DIP Episode 358 - USMLE Step 2CK/3 Rapid Review Series 68

Okay, welcome. My name is Divine. This is episode 358 of the Divine Intervention Podcast. And into this podcast, I'll be continuing the Rapid Review Series for the USMLE Step 2 CK Slash Step 3 exam. As a reminder, if you're taking the USMLE Step 2 CK Step 3 exams, sometime this month or the next month, I do have a Testicking Strategies Class taking place next week Monday. That's the 27th of December from noon to 2.30pm Mountain Standard Time. And then, if you're taking your exams, late January or early February, I do also have an MBME Testicking Strategies course that is going to be taking place on the 24th of January, then I have the full Step 2 CK 24 hour review course taking place from the 25th to the 28th. And also, if you're studying for the USMLE Step 1 exams or you're studying for Step 2 CK Slash Step 3, and you have very weak foundational knowledge. So, let's say your foundation in physiology and pathophysiology is flawed. Then you may also want to register for the 25 hour foundation's bootcamp. That's going to be taking place from the 31st of January to the 4th of February 2022. Again, it's a foundation's bootcamp. The goal is to really help you do well with physiology and pathophysiology. That's something that many people don't realize, but they think that, oh, wow, if I do Anki, if I do this, if I do that, I'll magically start doing well on Step 1 through Step 3, which is not true. If you have a good foundation, it will carry you through those exams.

But if you have a poor foundation, it will also hurt your own all through those exams. So, I see all these cases of people that the deep polyon Step 1, and then they magically believe that things will turn around on Step 2. It does happen that we force some people, or for most people, it does not work that way. Most people that do polyon Step 1 will do polyon Step 2 and Step 3. So, again, if you're studying for the Step 1 exam, this is a course that is absolutely applicable to you. But if you've taken Step 1 already, and you have a poor foundation from Step 1, let's say you did really polyon Step 1, then the foundation's course will be extremely helpful for you with Step 2, so you can't Step 3. Just getting that understanding, once that understanding is there, you'll see you start succeeding academically. So, if you're interested in any of those courses, just shoot me an email through the website, and I'll be more than happy to give you some more information. So, what if they give you a question about 25-year-old male, the tell you that he's an IV drug user, and they say that, oh, for the past, 3 D says he's been having very severe headaches, he has been having mild fevers, and he's also been having like a progressively deteriorating mental status. If you see that, and then they say that they obtain an image of the brain, and they see calcifications in a circular orientation in the person's brain. If you see that, what should you think about?

I already hope you're saying, oh, divine, this person looks like he probably has toxoplasmosis, so what's going on here, essentially, the thing that's going on here is that this person's an IV drug user. So, essentially, the MDM is giving you the fact that this person has high risk behavior. The person literally has high risk behavior at baseline, so this person probably has HIV, right? So, with this HIV, when you see these ring enhancing lesions in the brain, they're probably thinking of toxoplasmosis, right? So, this person likely has toxoplasma-gondia infection. Remember, when you see ring enhancing lesions in the brain of a HIV patient, you first assume they have toxoplasma, right? So, you're going to treat them. So, how you're going to treat them? Well, you're going to give them pyramethamine and sulfa-diamsine. Remember, it's very high you to know this. The treatment of toxo is different from the peripheral axis of toxo. You're peripheral axis against toxo with trimethoprim sulfanethoxazone. You treat toxo with pyramethamine and sulfa-diamsine, right? Those are both fully synthesis inhibitors, right? So, many times you would have to add a local worry when people are pleased on those medications so that they don't have bone marrow suppression. But, if a person is pregnant, actually toxoplasmosis is treated with a drug called spyramycin. Because if you're pregnant, you don't want to be given a fully synthesis inhibitor, right?

