoma presents, right? So for the most part, a melanoma, right? You know, it will be, there's this ABCD in the manicure, myaverin, in med school, right? Like, A for asymmetry, right? So, you know, it's, again, it's not fully round, it's not fully oval, right? And then you notice that this means tends to have like irregular borders, right? tend to have irregular borders. So what do I mean by that? What I mean by that is that essentially the lesion would have, the lesion would, like the borders would not be very well defined. The borders would not be very well defined. If you see that, you want to think about a melanoma, you want to think about a melanoma on your test, right? And again, the C stands for like colovaration, right? So like, you know, looks brown here, right here, black here, blue black, all that stuff, right? And then the D's for diameter, if it's more than six millimeters, right? If it's more than six millimeters, right? Again, you want to be worried about that. And then the E's for evolution, the patient will tell you that, oh, this thing has been changing over time. If you see that, right, you want to think about melanoma. And some things I guess I want to say melanoma, there's this phenomenon that's known as like a, like a dysplastic nervous, like dysplastic nearby.

They actually, they're not the most important risk factor for melanoma, but they are one of them, right? So if they give you a question about a person that has a history of dysplastic nearby, then they give you like many of their like things in their history. You want to think about dysplastic nearby as being like a risk factor for melanoma in those people. And the thing about dysplastic nearby, they actually look a lot like melanoma, right? It's like they are trending towards becoming melanoma. That's why they're called dysplastic. Remember dysplasia ultimately can lead to cancer, right? So like in fact, this is plastic nearby. They can be asymmetric. They can have the irregular borders. They can have the color variation, right? But again, the MDMA will not try to be evil to you like that on exams, right? So just stuff to keep at the back of your mind. If you notice that a lesion is evolving, like it's changing in characteristic, you want to go more with melanoma than dysplastic nearby. That's the key differentiating factor between those two disorders, right? And one thing that again, you may occasionally see like you see the expression people see don't test and they're like, I've never seen this in any resource. I've never heard of this. I've never seen this anywhere before. If you see this, so if they tell you that, oh, you have this person and they give you like all these family things like, oh, this family member had melanoma. This sort of family member had melanoma.

And then they tell you that, oh, this person has like a ton of dysplastic nearby on their skin or like tons of nearby, right? If you see this, you want to think about something called familial melanoma dysplastic nervous syndrome. I'll say that again. Familiar melanoma dysplastic nervous syndrome. Remember, it's actually a herethane and orosomodominant fashion. Let me just go ahead and teach you a test against strategy here real quick. If you ever see a question where there are multiple family members having a problem, it's a genetic disease, right? So don't be an answer choice that is non-genetic, right? You'll probably be getting that question wrong if you did that. So what are some key, I guess, quick hits with melanomas that you want to keep at the back of your mind on the exams? There are some kinds of melanomas that you kind of want to know about. So like, there's this one that's called a nodula melanoma, right? It's the one that has the worst prognosis of all, right? Like, basically, for persons dying from melanoma on your NV Me exam, it's likely because they have a nodula melanoma, right? And then there's this one you may find in African Americans, especially like under the nail bed, under like nails in the hands, right? Basically, if you see a person with dark skin that has a melanoma on your test, it's an acral lentiginus melanoma. It's an acral lentiginus melanoma, right? If you see a person with dark skin that has a melanoma, it's acral lentiginus.

This one's, you know, the prognosis not as bad as nodula, but it's not great either, right? Melanoma is actually not as good as people make it out to be like, oh, it's been nine. No, it's not been nine. It's actually pretty, pretty gnarly melanomas can spread to small balls, spread to the brain. Yeah, basically, they're not malignancies you're going to have. That's why again, if you live like on the West Coast, you know, just quite a scale, stay away from the sun, it's not prevent, right? Not saying you shouldn't go under beach, but take all these preventive measures, although I guess COVID-19 is kind of sped up that process for many people. They don't have to get get unnecessary sun exposure. Okay. Anyway, so and then if, for example, you know, they give you a question about a person that has like a melanoma and you notice that it's like on the face, on the upper trunk, right? You know, basically like areas of the body that are prominently exposed to the sun, right? You want to think about this one known as lentigoma ligna, right? You want to think about lentigol, L-E-N-T-I-G-O, maligna, M-A-L-I-G-N-E, right? So, there are just certain things they will give you in the question that will help you identify, oh, this is the exact kind of melanoma they're going after in this question, right? And then there's this one called the superficial spreading melanoma. This one has the best prognosis of all, right?

