DIP Episode 261 - USMLE Dermatology 3 (Part 3 of 3) + Reminder of 2CK Courses from 9/21-23

Okay, welcome. My name is Divine. This is episode 261 of the Divine Intervention Podcast. And in this podcast, I'll be finishing up a dermatology review for the USMLE exam. This will be helpful to represent the one step to the G-Step 3. And remember, there's three parts, a Dump part 1 of 3, a Dump part 2 of 3. This will be part 3 of 3. The thing is basically, I need my goal making this podcast is to make it as comprehensive as possible. Right? Make it as comprehensive as possible. Make it as comprehensive as possible. Right? Make it as comprehensive as possible. So basically, I feel like if you know these three podcasts, there will be very few dumb questions you cannot answer. Right? Because I feel like I've been pretty exhaustive covering most of the Dump pathologies and essentially describing them to you in the ways they will test them on exams. Right? And today what I'll be doing is I'll spend a lot of time talking about associations that I feel like will be really helpful because sometimes one thing your friends at the NBM love to do is they love to give you like dermatologic manifestations of other kinds of disease. Right? So we'll kind of hit those pretty hard today. Right? So that you feel comfortable. And again, just as a reminder, if you're taking your exam like your complex level 2 or your step 2 CK exam anytime soon, right? I do have three courses next two courses next to that I think will be helpful. Right? I call it like the trifecta in a sense. Right?

It's like September 21st, we have a we have a two and a half our test against strategies course specifically for the NBM is I'll bring like 20 questions that will work on right? Very carefully retain questions again. I have a ton of experience writing NBM style questions will use those review test against strategies in real time. Right? And then on Tuesday, the 22nd and Wednesday, the 23rd from noon to 5 p.m. Pacific time will be like content from Peds, surgery, OB guy, I am psych in Europe in an integrated format over 10 hours. Right? So if you're interested in any of those things, the test against strategies courses from 2 to 4 30 p.m. Pacific on Monday. And then the course, the course, the step 2 CK comprehensive course is on Tuesday and Wednesday. Right? So the September 22nd and 23rd from noon to 5 p.m. Pacific on both days. Okay. So let's jump right into things. Right? So I remember the last time we had this Derm podcast, right? You know, I kind of talked about how again penicillin allergies are pretty common. Right? In fact, if there's any drug allergy, right? I'd ask for your exams, right? Penicillin, if the asshole, which of the following agents is the most likely cause of blah blah blah blood allergy and give you a bunch of drugs that are patient is taking. Pick the penicillin, right? Pick the penicillin, pick the penicillin. Right? Now, the thing is again, if you want to check a present for a penicillin allergy, right?

Again, don't forget, you'll try to treat you into picking like an like an Eliza test or you'll try to pick you, trick into picking like a arast, like a radio allego, Xerbin, something like that. It's like a R A S T. Right? Don't pick any of those, right? To diagnose penicillin allergies, you know, go ahead and pick a skin test, right? Pick skin testing and you're being good shape, right? You're being good shape. And again, for the most part, if a person has like a reaction to penicillin, right? That doesn't mean that the cannoti get cephalosporine doesn't mean the cannoti like a carbapenet, right? But there's an exception to that role. If a notice a person has had an unaffilactic reaction to penicillin, then you cannot give any of that penicillin continuing agent, right? You cannot give anything like a carbapenem, right? So those drugs like any penem, marrow penem, other penem, duri penem, right? You cannot give any of those drugs and you also cannot give any of your cephalosporines, right? You should know what those are at this point, right? Like your cephalzolen, your cep triaxone, your cephepim, your ceph tazidim, your, your, um, ceph denier and things like that, you cannot give, you cannot give any of those drugs, right? So if a person has had an unaffilactic reaction to penicillin, again, please do not give them, this is actually also real, right?

For like, you know, like, in him, in exams and also for the real world, do not give those people us penicillin continuing agent anymore, right? Remember, astrionam, this is one of those unique ways they can test astrionam on an exam. Astrionam, right? It kind of works like a penicillin. It's a cell wall inhibitor, but it doesn't have that bitter lactant chain, right? It's a monobactam. So because it's a monobactam, you don't have any cross reactivity like you have with the other penicillins. Again, that's a high ulyt can bring step one stuff to step two seeking, right? Again, remember the imbimian recent times over the last few weeks to months, they've been bringing in a decent number of step one relief at things to step two seeking, right? So again, just something to keep at the back of your mind on imbimian exams, right? And then I also remember the last time we spoke, I'm just trying to kind of like maintain my bearings here. We also did talk about like the Jarash Hexheimer reaction, right? So they will give you a question about a person that's being treated for some spirochet based infection, right? So it can be leptospiaraosis, it can be Lyme disease caused by Borrelia Baudophrie, right? It can be syphilis, right? Trapponema Paladum, right? And they will tell you that, oh, this person studied this therapy and it's not something that, oh, they've been on this therapy for two weeks. No, no, no, no, no, no, no, the Jarash Hexheimer reactions and acute reaction, right?