That doesn't seem like a very stellar idea because it's not like we're trying to give the child like a neuro tube defect or something of that nature. So, in those circumstances, we're really going to give a spyramycin, SBI, R-A, M-Y, C-I-N, spyramycin, spyramycin, right? So, that's how we treat toxo in people that have a H-I-V, right? Obviously, they don't recover then. We're worried about primary C-N-Islam phoma, so in those circumstances we'll get a brain biopsy, right? Because they probably have a primary C-N-Islam phoma. And I guess one thing that may be helpful here since we're talking about the primary C-N-Islam phomas is having a solid idea of the malignancies that are associated with the B-V, right? Because primary C-N-Islam phoma happens to be one of them. The thing is, these B-V associated malignancies, they are things that people kind of ignore, but they're very high on actually to know for the USML exams, right? So, besides the primary C-N-Islam phoma, which is an example of a B-C-L-L-M phoma, what are some other ones? Well, I really hope you're saying old wine, you know, some African kid with a jaw mass, right? Burketslam phoma, don't forget your 814 translocations with that, right? Remember if you get a histopathological image, you're going to see the starry sky pattern of the lymph node. And then don't forget, a Nizofarangio-Carsinoma is also something that is associated with the Epstein-Bar virus. And also just many of the lymphomas, right?

Many of the non-Hochkin lymphomas have an association with E-B-V. So, that's something you want to keep at the back of your mind for purposes of exams. Okay, now what if they give you a question about a 26-year-old female, they tell you that, oh, you know, she has a history of HIV that is poorly controlled, she hasn't seen the physician in like 10 years. And they tell you that, you know, for the past two days, she has noticed that she has had like a vaginal discharge. And they show you an image, you know, they give you like a histopathological image, you notice like a blue background, and you see all these linear branching things, right? Linear branching things. So, you see all these wise, like yyyy, like the letter y, right? If you see this, I really hope you're thinking about Kandida, right? Remember Kandida has a certain signature of people who have effects on exams. It can be people that have recently taken antibiotics, right? It can be people that have HIV, it can be people that smoke, people that have diabetes, right? Remember diabetes makes your perineal, and your vagina, your vaginal ear is sugary, right? So bacteria is almost like you're organizing a party for them. So, this person has a Kandida, it says, right, vaginal Kandida, and how do we treat vaginal Kandida? I say, remember, you're going to use like an oral or a topical isle. Most times on exams, a topical isle is more than fine, right? So, like flakona zon, or something like that.

And I guess maybe one thing I will say with these isles, you know, friends at the NBM Es, if they give you multiple isle answers, I will strongly encourage you to pick, let's say they give you flakona zon, kidokona zon. In general, if they give you multiple isles, try to pick the one that is not kidokona zon, because kidokona zon has a lot of side effects, right? So, it's not something you just want to give to people willingly on NBM Es exams. And remember, Kandida, if you're a diagnosis, Kandida, right? If you get like a wet prep, you put it on the other microscope, right? You're going to see these pseudo-hifi, right? You're going to see pseudo-hifi, you're going to see pseudo-hifi on a wet prep, right? And remember, people have Kandida vaginal infection, right? Essentially, what you need to do is, if you check the vaginal pH, it will be 4.5 or less, right? It will be 4.5 or less on NBM Es exams. Okay, now, what if they give you a question about 49-year-old male? They tell you that, oh, he has like a two-pack per day smoking his strands, he's smoking for the last 25 years, and they tell you that he has a history of alpha-1 antitrips in deficiency. Then he comes to the emergency room. That for the last 30 minutes, he's been having a lot of hematemesis, we have an alterment of status. They tell you that this papal bull's historic blood pressure is 60, right? And his stony blood pressure cannot be measured, his tacky cardic, his heart rate is like 150, it's the kidney, right?