And typically we'll show up either on the back in men or we'll show up on the legs in women, right? That's the classic presentation on MDM exams. Back in men, legs in women, right? That's the way you think about a superficial spreading melanoma. It's superficial spreading, right? So it tends to not invade deep structures, right? So again, it tends to have a pretty good, pretty good prognosis, right? Tens of a pretty good, pretty good prognosis. Now, the way you treat melanoma for the most priorities, you need to completely excise the lesion, right? You need to completely excise the lesion. And one thing you want to remember, this is probably more useful for a present-teach and a surgery shelf. If the melanoma is more than a millimeter thick, right? You actually need to go ahead and do some kind of sentinel lymph node biopsia. Remember, the biggest predictor of prognosis in a person that has a melanoma is the breast load depth, right? So how deep, how thick is the lesion, right? Those are all things again. You want to keep at the back of your mind on exams, right? And then, you know, if they give you a question about a person that you know just recently sat on a couch or something, and then this person has like, these just has been itching, itching, itching, itching, itching, itching, right? And you see like all the like, basically like a wheel on the skin, right? They may ask you like, oh, what's the next best step in management, right?

Wheels, I mean, for the most part, you need to go ahead and just give this person like an anti-histamine, right? You know, give them those anti-histamine that are non-sedating, right? Like satirisine, or faxofenadine, stuff like that, right? And the person should get better. And one thing they may try to trick you with on exams is they will say, oh, they will try to install, they'll put like what they carry as an answer choice. And then, and that answer choice, they may throw an exam is, on an exam is like, seonistries inhibitor deficiency, like hair decangioidema. I'll just go ahead and tell you this key critical factor. People that have hair decangioidema, they do not have hypes. Hypes is not a component of hair decangioidema, right? So you just go ahead and run that into your mind right now for exams. Okay. Now, what if what is the most common medication, right? That people kind of like report that they have like an allergy to. I hope you're telling me that this is a penicillin, right? Again, remember penicillin? It just, it just has a lot of problems with that, right? Has a lot of problems with that. And I guess one thing I'll say with penicillin that you maybe want to keep on the back of your mind on exams is if they're trying to get you to test a person for like a penicillin allergy, go ahead and do like penicillin skin testing, do skin testing. They will try to trick you on the test into picking an answer that says like, arast test, right?

The arast test is it's called like radio, allegor, sobbing, something, something, whatever. Basically, it's a blood test. Don't do that. Don't do arast test or don't do an eliza test for like a drug allergy. That's usually not a prudent idea on exam. So an endemic exam, what you want to do is do skin testing. And the thing is if a person has had an anaphylactic reaction to penicillin, then any penicillin-based product is contraindicated in this in those people, right? So like the anti-staff lococo penicillins, the sephalosporins, right? Your carbapenemps, you probably want to go ahead and avoid it in those people. Well, let me know stretch it that far. I'll say your penicillins and your sephalosporins in general should be avoided in those people. And one classic thing that people tend to scroll up on exams and think, oh, this is an allergic reaction or this is a drug reaction. Yeah, let me know see drug reaction. A allergic reaction, is this thing called, if I let me make this a veneer. So what if they give you a question about a person, right? They think that, oh, this person has a histro, it's like a six year old boy, he has a histro of a Lyme disease, right? So he was obviously, you can give him doxia cycling, that would be a terrible idea, right? So although they can make this an adult, right? That is given doxia cycling. But for the most part, right? Like you'll be like a kid or an adult, gets a penicillin-based product, right?