It's an acute reaction. It'll be something that happens like couple hours, like four, two, three, four, five, six hours after a person just started a penicillin, right? And they notice that the person has like, you know, they have like joint pain, they have like a rash, they have like hypotensive. If you see that, think about the Jarash Hexheimer reaction. For the most part, just a body of care, given fluids, don't stop the antibiotics, they'll put an answer on your exam that involves stopping those antibiotics, don't do it, right? And one thing they love to do is ask about the mechanism behind the Jarash Hexheimer reaction is just basically as you're killing those spirochettes, they're releasing endotoxin into the bloodstream, right? And that endotoxin, right? It's basically causing these systemic symptoms, right? So again, kill that at the back of your mind as you go through these exam questions, right? And then what if they give you a question about a person that you know recently studied like a drug regimen for acne, right? And in detail, you that mean this person like, you know, he lives in California or whatever, like some state that has a ton of like beaches, not like a beach, B-E-A-C-H, just want to clarify that for people that having their minds are running wild. So essentially, if you notice, right, like they give you a question like that, right?

And you notice that, oh, you're like, man, it's a person studying an acne regimen, they may tell you that the person who studies that it an oral regimen for acne, right? And then this person went to the beach and then this person has been having like really bad extensive sunburns, even if the person has been using like, what is this thing that you should protect people from sunburns? I've never used it before. Sunblock? Like, sunscreen, yes, sunscreen, sunscreen. And again, remember sunscreen, if you're less than six months old, shouldn't be giving sunscreen to a kid, right? That's a, that's a terrible idea. Okay, but back to this, right? So if you say a person having that kind of stuff, right, you want to think about a tetracycline allergy, right? Like not an allergy, think of it more as like the tetracycline photosensitivity, right? Remember, there are some drugs, or an endemic exams that cause photosensitivity, right? So the classic pneumonia, you probably remember learning from back in the days, the term sat for photo, right? So like the S stands for sulfonamides, right? So like pyramidamine sulfodizing, trimethoprim sulfonamethoxysol, right? Sophosalazine, so they can make that a question about a person being treated for ulcerative colitis or Crohn's, right? And then the A stands for amyldurum, right? So they give you again a question about a person that recently studied some kind of antaridmic and then the person has been getting a lot of sunburns, right?

Think about a amyldurum photosensitivity, right? And then the T is for tetracycline, right? Classically again, a tetracycline will be a person taking the tetracycline, then you're getting all this sunburns, right? And again, what do we use tetracycline for? It can be a Lyne disease question, right? It can be a question about a person that has Rocky Mountains spotted fever. It can be a question about a person that is being treated for acne. Again, remember, you can use an oral tetracycline as one of the treatment regiments for acne, right? And then don't forget that sulfonamides, right? Especially like TMPSMX, Pyrametamine, sulfidiams, right? Again, they can cause that photosensitivity. But one key thing that I think is very critical here is people that have this sulfonamide skin problems, right? They tend to, they can actually get it just like skin rash days after they started the drug, but they can get it years after they've been on the drug, right? So don't be afraid if you see an amy questions where you see a person like, you know, it's been having like this rash, right? And they've been on like a sulfonamide for like a year, right? So they can get a question about a person that has like Neocistis-Drovetsi, right? Or a person that's on chronic therapy, you know, that is taking TMPSMX, right? As prophylaxis against Neocistis-Drovetsi, right? When you ever see stuff like that, right? Again, keep that at the back of your mind with these sulfonamides, right?

And then what if they give you a question about a person that, you know, comes in with like pylonophritis and the person is given like IV-C pro and in this person, you know, has like flushing in the body, right? Like really hypotensive, having all this muscle aches and pains. If you see that, I hope you're thinking about Redmond Syndrome, right? So the thing is your friends at the MBM is they're becoming very clever, right? So they know that every human being, again, that has the job description met students, probably remembers from step one, vaguely, that Redmond Syndrome is caused by Vencomaicin. Do not forget that actually Cipro-Flox is saying also has the ability to cause Redmond Syndrome on MBM exams. Again, that's a floridly high-ealth thing to know, for example, right? It's a veridly high-ealth thing to know for exams, right? And then what if they give you a question on a test and it's about like a patient and they tell you that, oh, this patient recently started like some kind of antibiotic or something, right? And then they tell you that, you know, a few days later, the patients that they notice in like these like round oval like discrete lesions, like on the torso, on the bodhocks, on the back and stuff like that, right? And they're trying to get you to pick and answer us to like what in the world is this? If you see that, I want you to think about some kind of right? Because these things usually on MBM exams, like a fixed drug your option, right?

Like a fixed drug your option, right? And then what if they give you a question about like a college student, she's 21 years old, right? You know, they tell you that, you know, she had like Pharyngeitis, like, you know, she had like throat pain, sore throat, like three days ago. And then she went to the student clinic, she was given a prescription for like, for like, um, um, pistling, right? Because remember, yes, um, pistling is classically ivy, but there's actually oral formulations of, of an pistling, right? And then they tell you that, oh, she develops like this diffuse rational over her skin, right? After taking the ampistamine for two days, if you see that, right? I would encourage you to think about mono, right? So this person has mono from EBV. Remember EBV, if you get like a penicillin-based product, it can actually cause a big, big, big rash in a person that has mono, okay? Because that pharyngeitis was basically misdiagnosis, like some like regular angitis, when it was actually an EBV infection, the suspicion had. Okay, now what if they give you a question about a patient, right? And they tell you that, oh, this patient, you know, for the past two days, right? Has, you know, maybe recently, uh, started on like some anti-biotic, right? Or maybe not an anti-biotic, the first thing you should do, just tell you that, oh, this person has been having like this painful, uh, like, like erosions, like on the, on the oral mucosa, right?