All of this guy has. A real piercing oedivine, this guy has cirrhosis, right? That has increased his photo pressures on claustrobleen varicides, right? So, this person does, in fact, have a surface of a jaw varicides. You know, remember, when you have alpha-1 antitrips in deficiency, if you do the right thing and, you know, not smoke, you can have a pretty good, pretty normal life. But if you choose to smoke, then you're not going to have a good life at all. You're going to have accellerated decline of your lungs, right? So, these people in their 40s, they're going to start getting like really bad COPD, they're going to get thrown into cirrhosis. And the reason they have cirrhosis, right? Is that on 4-dialophone antitripsin? I mean, how come leeching their hepatocytes and then those hepatocytes on the great poptosis, right? So, they get cirrhosis pretty early in life. And when they get that cirrhosis, the thing that's going to happen is that, you know, they're going to have increased photo pressures, they're going to have photo hypertension and that can cause varicides, right? So, obviously, the person has varicides. What do we do for these people? Well, the first thing you're going to be doing on NVM exams is you're going to go ahead and give them fluids, right? You're going to please to I Vs, you're going to give those people fluids. No more ceiling is usually just fine, right? I don't know.

I feel like med students, whatever bizarre is in the paciferate on the specific kind of fluid, or should I give this or give lactated rangers or give a argument that that that that that that that that that that that that that that that that that that that that's one of the big reasons. I mean, I will very likely make a podcast on fluids in the future, but it's not as relevant to the US analysis people make it out to be. Again, I know Cubans just paciferate, paciferate, paciferate, but the endgame is largely don't care. For the most part, like 98% of the time, normal ceiling is going to be the right answer on exams. The only exception to that rule is say, for example, a person has had like a large volume parts and T-sys and I'll go back to our four annotations in a bit, but large volume parts and T-sys and you need to restore these people's volume. The thing that you can do is you can give those people argument, right? Because the thing is the person that needs a large volume parts and T-sys probably doesn't have the best livers to start. So if you don't have a great liver to start, you know, it would make sense that because you remember the liver makes arguments like the primary protein in the body. So if you don't have a great liver to start, it may be helpful to give those people some argument because whatever fluid you're giving them, it will keep it in the vasculotry because by giving an argument, they essentially increase in the oncotic pressures of the vasculotry.

So again, that's very high you to know for for exams, but other than that, normal ceiling is just fine. I mean, like if, for example, you don't see normal ceiling as an answer and they put lactated rangers, you can give LR as well. That's totally fine. Remember, normal ceiling and lactated rangers, they're an example of what we call crystal void, right? That's what we call crystal, those are crystal void solutions. Okay, right? So this person has this oligioveracy. So obviously, again, you're going to place two I Vs, right? Peripheral I Vs, believe it or not, they can actually give fluid at a very high flow rate compared to all that kinds of mediums. I mean, there are other mediums that are really amazing, but peripheral I Vs, they don't get enough of a good reputation for, they're actually pretty good means of giving people fluids, but again, that's a completely different physics discussion. We're not going to go into that right now. But basically, you place to peripheral I Vs, right? If the person is really low in hemoglobin, you can give them blood. And then those people should also get like sclerotherapy or banding for their varicies. Some other things you can also consider slash, I guess, keep in mind, is that those people, you know, they should get IV octriolide as well. And they should get a PPI as well, right? They should get a PPI. That's actually very high, you know, that's the acute treatment for varicies. But then after a person has been treated acutely, right?

Well, you don't want them to have varicies in the future, right? I mean, they'll have the varicies, but we don't want them to bleed in the future. So what you can do is you can place them on peripheral active therapy, right? So you can put them on like, prepare a role or need a you can put them on spironolactone, right? Those are those are receptor antagonists. Those things cause a splansionic visual constriction, so they help with the subgeal varicies. But another thing you should also consider your exams is that those people need SBP peripheral axis. They need peripheral axis against spontaneous bacterial parotonitis. If you've had bleeding varicies, or if you have varicies at all, you absolutely positively need to be on SBP peripheral axis. Because essentially, you're already having one sequelae of portal hypertension. So you should already be protected. It makes sense to protect you against all the sequelae of portal hypertension, right? So those people deserve SBP peripheral axis. Most times the fluoroquin alone or, you know, except triaxone is perfectly fine on on NV Me exams. And then what if they give you a question about like a 39 year old farmer and they tell you that for the last two months, he has noticed like this rough lesion on the upper, you know, on his upper back, right? And then they ask, what's your diagnosis, right? Or they can even give you an image. You may notice all these circular pinkish material, right?