Or gets treated for like syphilis, or gets treated for like Lyme disease. And then they tell you that, oh, this person, have been having like, fevers. And this is something that starts acutely, right? Presents, we have in like fevers, has like really bad headache, has all these myalges, has like a rush on the skin, is hypotensive. If you see this, you want to think about the gyroshexheimer reaction. So gyrosh, from now on, is taking is J-A-R-I-S-E-H. And then there is a hyphen, and then you have herxheimer. So I think that's H-E-R-X-H-E-I-M-E-R, right? So the gyroshexheimer reaction, this is not an allergic reaction. Basically, anything you're treating as spirochina in your test, right? You know, like, shape on your paladum, or Borrelia-Bok-No-Free, right? Basically, as you kill those spirochids, they will explode, they release all these, because remember, you're literally given a cell wall inhibitor, right? So those cells will explode, right? And they release all this endotoxin, right? They release all this endotoxin. And again, you start very quickly, like, you can start like within a few hours to like two, three hours after the pressing, start treatment, right? And again, for the most part, your resolve pretty quickly, right? It's not an allergic reaction. So for these people, all you need is supportive care, and you need to continue the antibiotic, right? Do not stop giving the antibiotic, because that's a classic pitfall that many met students have on exams.

You don't stop the antibiotic when a person has a gyroshexheimer reaction. And having a gyroshexheimer reaction is not a contraindication to future use of the antibiotic. Again, there is floridly high-youtu-no, for exams, especially step one and step two, CK. Now, what did they give you a question about a person that, you know, recently, it took like, trimethoprims, alpha-mythoxes, or for, you know, some UTI, like, cystitis, right? And then the tale of that over the last two days, the patient has been having like, really high feverers. His face looks swollen, right? So he has like, like, a dimadose face, right? And they tell you that he has like, just this general eye-skinny option. And then they give you some lamps, and you notice that, man, this person's ASTLT is elevated, the, your synophiles are elevated, they have a high white count, there's a ton of lymphocytes, right? And they have like, they have like lymphatic lymphatic, and not with the everywhere. If you see that, you want to think about dress syndrome, right? Sometimes on in-beaming exams, again, just like the way they call some of my body's laminated calcifications. If they want to mess with your head on a, on a test, instead of cleaning dress syndrome, right? They'll call it hypersensitivity syndrome. It's one on the same thing on an in-beaming exam. It's one on the same thing on an in-beaming exam.

So again, the way you treat dress syndrome on tests for the most part is, you know, you just give them like IV, cortical steroids, or you give them like IVIG. That's the way you treat dress syndrome on in-beaming. So this is more than 34 minutes. So I think I'm just going to go ahead and stop here. Again, as I do at the end of every podcast, right? I, you know, I tutor a lot for these USML exams. I hold these classes for step two CK. Again, I'm going to actually start classes very soon for step one and step three. So that's something I'm interested in, feel free to reach out to me. And then, please subscribe to the website, right? It's divine intervention podcasts with an S.com, right? Please, you know, subscribe, like our page. I have like a You Tube channel, divine intervention, USML podcasts and videos. And in these podcasts, also an Apple podcasts on Spotify and on Google Play. The podcast from number one, you have to get them on the website, right? But if you want like, you know, the most recent 150 podcasts is just like a Word Press role. It's nothing I can draw about that. You can pretty much find them on Apple podcasts. Just look for divine intervention podcasts. And thank you again, everyone for the support. It's been really helpful. And again, remember that there's a crowdsourced Google doc of people just transcribing my step two CK stuff. If you go on the website, you click on episode notes.

I just included a link there to the to the Google docs, a page where you can again go ahead and download notes if you want to do like a quick review. But again, I'll encourage you to listen to the podcast first to get the understanding, right? And then after that, you can read through the notes or you make your notes. Obviously, notes you make will stick a lot better than notes that you don't that you don't make. Okay. Now, I guess my life lesson for today, right, is to ask yourself this question. Is it worth it? So maybe like, um, divine, what do you mean by is it worth it? So is it worth it? What do I mean by that? Basically, what I mean by that is I feel like in life, and this is something that I think I'm maybe beginning to get like more and more perspective on as the days and as the years, you know, as I get older, basically, right? Is it worth it? What do I mean by that? What I mean by that is you see all the situations in life where people just keep running, running and running after something, they spend their lives like in the morning, they are all by 5 a.m. They do this thing till midnight, 5 a.m. till midnight, 5 a.m. till midnight, 5 a.m. till midnight, right? And even the times where they're like off from work when they're supposed to rest, it's not really rest, right? Like working, working, working, working, working, working. The thing is I have this friend who believes I'm not saying you shouldn't work hard.