You see like this purulent bully and vesicles on the skin, right? And they tell you that, oh, when you sweep, when you apply like sliding pressure, right? Like when you slide your hand over the patient's skin, uh, that you notice like a lot of purulence, right? Like purulent discharge and stuff. If you see that, right? Again, think about PENFIGOS-VOLGARIS, right? Think about PENFIGOS-VOLGARIS. And remember, it has the positive Nikolsky something, right? And the thing is, uh, PENFIGOS-VOLGARIS, right? So what is the classic distribution of the virus that affects on exams, right? Tense of effect like the trunk, right? The person's like extremities, right? Especially like they are more proximal extremities like their arms, right? Or their thighs? And it also definitely affects the oral mucosa, one in being exams, right? Again, don't forget that for PENFIGOS-VOLGARIS, right? These people will have a positive Nikolsky sign, right? And to make the diagnosis, again, they love to ask about the diagnostic test on exams. You want to do direct immunofluorescence, right? You want to pick the azure access to do direct fluorescence. And you'll notice that there is IGG deposited between the cells, right? So you see, like they may tell you the Nikolsky equation and see which of the four things is the most likely finding on direct immunofluorescence, right? So you buried in the question, I'm sure you've had this experience many times before.

You're reading a question, you know, like, oh, I know what this is, and then they tell you what it is and the question is like, oh, oh, oh, right? And then, as you keep reading, right? They now ask you something completely bizarre. That's like one classic go-to move for the newer NBM exams, right? So, you know, they'll tell you which of the four things are most likely finding on direct immunofluorescence, right? You want to think about intercellular deposition of IGG, right? So if you see that, I want you to think about a Pemphigosa vulgaris, right? Come trust this with a Boulos Pemphigo, right? Boulos Pemphigo, remember, these people have like tens blisters, right? Tens blisters. So the reason they're tens is because the Nikolsky sign is negative, right? And again, the diagnosis is maybe exact same way, right? The exact same way, right? You perform direct immunofluorescence, right? And you'll find like this linear IGG pattern, but it will not be between the cells, it will be in the basement membrane, right? So you find the linear pattern, right? So again, remember, linear deposition of IGG in the basement membrane, you can find it in two disorders on your test. You can find it in Boulos Pemphigo, right? But it will be in the skin, obviously, right? And you can find it in good posture syndrome, but obviously that being the kidneys on the lungs, right? In the kidneys on the lungs, there'll be an ephretic syndrome presentation, right?

Remember, that's a type 2 hypersensitivity reaction. And really, pemphygoczo-algaris, because again, they love to occasionally bring in immunology on these neuro-nbim exams. Pemphygoczo-algaris and Boulos Pemphigo, I will consider those to be type 2 hypersensitivity reactions on your test, okay? Type 2 hypersensitivity reactions on your test. Okay, so again, just key critical things you want to keep at the back of your mind as you, as you take a, as you take these exams, right? And really, for the most part, we treat pemphygoczo-Boulos Pemphigo, right? It's pretty easy, right? Quit and give those people oral steroids or oral steroids at a treatment of choice. But if you notice that the person is not getting better, right? Or the oral glucocorticoids are not caught in it, then your next step in management for these people is plasma freces, right? Plasma freces is the second line treatment, right? It's the second line treatment for Boulos Pemphigo or Pemphygosa-algaris, right? And one thing they can also see, they can give you these questions on exam 3, they will see like, oh, you know, they tell your person that has like Boulos Pemphigo or Pemphygosa-algaris. And then they'll see in addition, again, one of these evil ways, let's not call it evil, but one of these unique ways they can test, again, like weird stuff with these diseases, they can say, oh, in addition to steroid therapy, right? So they already tell you we're going to give steroids, right?

That's a settled thing, right? So you're like, oh, man, I thought this was going to be asking me to pick steroids. And I know, right? So then they say, oh, in addition to steroid therapy, which of the following medications can be added to reduce morbidity or histone symptom resolution or whatever. If it's this stuff like that, don't forget DAPSON, right? Don't forget DAPSON. And I may be making a mistake here. So, quick question here, right? So, um, um, sorry, not DAPSON. Plasma for aces, right? So again, if you want to histone symptom resolution, right? So, that's the thing that has like, bluspen figureoid or pimp figure's vulgaris, or again, so that's when we can test that, or we can test it in the context of, oh, this person has been given steroids and the person having like a slow response to therapy or no response, right? In those circumstances, consider putting that person on, consider placing that person on, on plasma for aces, right? On plasma for aces, remember, plasma for aces is also what we use to treat like a bunch of neurological issues, right? Like, um, like a Guillembury syndrome, for example, right? And then remember, if they give you a question about a person that, you know, has like iron deficiency anemia, right? And they also tell you that this person has like, um, these like very itchy, right? Very prickly, like vesicles, like on their elbows, right? Their knees, their back, their bodice, right? Like, basically a lot of extensor surfaces, right?

