DIP Ep 653: USMLE Step 2/3 Rapid Review Series 137 (Dermatology)

All right welcome my name is divine this is episode 653 of the Divine intervention podcast and into these podcasts I'm gonna be talking about the I'm gonna be doing a step two step three rapid review. This is gonna be series 137 right again. I'll encourage you if you missed the last one I would really encourage you to listen to the last one was episode 651 it was series 136 there was a bunch of just kind of weird high-ill things I emphasized that they love to test on the exams. So let's jump right into it right So and I will encourage you for this one the things I kind of plan to discuss I will encourage you to go back Have a computer in front of you, you know, and just look things up like look up photos look up images of these things as I discussed them Right, but what if they give you a question about a like a flat, you know dark Smooth skin lesion in a child, right and typically it's gonna be on the palms and on the souls Typically it's gonna be on the palms and on the souls if you see this I'd really hope you're saying or divine This is a junctional nervous. This is a junctional nervous. This is something they love to test on the exams This is actually the most common mole in kids, right? So look this up right again remember lesions on the palms and souls the USM is they know that everybody that has the job description Medical student has memorized You know coxacchi A with hand-forth mouth disease the new memorize re-ketsiary ketcy right You know so with a Rocky Mountain spotted fever, right and they know you know about secondary syphilis But don't forget you can have lesions on the palms and souls in a person that has a Kawasaki's disease as well, right, but a junctional nervous can also be found on the palms and souls, right now What if they give you a question about a farmer or a gardener, right? So a person that works outdoors, right? Although they know that most people have caught on with farmers or gardeners So these days they can give this exact same thing to like a lifeguard, right to a lifeguard or a person that Works outdoors a lot for whatever reason, right? So you can be a person that is in the military in the desert or something like that right? So you know how they love military questions so they can give you a question about a person that is deployed You know has been deployed for the last couple of months in the desert or in North Africa or in the Middle East or something like that And then they tell you that this person has this small, you know, has these a small rough, you know Erithemidos, you know, papules on the back, right? They have like a sandpaper texture or do you see that have a rough texture when you see something like this I'd really hope you're thinking of Actinic carotosis. I'd really hope you're thinking of what? Actinic arotosis remember they can ask you what is the most likely outcome of this person's skin lesion You want to put a resolution right resolution is the most likely outcome most people that have Actinic arotosis it becomes a nothing burger. It completely results But remember, actinic arotosis one of the reasons we treated is that it can proceed to Scrimal cell carcinoma of the skin scrimal cell carcinoma of the skin right and again How do we treat it? We're gonna treat it with topical five-floor yourself topical five F you right sometimes on your exams instead of using the term Topical five F you because again, they know that that is in every on key deck known to mankind The thing that I'd rather do is they'll put like topical chemotherapy right topical chemotherapy I'm telling you this and this is a sermon. I've been preaching now for the last couple of classes that have been teaching with my Test taking class and actually many of mother review horses the US Emily's they are almost on an anti-onkey crusade Anti-onkey crusade is almost like literally the words and expressions don't get me wrong right a lot of what you're Studied you're still gonna see it on your exams but every year things are getting they're getting better and better at Taking the words that you're familiar with and putting different words or putting things that are intentionally vague It's still mirrors and reflects the same thing you've learned but just put differently just to see if they can force you to think or if you can get Tricked up easily right now remember for a tini caratosis You can ask your risk factor question right the biggest risk factor is gonna be son exposure and again Don't forget the demographic I just voiced right gardeners, landscapers, farmers people that work outside Right okay now What if they give you a question about a 75 year old male and they tell you that oh, he has a history of our Parkinson's disease Right and that for the last three months he has noticed this discolored, you know skin lesion right and then they show you an image And you see this like this plaque that kind of looks like somebody like a glu-deeds to the person's skin right if you see this I'd really hope you're thinking of what of Seborick caratosis seborick or toses remember it can also be found in Parkinson's disease Parkinson's disease has a very strong association with two seborick problems, right? It can be a zero seborick dermatitis Because remember Parkinson's affects the other make nervous system right so You know you can secret more sebum and that can create like a really good environment for for bugs that can cause Seborick dermatitis but Parkinson's is also a street with seborick or caratosis right typically is gonna have this stock on appearance gonna have this stock on appearance Right is gonna have this stock on appearance now. What if they give you a question right on your exams? This question that I'm about to voice