I mean, like, I'm not saying this to be proud of anything, but you know, I work pretty hard for the most part. I mean, maybe I'm lesing some ears of my life and that's fine, but I feel like I do work pretty hard, right? So the thing though is you need to ask yourself when you're doing certain things that are great, right? They are certain blessings, they are certain rewards that are awesome, right? But the thing is you need to count the cost of certain rewards you're looking for. Again, I'm not saying you shouldn't work hard, again, you need to give this thing straight, right? I'm not saying you shouldn't work hard, but there are certain types of things that people engage themselves in that at the end of their lives, they say, you know what? This thing I burned so much of my life doing or because I want to make so much money, you see some people, they have like this huge, huge, huge quest for money, they want to make tons and tons of money. So like they will take everything that is thrown at them, just in the, they want to like make money, do this, do that. But then you notice, you know, they end up having like a bad quality of life, like, oh, they have like marital problems, their kids do not know them, this and that. Again, you need to ask yourself, is it worth it? You know, there's this verse of the Bible that I love, right? It says that the blessings of the Lord makes a person rich, right? But it doesn't add sort to it, right?

So that's the thing, like many times, you know, you ask yourself, is it worth it? There are certain things I feel like I've done in my life where I've like just sleep then sleep then sleep then sleep the way, right? And those things, my buddies started taking a big hit with those things, right? So those are things you want to consider when you're making certain life choices on examples. Again, it's sometimes it's good, I'm not saying again, it's not a crime to be rich, right? You want to desire to be rich, I'm not saying it should be poor. No, that's, that's not what I'm saying, right? But again, sometimes you just need to be content, right? Like, do your best, but again, just count the cost when you're doing certain things. If there is an activity that you're doing that just completely has taken over your life, like you don't have time for your family, you don't have time for your friends, you don't have time for self-care, brethren, I will encourage you, think long and hard, maybe go ahead and adjust how you participate in that activity or drop it entirely. So just something to keep in mind. So I think I'm going to go ahead and get off my softbox and stop here. So thank you for listening. I'll see you in the next podcast and remember there is one more part of this Derm podcast and then we'll be done with Derm and you have a comprehensive review for the USML exams. Thank you, God bless you.

Erythematous, painless papule/ulcer on upper extremities, especially if returning from endemic areas (e.g., Afghanistan, Peru).

Recombinant vaccine can be given starting at age 50; Live attenuated (Zostavax) is typically reserved for immunocompetent individuals over age 60.

Scabies, caused by Sarcoptes scabiei.

Grouped, itchy papules/papules resembling meals (breakfast, lunch, dinner), characteristic of bedbug bites.

The presence of evolution or change in characteristics over time strongly suggests melanoma.

Disseminated zoster (widespread rash) or mononeuropathy multiplex/primary cutis tarda.

Wearing protective clothing and avoiding sun exposure altogether.

Basal cell carcinoma (BCC).

Asymmetry, Border irregularity, Color variation, Diameter (>6mm), and Evolution.

Permethrin (topical); Ivermectin should be avoided in infants or pregnant women.

Topical 5-Fluorouracil or Imiquimod.

Penicillins and cephalosporins (and other related beta-lactams).

It is not an allergic reaction; supportive care is needed, and antibiotic treatment must continue.

Wearing protective clothing and avoiding sun exposure altogether.

Basal cell carcinoma (BCC).

Asymmetry, Border irregularity, Color variation, Diameter (>6mm), and Evolution.

Permethrin (topical); Ivermectin should be avoided in infants or pregnant women.

Topical 5-Fluorouracil or Imiquimod.

Penicillins and cephalosporins (and other related beta-lactams).

It is not an allergic reaction; supportive care is needed, and antibiotic treatment must continue.