If you see that, right? And the person has like a low weight or something like that. Think about celiac disease, right? This person has been retarded for this, right? This person has dematitis, uh, repartiformis. And the thing is, you're matitis repartiformis, right? Like, if they're asking you for the first step in management, right? Your first step in management is actually to exclude gluten from the diet. Usually, that's, that's great. And that's usually good enough to fix the problem, right? But if you don't see that as an answer to it, the second line treatment is dapsone, right? Dapsone is the drug of choice for treating, uh, dematitis repartiformis on, on MME, me exams, right? And then, what did they give you a question about a patient? And they tell you that this patient is an IV drug user, right? And then they tell you that, oh, that this IV drug user on the back of his hands, this IV drug user has like these, like, again, like these vesicles, boule, right? And they tell you that, oh, that, you know, that he noticed more vesicles and more boule after he hit his hand on a table or something, like, you know, something super minor that shouldn't cause like that kind of profound skin reaction, again, especially on the back of the hands, right? If you see stuff like that, I'll really, really, really, really hope that you're thinking about prefer cutaneous tarda, right? I'll really hope you're thinking about prefer cutaneous tarda.

And again, one way the MME can go after this is, you can see, which of the following is the biggest risk factor, right? For prefer cutaneous tarda, you want to pick hep C, right? About 50% of people that have, uh, PCT, right, which is prefer cutaneous tarda, right? They tend to have hep C infection. In fact, they can ask, oh, in addition to treatment, what is the next best step in management? Go ahead and test that person for hep C, right? So go ahead and do like a HCV PCR or something like that, right? Or look for the HCV antibodies in the patients are serrated, right? And again, remember those people because it's a hym synthesis, the sort of reticuring from those folks, right? And put it on the woods lamp, right? They're hearing what kind of give off, like, this dark orange color, right? Or give us this dark orange color, right? And again, if you do direct immunofluorescence on these folks, right? Again, you may see, like, all these immunoglobulins, right? All this IgG, it's kind of deposited around like, like the capillaries that line the dermis, right? And also around the basement membrane, right? So again, look at the context, right? Again, there are many different ways they can go with derm because they know that most people just kind of give up on derm, so they don't even bother studying it, right? The thing is, dermis is just one of those things where if you know, you can potentially get, like, 10 questions right, right?

And again, that can be the difference between getting into the two 30s and getting the two 40s on your exam, right? So this one of those things that will encourage you to not ignore, essentially, on exams, right? Now, this dermatitis-separated form is that I talked about earlier, right? So what if they tell you that, oh, the person has dermatitis-separated form, and you know, you studied on dapsalm therapy, and then the person starts having, like, hematuria, has an indirect type of urbinemia. If you see that, I hope you're, and it'll be a guy, it's not going to be a woman, it's going to be a guy. If you see this, what should you be thinking about? I really, really, really hope that you're thinking about g6pd deficiency, right? Again, the NBM, they are all about integration, integration, integration, right? Integration, integration, integration, integration. That's the thing, like, I feel like as we go along later in the year, like, early next year, right? You'll start seeing a somewhat different focus with some of the courses I'll be offering, right? The course is, I currently offer, like, retuckle, like, the context of the NBM is, it's very, like, the test against strategy's course. But really, the NBM, they are getting very creative in the way they're writing questions, right? So again, try to not just learn something, like, one-dimensional, try to learn things in a multi-dimensional fashion. I feel like that's a very helpful thing to do.

In this day and age on NBM exams, and it's also a good way to think about patients as you're treating them. Okay, right? So remember, g6pd deficiency, because again, DAPSON, right? DAPSON is a very powerful agent, right? It's a powerful, oxidizing agent, right? So, if a person has g6pd deficiency, they can deal with oxidative stress, they're gonna get in trouble, right? And again, DAPSON is not only used just for g6pd deficiency, I mean, for, for, for dermatitis, they're pretty famous on NBM, you remember? You can also use it to treat, um, leprosy, right, on a test, right? So they can make this a leprosy question in a person that's having these exact same, like, again, hematuria, indrytipabular bimemia, and all that stuff, right? And again, remember, to treat leprosy, you give the person a triple regimen, right? And I almost think of this as like triple therapy. It's a combination of DAPSON, right? FAMPING, and CLOFAZING, right? DAPSON, right? FAMPING, and CLOFAZING, for, for, um, leprosy. And then another thing you can use DAPSON for, on NBM exams, is also as PCP-prophylaxis, right? Um, well, that's a much rare, uh, presentation on an exam for, usually, you do TMPSMX for PCP-prophylaxis on an exam for, and then, what do they give you a question about a patient? And they tell you that, oh, this patient, um, she has been, she has like these, uh, vesicles on her, on her, on her lip, or you may see vesicles like on her genitals, right?

And then they tell you that, um, this person has had these things like many times, or you also notice that, oh, this person also has like these like, both eye lesions, multiple, notice that I'm not saying one, multiple, both eye lesions, right? Multiple, both eye lesions, like on the skin, right? If you see that, I would really, really hope you're thinking about area theme, I'm multi-forming, right? I would really hope you're thinking about area theme, I'm multi-forming. And one thing you're, again, your friends at the NV Me love to do, they can ask, again, they'll give you all these risk factors that the patient has, and then they'll see which of the fully is the biggest risk factor in this patient for area theme, I'm multi-forming. The biggest risk factor for EM on exams is actually having like a lot of HSV infections, especially when you have it on a recurring basis, right? So whenever you're present having a recurring HSV infections, that's actually the biggest risk factor for area theme, I'm multi-forming. Although this can also be caused by drugs, right? Again, the classic cooperates, right? So phonomites, pinesilins, pinesitoins, right? Those things love to cause a lot of problems, right? So how do you treat area theme, I'm multi-forming? Easy, right? Stop the drug, right? If you see that answer, just answer, just answer, just answer, stop the drug, go ahead and stop the drug, right? Go ahead and stop the drug, right?