most people get it wrong, but you will not get it wrong because you're paying attention to this podcast So what if they give you a question on your exams and they tell you that you know this person is an adult right and this person You know has this you know and they may even show you an image where you see this large pigmented lesion right it has irregular borders right and It's actually in an area that is Protected that is son protected that is son protected right if you see something like the and then you're looking at your answers And you're like wait, I'm looking for melanoma. I can see melanoma as an answer You're kind of scratching your head if you see something like this I will strongly encourage you to pick the answer that talks about a dysplastic Nevis as strongly strongly encourage you to pick an answer that talks about what dysplastic Nevers right so how is it gonna be tested on your exams? It's gonna be a large lesion. It's gonna be pigmented Right and it's gonna have irregular borders and typically will be on a son protected ear if you see this Think of a dysplastic nevers think of a dysplastic nevers right now the thing is again Typically it's gonna be a chronic problem. They're gonna have had it for a long time right and you'll notice that it's not something that is necessarily Changing recently right like you know like melanomas right change right you'd probably know your EBCD easily Melanoma I'm gonna talk about that after this right but you notice that it's like a chronic on changing lesion and Classically, they will not put melanoma as an answer choice when you see something like this think of a dysplastic Nevis right and I was saying hey, what's the ABCDE of melanoma? Remember the A stands for asymmetry right the B stands for border irregularity the C stands for color It's gonna have multiple colors the D stands for diameters. It's gonna be greater than six millimeters in diameters Right and it's gonna the the easy evolving right is gonna have that quality of change is gonna be changing is gonna be changing right That's pretty pretty high you to know for your for your exams right now What if they give you a question about a patient and they are or they won't just make it like an epidemiology question Like what's the most common skin malignancy? Remember the most common skin malignancy obviously is gonna be based on cell cross in the of the skin right and Typically it's gonna be there both the upper lip right but again our friends at the NBA knees They know that many people have learned some of these general rules right many people have learned some of these what general rules Right so remember it does not always have to be above the upper lip It can literally be below the lower lip so just be careful But classically it's gonna be above the upper lip is the most common skin malignancy right and it tends to have Telanget Asia's that's a very critical thing to know it tends to have these blood vessels these tiny blood vessels kind of overline it Right so those telangetations that's very characteristic of basal cell cross inoma right Classically scream or cell cross them on the other hand tends to be below the lip right it tends to be all serrated and you have no Telanget Asia's right tends to be what below the lip not all serrated no tell sorry below the lip is all serrated and has no Telanget Asia's below the lip is all serrated no tell and just Asia's think of scum or cell cross inoma of the skin right and what is the biggest risk factor for Skin cancer just in general what is the biggest risk factor for skin cancer well the biggest risk factor is gonna be UV exposure right and sometimes on the exams they'll give you different kinds of UV light and you have to pick the correct one pick the one that says UVB Right ultraviolet B UVB exposure is the biggest risk factor for skin cancer on the US Emily exams right and typically the people that get skin cancers on the US Emily's gonna be Caucasians right it's gonna be Caucasians they can have blue eyes right that's gonna be like the classic patients the classic Demographic that they threw in on the exams for for skin skin cancer right now What if they give you a question about a patient right and they tell you that oh, this is a ten-year-old child and this child It just has like severe photos sensitivity like blisters and what not when they expose to the sun right and you know They tell you that all that you know whenever they have some exposure is just terrible terrible terrible terrible terrible terrible terrible for them when you see something like this Think of the Xero-Germa pigment to some right Xero-Germa pigment to some Xero-Germa pigment to some Xero-Germa pigment to some right it's an Orozomer recessive disease right and these people have defective DNA damage repair defective DNA damage repair what kind of DNA damage repair Today's struggle with well, it's the repair of 5 million dimers is the repair of what of 5 million dimers right don't mix this up with a taxi Atelangiectasia 8 taxi atelangiectasia they have an ATM mutation and those people that have a taxi atelangiectasia the thing they struggle with is Double-stranded DNA repair double-stranded DNA repair right so those people struggle with X-rays It's X-rays they struggle with right so please please please let me really make sure that I throw this out there People that have Xero-Germa pigment to some they struggle with UV rays People that have a taxi atelangiectasia struggle with X-rays right so UV rays are not gonna be a problem for pressing with a taxi atelangiectasia Okay, keep that in mind right people that have Xero-Germa pigment to some Distrogued UV rays UV rays leads to the creation of thymidine dimers those people struggle with those things okay? Distrogued those things okay, so