If you see this, what should you be thinking about? Well, I'll really hope you're saying, oh, divine. This looks an awful lot like a tini-carotosis, right? It's going to be a person that works on the outdoors, right? The biggest risk factor for tini-carotosis, believe it or not, is a son exposure, is son exposure. Again, risk factors are things that people do not be attention to. But again, those things will burn you very quickly. On NV Me exams, if you don't know them, right? So I strongly encourage if you can, really, really consider, really, really consider listening to my podcast on risk factors. I do actually have many podcast on risk factors. Those are probably my most famous podcast of all time, right? Episode 37, episode, I believe 37, 97, 184, 239, right? I have a lot of risk factors podcast. You should definitely listen to those things. Okay, so let's keep going here. This person has a tini-carotosis. Again, it's going to be a rough, sun-deeper, like, lesion on the skin. It's going to be in a person that has a lot of son exposure, that is the biggest risk factor. Remember, most people that have tini-carotosis, most of them, their lesions resolve. They get better over time, right? But some other people can develop scumous cell cancer of the skin, so that's why tini-carotosis. You want to tell those people to try to avoid the sun if they can, right?

If they avoid the sun, then that's going to keep them safe from getting this, getting into this problem in the first place. So again, the biggest risk factor for tini-carotosis is going to be sun exposure. And again, the way most people that have a tini-carotosis they will recover. Most people that have it will absolutely recover. But some of them, right? A few of them can proceed all the way to scumous cell cancer of the skin. And how do you treat it? Well, you can treat it with medication, right? You can treat it with like a with a five-friar cell cream. You can treat it with a drug called a emicoemod. These are just all topical agents that can help, right? And actually one thing I would say is believe it or not, because many people on, you know, many people studying for the USML is like, oh, you know, keratin pearls are only found in scumous cell cancers. Let me tell you, let me shock you. Keratin pearls can also be found in tini-carotosis, right? Keratin pearls can absolutely be found in tini-carotosis. So that's something you want to keep keep out the back of your mind for purposes of the USMME exams. Okay, now, what if they give you a question about a six-year-old male? They tell you that for the past two weeks, he has been having like worst-name shortness or breath, and his parents have noticed that he has periodoscene analysis.

And then they tell you that, you know, they give you like a, and they tell you that he had like a viral respiratory infection, like two, you know, like two weeks ago. And you then notice that they give you some labs. You notice that his white blood cell count is like 3,800. And you see his hemoglobin is like one. And then you notice that his platelet count is like 100,000, right? So he's a little low on the platelets. He's a little low on the white blood cells, but he's really low on the hemoglobin. When you see stuff like this, what should you be thinking about? I really hope you're thinking about this person having an aplastic crisis, right? Probably from parvo-bilan team, right? Probably from very likely from from parvo-bilan team. Although remember, you can also get an aplastic crisis from many different kinds of viral infections, right? But again, the one I want to focus on now is parvo-bilan team. Remember, parvo-bilan team presenting many different ways on an ambient exam, right? So, it can present as an aplastic crisis, especially in people that have hemoglobin apathy. So, if you see a hemoglobin apathy person that for whatever bizarre reason has a lower eticholocyte count, you really want to think about a parvo-bilan team problem. Because most times, people that have hemoglobin apathy, their eticholocyte count is really high because they are cranking out as many or as immaturely blood cells as possible.

When you see a lower etich count in a hemoglobin apathy person, for the most part, again, there are some weird exceptions to that rule. For the most part, an ambient exam, you want to think about a parvo-bilan team infection, especially people that have sickle cell disease, right? And then, don't forget that parvo-bilan team also causes that slap-cheek rash. You don't do anything for it, right? It's a pretty benign rash. You'll go over time. And it's probably pertinent to remember that parvo-bilan team is a single-stranded DNA virus, right? Most DNA viruses are double-stranded, but parvo-bilan team is kind of weird in the fact that it's a single-stranded DNA virus. If you look at things from the RNA virus site, remember, rotavirus is kind of weird because most RNA viruses are single-stranded, but the rotavirus is actually a double-stranded RNA virus, right? So just read tidbit that the communicationally thrown exams of people will be like, what? I felt this was just from step one, like, why am I supposed to be aware about this stuff? Well, that is stuff, unfortunately, they need to worry about. And they remember parvo-bilan team, right? It can also cause hydrops fetalis, right? I've talked about this, acknowledging many podcasts, right? Because again, in a child, in a fetus, it can cause any plastic crisis, right? And when you have a really bad anemia as a fetus, then your blood oxygen content will be very low.