And then, you know, just support if you care fluids, make sure you're fixing the electrolyte problems, that's pretty much it, right? But if they give you this specific scenario of a person that has a theme, I'm multi-forming, and this person is getting like recurring HSV infections, recurring infection, recurring infection, right? Then, and you see, which of the four is the best long-term management for this person's disorder, right? On exams, you want to pick like, like the person taking like, suppressive acyclovere, right? So they're taking acyclovere like on a regular basis, just like, oh, you know, like if a person has like herpes, right? And they're like, well, I want suppressive therapy, they can take acyclovere like all the time, right? Kind of like the same thing, for a person who is having like recurring, recurring, or theme, or multi-forming, I usually will be like, kind of mild, right? For these people, again, for long-term, notice what I said, for long-term management, right? Wait a minute, put these people on like, suppressive acyclovere. But again, for a person who has a theme on a multi-forming, let's say it's like, it's like acute presentation, whatever. Acyclovere, it's not going to be the right answer again. That's why I said long-term management. The acute management of your theme on multi-forming is to stop the drug that's causing problems. If they are not on any drug that's causing the problem, just support if care, right?

But long-term management, in the present, that, you're like, man, the person keeps getting HIV, HIV, HIV, right? Why don't put them on a daily like acyclovere, okay? So hopefully that's something you feel confident with, right? And then in this, I guess, circle of dermatology, for talking about a theme on multi-forming, it probably makes sense for us to talk about like, SGS and T, right? Stephen Johnson saying, from toxic epidemiocrylysics, again, these are just people who skin slough off, right? They can show you like a person's hand, and you see like, he's almost like, their skin of their hand is like a covering, right over that, right? So the thing is, essentially, the way these conditions present is, you'll just see a person, like, flu-like symptoms, they'll have like, my allergies, fevers, basically feeling like crap, right? And then, after that, you'll now start having like, big-time skinnier option, right? And again, the percentage of the skin that's affected tells you exactly what you're dealing with. If it's less than 10% of the skin that's affected, that's Stephen's Johnson saying, right? But if it's more than 30% of the skin that's affected, right? That's toxic epidemiocrylysics, right? And it's easy to remember, right? Toxic. If something's toxic, right? It means it's super bad, right? It's super bad, right? So think about that, right?

And then if you're between 10% to 30% because I know some of you may be like, okay, divine, what's this black hole that exists between 10% to 30%, that's just a combination name. It's called like, S-G-S-T-N, right? S-G-S-T-N, right? So again, some of you keep at the back of your mind on exams. And these people, again, so they'll have the flu-like symptoms, and then again, a few days to weeks afterwards, right? You have like this bigger option on their skin, right? And then you'll notice that you'll have like a ton of skin pain, and these people, it's very high you to know. You have a lot of vesicles, bullies, right? And then you'll also have a positive Nikoski sign. The Nikoski sign is absolutely positive in S-G-S-T-N on exams, right? In S-G-S-T-N on exams. And again, your next step on exams is to go ahead and stop the drug. That's always the first thing you do. Stop the drug. Stop the drug that's causing all these problems, right? But then, if the person has a particularly severe presentation, especially T-N, this is something that's usually done with people that have toxic hypodemonic realizes, you need to actually get those people to like a burn unit, right? Like a hospital that has like a special burn unit, we can get them to a nice CU. These are not patients who take care of them from the floor, right? Again, just something to keep in mind on exams. And then, so let's kind of boss through some associations here.

So what if they give you a question about a patient and tell you that, oh, this patient has a, you know, history of like, you know, is an African-American female. She has like these painful lesions on her low extremities, the around, the attendor and all that stuff, right? And you see that I hope you're thinking about them. A Thiemannodosum, right? That's pretty easy. Remember, Thiemannodosum is associated with sarcoidosis on exams. Is associated with a coxidiumicosis on exams. And it's also associated with like inflammatory bowel disease, right? So like ulcerative cries or Crohn's disease, right? And then what if they give you a question about again, this same African-American female, right? And you tell you that, you know, she has like these like purple colored lesions, right? You know, around her nose, around her eyes, like in a male or style distribution, right? Like around the cheeks. If you see that, right? You notice this thing is sort of kind of like a lupus like presentation. And you're like, man, this person has got sarcoid, which is having like this purple rash, right? Around the eyes, around the nose, around the cheeks. If you see that, right? Think about something called lupus perneal, right? Lupus perneal, it's a finding that it's a classic dermatology finding usually in the face, in a person that has a history of sarcoidosis, right? Now, what if they give you a question about a patient, right?

And they tell you that, oh, this patient, you know, is like a twin-three-year old male, has a history of like chronic bloody diarrhea, right? And then it gets for like three to five months, right? He has lost like a ton of weight in that period. And then they tell you that he has like this painful ulcer, that's very exudative, right? You've seen like a lot of like discharge from the ulcer, right? And he has like raised edges, a big ulcer, right? And you notice that it's on, it's on his like lurex remedies. If you see that, I really, really hope that you're thinking about pyrodermal gangrenosa, right? Pyrodermal gangrenosa. Remember, that's something that again, you're classically finding people that have inflammatory bowel disease. And then, what if they give you a question about a patient, they tell you that, oh, this patient is currently being treated, this patient has like a history of like nstitriental disease, right? And the person is being treated, you know, for like a spinal epidural lapses that was diagnosed by MRI like two days ago, right? And then they ask you like, they tell you that over the last like 12 hours, this patient has been having like this, like in the duration of the skin, the skin is very thick, right? And they tell you that this person's skin is very tight, right? If you see stuff like this, right? Then you want to think about nephrogenic systemic fibrocytes, right? NSF, right? Remember, that's caused by gadolinium, right?

So this person got like spinal imaging, if you're getting spinal imaging, usually, right? You're going to get some kind of gut, right? You're going to get gadolinium, right? And then you're going to get in trouble, right? And then again, if they ask, which of the following factors in this patient's medical history is the most likely predisposing condition, right? Or most likely predisposing factor to this patient's presentation. I want you to think about having an history of nstitial disease, right? Having an history of nstitial disease is one of the biggest risk factors for getting NSF, right? And again, these people will get it in the context, right? They'll get it in the context of getting gadolinium, right? For like MRI imaging. And there's really not much you can do for that. Unfortunately. Okay. Now what if they give you a question about again? Let's maybe talk about these kidney people, right? Where did they give you a question about a person? You know, has a history of like nstitial disease. And then the tell you that this person has like these really painful like nodules, like under the skin, right? Really painful nodules under the skin and the tell you that, oh, they kind of look like red or the material that they look brown. If you see that, you know, you should be thinking about really, really hope you think about calcium relaxes, right? Or really, really hope you think about calcium relaxes.

Remember, people that have nstitial disease, they tend to have like a crap, a crap ton of phosphate, right? So because they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of blood, they have a lot of phosphate, they're not able to maintain like an appropriate solubility product. If you remember from like college general chemistry, like you probably remember learning about ksp, right? But don't worry, we're not doing college chemistry here today, right? So the essentially we'll have like, they have like an inappropriate solubility product for for calcium and phosphate, right? So whenever they have that, right? That will begin to precipitate in their skin, right? And then because it's calcium, right? Again, it can change color pretty easily, right? So you'll be like a red or brown coloration, like painful nodules, like a little skin, institutional disease patient, I want you to think about calcium relaxes on an in-bim exam, right? And then again, if they give you a question about a person, again, IV drug user, and in detail that over the last three days, this person has had like this big, big, big, big, like just break out, right? Of like, what is like, you know, like these oil regions on the skin, on the head, everywhere, like basically like separate dermatitis that just breaks out, like suddenly, right?

Like this big, big, big, big break out of a, of a separate dermatitis on the skin in an IV drug user, right? This IV drug user needs to be, and the answer for your next step in management on the test, go ahead and that, uh, screen that person for HIV, right? The person very likely has a HIV, right? Person very likely has a HIV. And then, again, another skin finding already, if they give you a question about a patient and they tell you that, oh, this patient, you know, recently have like some kind of cardiac catheterization, right? Or this patient has like, uh, like, uh, recently diagnosed vasculitis, and in detail, that, oh, this person has like these like, net-like lesions on the extremities, um, think about leviedoreticularis, right? Again, they love leviedoreticularis on these exams. If you see leviedoreticularis, think about like, again, like this aortic catheter and molecular disease that people get after getting like a recent cardiac cath, right? Or think about it in a person that has like some kind of vasculitis, okay? Think about it in a person that has some kind of vasculitis, right? And then if they give you a question about a person, you know, they tell you this person has like these velvety lesions, right? Like on, you know, like, flexure surfaces, right? Like this, like, the neck, under the breast stuff like that, right? I want to think about insulin resistance, right?

Pressing me have like diabetes, but don't forget, this stuff is also a sure little like a person having like some kind of GI malignancy can be like a gastric cancer, something like that, right? So that's a canful cesamaic cancer. If you see the no big-one question, that's a woman that has PCOS pretty much, right? So, you can don't get that stuff wrong, right? And then, you know, don't forget how, you know, if a person has these genetic syndromes, like these are familial hyperlipidemia, right? Those people tend to have like, zanthomas, like on the, uh, nice, um, especially like the eyelid, they can have it like around their ankles, right? Like their so's of their feet, stuff like that, if you see that, right? Think about like, zanthomas, right? Zanthomas and thelasmas, those tend to be associated with these are familial, uh, dyslipidemias, right? And then if they give you a question about a patient, and they tell you that this patient, right? Have you having like a lot of like proximal muscle pain and also proximal muscle weakness, right? And then you notice the, give you like a picture of the person's hands and you're like, man, this person's hands look like concrete, right? It's like very like fissured, right? Feels looks very thick. Just terrible, terrible, terrible hands, right? Like kind of looks like a person that has been walking, you know, like mechanics, right? How their hands look literally, right?