So your body is going to be like, man, I need oxygen, I need oxygen, I need oxygen, so your heart is going to be like, okay, okay, I'm going to raise my cardiac output. Whenever you become hypoxic, your cardiac output goes up, right? Well, because this is one of, like, a long-standing problem for the fetus, the cardiac output is going to chronically, chronically, chronically elevate, right? And again, the heart is a muscle, over time it will die out. The child will go into a high-up or heart failure, right? And then they will have a dimi everywhere. That's how hydrops fetalis really arises, right? And then don't forget that parvo-bilan team also, namely, in exams, lots to cause problems with, lots to cause problems with people that work with kids, right? You see a pediatrician that has joint pain or a kindergarten teacher or a DK worker, stuff like that. That's going to be parvo-bilan team infection. Again, just to body care is really all those people need. So I think I'm going to go ahead and pause here. Again, as I do at the end of every podcast, I'll offer review courses for step one, step two and step three. I also, on a limited basis, offer one or one two to run for pre-clean cool exams, 30-ish-off exams, and also step one to step three. And then I have these podcasts on Apple, podcasts, Google podcasts and Spotify. So just subscribe. You'll see the most recent 150. And then I do also have the website, divininginterventionpodcast.com.

If you want everything from episode one, all the way to 358, it's the available for download. You can see them on the website. And then I have a You Tube channel, the Vine Intervention, USML, Podcasts and Videos. That's where I post the videos that I make. And then I also have another website called divininginterventionlifelessons.com. It actually has a podcast on Apple podcasts, actually. Right now, I have about 45 podcasts. And again, they're just live lessons podcasts based on the Bible that just address common problems that face humanity. So thank you for listening to me. Have a wonderful rest of your day. God bless you. I'll see you next time. Thank you.

Toxoplasmosis.

Pyrimethamine and sulfadiazine (both folate synthesis inhibitors). Peripheral toxo uses trimethoprim/sulfamethoxazole.

Spiropyramycin (or pyrimethamine derivatives that are safer for the fetus).

Pseudo-hyphae seen on wet prep, and a vaginal pH $\le 4.5$.

Old World Syndrome (jaw mass), Burkitt lymphoma (t(8;14)), and Nasopharyngeal Carcinoma (associated with EBV).

Sun exposure. Keratin pearls can be found in tinea corporis, not just SCC.

PP Is (acid suppression), Octreotide (splanchic vasoconstriction), and prophylactic antibiotics (SBP prevention).

Ring-enhancing brain lesions, fever, and headache.

Because they are folate synthesis inhibitors, which can be teratogenic for the fetus. Spiropyramycin is preferred.

Pseudo-hyphae; vaginal pH $\le 4.5$.

Parvovirus B19.

Cirrhosis (often secondary to AAT deficiency or chronic liver disease).

Burkitt lymphoma (t(8;14)) and Primary CNS Lymphoma.

It is a single-stranded DNA virus (most RNA viruses are ss RNA, most DNA viruses are ds DNA).

Ring-enhancing brain lesions, fever, and headache.

Because they are folate synthesis inhibitors, which can be teratogenic for the fetus. Spiropyramycin is preferred.

Pseudo-hyphae; vaginal pH $\le 4.5$.

Parvovirus B19.

Cirrhosis (often secondary to AAT deficiency or chronic liver disease).

Burkitt lymphoma (t(8;14)) and Primary CNS Lymphoma.

It is a single-stranded DNA virus (most RNA viruses are ss RNA, most DNA viruses are ds DNA).