Like if they work on questions for a long time, like for many years, you see, their hands just look just very nasty. You see stuff like that, right? Think about mechanics hands, right? Remember, that's a classic finding in people that have these are myopathies, right? Like these, what do I mean? My apathy is like polymyocytes, or dermatomyocytes, right? So again, just I'm going to keep at the back of your mind. On exactly the same sense, right? And then don't forget, right? If you see again, I'm just at this point, just kind of steam rolling through some of these classic like systemic disorders, right? They have like dermatological manifestations, right? So if, for example, you see a question about a person, right? And they tell you, you know, this person has like, you know, he mow glow in of like seven and this person's creatinia has been rising progressively over the last like one year, right? And this person has been getting like, it's had like three pieces of like pneumococon ammonia, right? And then you notice that this person has like a large tongue. Right? And they tell you that this person has salo. This is like a term the endgame is love disease, salo, right? So it's a person's skin that looks like candle wax, right? Salo is spelled S A double L O W, right? Salo skin, right? Salo skin, salo skin, right? If you see that, right? I want you to think about like multiple myeloma, right? Because remember, multiple myeloma can present as aminoidosis on a test, right?

And people that have an alloy, you tend to get like big tongues, they can get like a restrictive cardiomyopathy, right? They can get ameloid kidney disease and stuff like that, right? So give that a buck of your mind on exams, right? And then if a person has like again, like like cross dead lesions around the nipple, right? Kind of looks like Xima, right? If you see Xima breast right again, I really hope you're thinking about like Pages Disease of the nipple. Remember those people need like my mom, my mom will grandma and a corn you do buy up C, right? Because many times people that have Pages Disease of the breast, they tend to have like on the line in feel treating a doctor or carcinoma, right? And then what if they give you a question about a person, right? And again, the tell you that this person has like a lot of Xima, right? And it's maybe like a middle-aged person has a lot of Xima, like under the feet, right? On the elbows, right? Or like the underside of the knees, right? And the tell you that this person has been like losing weight and has like neon said diabetes. If you see that, I would really, really hope you're thinking about a glauca glaucoma, right? Remember again, they're not going to say a patient presents with diabetes and necrolitic migratory erythema. Now, then I'm going to do that on the test, right? That's not pretty. You shouldn't be going to exam expecting those kinds of things, right? So if you see stuff like that, think about a glauca glaucoma.

If you see a person that has like neon said diabetes and Xima, especially like on the flexural surfaces, right? I want you to think about a glauca glaucoma on an endemic sense, right? And what if they give you a question about a patient, you know, the tell us, especially as a history of HIV, right? And you know, this person went swimming recently and this person, you know, you know, had like this painless lesion, that, you know, for the most part, you know, kind of started like on his like arms or trunk or whatever. But it has quickly become like very necrotic, right? And it has become painless, right? So like is you know, painless like necrotic and all that stuff, the person that just recently, like, you know, when swimming in the beach or community pool or whatever, right? And this person has like HIV and let's see the person has like a CD4 count of like 100, you know, telling you that this person is immune system is not very great. If you see that, I want you to think about Xima gangrenosa, right? I really want you to think about Xima gangrenosa, right? I want you to think about it. Thema gangrenosa. And one of these weird unique things that we do to your name, being an exam, right? Is, let me give you a question about a person, right? And they'll tell you again, this person has like, again, like this chronic history of bloody diarrhea, right? That, you know, the person has never seen a physician for, right?

And again, the person has like this necrotic lesion on the lower extremities, that's very exudative, right? Heard's a lot, right? Has like these raised edges, right? Again, think about pyrodeamer gangrenosa, right? And he may ask, what's your next best step in money for this patient, right? Go ahead and pick an answer, it says to the colonoscopy, right? Because again, you want to diagnose the inflammatory bowel disease that you have. Usually in this case, it's going to be Crohn's disease or arthritis. I'll say usually it's arthritis that tends to have that association, in the exact same way. So again, hopefully you found this drum podcast to be helpful. Again, my please subscribe to the You Tube channel. Again, I promise I'll start making more videos actually in the very near future. Which has been super, super busy, right? So subscribe to the You Tube channel is called Divine Intervention, you know, you have similar podcast and videos. That's where I have all the videos that I have like for all the shelf exams, although you will also find links to them on the website along with the slides, the slides are on the actual website. And again, I remember I have a Word Press website, you know, Divine Intervention Podcast.com. And then these podcasts on Apple podcasts, on Spotify and on Google Play. So please subscribe. That's always helpful and very much appreciated. And you know, leave any comments or feedback stuff like that, right? And then my life lesson for today, right?

So what's my life lesson for today? My life lesson for today is about the importance of being humble, right? So what do I mean by that, right? Again, I'm not using this to crap on another team, like an MBA team. But I feel like until you've got in the victory on something, even after you've got in the victory, still remain humble, right? Because the thing is it's better, right? To not have bragged, right? Or trash talked to other people, right? And you lose, right? And to have bragged, trash talked to other people, and then you lose and lose in big fashion, right? So I'll give you the classic example of the clippers, right? So if you're a basketball person, right? Like if you watch the MBA, right? You probably remember like the Los Angeles clippers, right? So you know, these people at the very beginning of the season, right? They were like, they're going to win the championship, you know, they got Kawai Leonard, saw the farm to get poor George, right? And these were people that they were like, yeah, we're going to win the season. I mean, like it was like clairs day, like every sports analyst known to man said, these people are going to win, right? And then you know, these people, they barely sneak through the first round of the playoffs, right? And then now they go to the second round, right? And you know, at the end of, you know, they were all three won, you know, the one out of the first four games, one of the first three, right? And then game five, they lost, right?

And then, you know, one of the stars on the team, you know, kept saying, oh, we should have put them away when the driver's seat were doing this, we're doing that, right? Like that's not the right thing to do. Like really, I'm telling you this, like you can basically remove a lot of shame from your life if you're humble, right? This team proceeded to lose game five, game six, game seven, and they got knocked out in the second round. Can you imagine that, right? So like don't brag, right? There are other players on the team that said, oh, the next five years are ours, right? But this, these people have not won a lick of a championship. They've not even gone into the NBA finals. I think the entire franchise history, like 50 years, something like some ridiculous number. So again, don't be proud, don't boast, right? It's better, even if you're succeeding, keep mom about it, keep quiet about it, because whether you like it or not, I'll tell you this right now. It's not everybody that is happy that you are succeeding. And those same people that are propping you up when they're when you're succeeding, they'll be the exact same people that will pull you down. Because you know the same media, it's the same, that's why I'm very distrustful of praise from people, right? Or I'm not, you know, some people praise you genuinely, they're like, man, you're doing good, good work. Thank you, blah, blah, blah.

But the thing is, those same people that are propping you up with the amounts, they are the same people that will push you into the ground with the amount as well. The same media that was propping on these people all besting in the West, this, this, this. They were the same people that absolutely just crucified these people. I mean, gone reddit, gone You Tube, gone Twitter, right, new cycles, right? These people were absolutely eviscerated, right? The clippers, right? Like it's so much shame. But I feel like if they were not being so proud, if you're kind of like kept, it's better to almost like in your speech, under promise, what over the liver, right? So like, let's say for example, in the especially, they were like, oh, you know, we absolutely respect this Denver team. You know, they are doing a very good job. I mean, like, you know, we're also figuring out this figuring out this whole basketball thing. You know, this is our first season together as a team or whatever, right? And if they didn't put themselves on such a big pedestal from the beginning, right? When they lost, then it's like they'll have a fall because people still trash them on a kind of that, right? Because they knew you have stars, right? But the fall would have been softer, right? Basically think about it. If a pressing fails and they are known to like millions and millions of people all over the world, then that fail is a big fail. Because it will go on new cycles, it will go on everything, right?

But let's say some team, right, in some small states, in some small area loses a playoff, like let's say it's a real playoff or something. No, we'll even hear about it. No one will even care, right? Because again, that team was not placed on a pedestal where that fall was colossal, right? So again, always try to keep a low profile. I'm telling you this. Always try to keep a low profile. Quite a lot of it keeps a low profile, but I feel like many other members of the elite clippers, they just a low profile was not a concept that they were familiar with, right? Because the thing is, it's better to keep a low profile. Don't come in as the person like, oh, like even if you're gifted in something, don't come in showing people that, oh, I'm the man in town, right? This is my city. This is my town. Oh, this is my area. I will dominate and destroy you here. No, don't make mouth because you never know. Someone that you don't know about can just calm and just absolutely like obliterate you, right? So like as a med student, how will this apply to you? Like, let's say for example, you've done like a surgery rotation, right? Or let's say you have like some kind of life experience that makes you just particularly good at something. Let's say you're very good at surgery or let's say you've been like a nurse before you're now in med school or whatever, right? You don't have to lord it over your classmates that all like, oh, I can surgery this. I can do this. I can do this. I can do that.

I can do this. I can do that.

No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no Yeah, you know, kind of powerful the course, we know this person has been a nurse before, and this person has done great work before right so the obviously I would have this thing right so again basically on either end of the spectrum whether like in a rise or in a fall your rise is always higher when you're humble and your fall is always softer when you're humble right so if you look at it again from both directions that's a very logical argument there right your rise is higher when you're humble and your fall is softer when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and your fall is higher when you're humble and usually people that are humble tend to rise more than the fall in life right so hopefully you find this lesson to be helpful and I will see you in the next podcast thank you for listening to me and again if you want to sign up for any of these courses just reach out through me through the website.

So thank you for listening to me God bless you have a wonderful weekend and I will see you next time thank you.

It is an acute, systemic reaction occurring hours after starting spirochetal antibiotics (e.g., penicillin). The mechanism involves the release of endotoxin from dying spirochetes.

All penem and cephalosporin agents (including carbapenems) must be avoided due to high risk of cross-reactivity.

SATP: S for Sulfonamides, A for Aminodarone, T for Tetracyclines, and P for Pyrimethamine (or sometimes just remembering the classes).

Linear deposition of IgG in the basement membrane zone.

Dapsone, Rifampin, and Clofazimine.

Calcium pyrophosphate deposition (CPPD) or pseudogouty noduli.

Intercellular deposition of IgG and C3 complement.

Sulfonamides (S), Aminodarone (A), Tetracyclines (T).

Recurring Herpes Simplex Virus (HSV) infections.

Bullous Pemphigoid or Lupus Band Desmos.

Pyoderma Gangrenosum.

Type II (Cytotoxic) Hypersensitivity Reaction.

Calcium pyrophosphate deposition (CPPD).

Intercellular deposition of IgG and C3 complement.

Sulfonamides (S), Aminodarone (A), Tetracyclines (T).

Recurring Herpes Simplex Virus (HSV) infections.

Bullous Pemphigoid or Lupus Band Desmos.

Pyoderma Gangrenosum.

Type II (Cytotoxic) Hypersensitivity Reaction.

Calcium pyrophosphate deposition (CPPD).