please I'm telling you this This is something that in the heat of an exam a person can mess this up don't mess this up because repairs attention. I'm going to repeat it again. So, I'll give a pigment to some, right? It is UV rays that bog bog them. It's going to be x rays that bother them x rays create double stranded DNA breaks. Okay? X rays do not create thymidine dimers. It's UV rays that do. Okay. So again, I've really hit this. I really, really hope that you don't get this wrong going to test, right? If you get this wrong going to test, you should feel really bad because I basically repeated this thing like, like three times, like literally three times, right? Both of those diseases, they have the same mode of inheritance is autozomo recessive, right? But you've got to know those things for your exams. Now, what if they give you a question about a patient and this patient has had a burn wound for like the last 10 years, it has not healed. And then they ask you like, what's the most likely diagnosis? I hope you'll pick an answer that says a squamous cell cancer, right? Squamous cell cancer. That person has a merjolins ulcer, M-A-R-J-O-L-I-N merjolins ulcer. They are less likely to put the term merjolins merjolins ulcer on your exams. I'm more likely to put squamous cell cross-inamone your exams, right? Because again, merjolins seems like something that will make its way to an onky deck, right? So again, they're not going to do that. They're going to use the term squamous cell cancer, right? So if you see a person that has a skin wound that just doesn't seem to be getting better, think of a think of a merjolins ulcer, which is again a form of a squamous cell, of course, in a way, right? And then if they give you a question about a patient that, you know, wants to move to an area like an area of the country that has a lot of sun exposure, right? That has a lot of, you know, water, you know, where they can go by the beach. And then they ask you which of the following interventions would most strongly reduce the person's risk of skin cancer? Right? You know, what are some things you can do to reduce a risk of skin cancer? Well, number one, don't forget like sunscreen, right? Sunscreen that has an SPF, a sun protective factor that is at, that is 15 plus, right? That is at least 15 plus, right? And then you also want to, wear protective clothing, right? Now, there's one strange thing, uh, amazing friend at the MBM is love to do to people on the exam. So if they give you between sunscreen as an answer and they give you protective clothing as an answer, they are literally both answers to the same question, which one should you pick to reduce your risk of skin cancer? Which one should you pick to reduce your risk of skin cancer? I would really hope you're saying, oh, divine protective clothing, protective clothing is what you should be. I know you're like, oh, divine, ever we have seen sunscreen, big sunscreen on your exams and see what happens. Just try that and see what happens. Right? Let's keep going. Now, what is the most important prognostic factor you mission your test in the setting of a person that has melanoma? What is the most important prognostic factor? Well, I hope you're saying that divine, oh, I should be thinking about the thickness, right? The brslo BR e slow BR ESL OW, the brslo depth of the brslo thickness, right? So that is the most important prognostic factor. The deeper, the thicker, right? The more likely you're going to get getting a bigger amount of trouble, right? You're going to have a worse prognosis that way. Right? Now, uh, let's do some matching games, right? Let's do some matching games. I think Durham is pretty good for this, right? So, let's let's let's do some matching games with like some uh, skin cancers, right? So, which one is a locally destructive with very little risk of metastasis, locally destructive, very little risk of metastasis, very good. It's going to be a bit of self-custom of the skin. Okay. Now, what is the one that can present on your exams as a small bowel obstruction? That's going to be melanoma, very good. And then which one can arise from our jollins ulcers or acynecarotosis? Okay, it's going to say okay, answer very good, right? Which one can arise after a person has got in a transplanted organ right on the binonaminosuppression? Very good. It's going to say okay, answer, right? Again, don't forget melanomas. I don't know for whatever reason, almost no resource covers this specific factoid, which is actually very, very high yield to know for you exams. Friends at the NBMEs can give you a question about a person that has a skin lesion, right? And it, um, melanoma literally metastasis to the bowel and causes a small bowel obstruction, right? Whenever you see a person that has like a history of like intense on exposure and they show you like a skin lesion and the person has been constipated for a really long period of time, think of metastatic melanoma. It has literally metastasis to the person's small bowel, right? Obviously, when you have that kind of metastasis, like that's a awful, awful, awful prognosis, right? Let's do another matching game. Let's do another matching game, but let's do it with melanomas, right? Let's use this matching game. I kind of like these matching games. Let's use these matching games to kind of hit some of these melanomas, right? So first things first, what is the most common kind of melanoma? What is the most common kind of melanoma? It's going to be superficial spreading. Okay, now which melanoma has the best prognosis? Which one has the best prognosis? It's going to be lentigo maligna lentigo maligna lentigo L-E-N-T-I-G-O maligna is a separate word M-A-L-I-G-N-A, right? Don't let that maligna word make you feel like, oh, this is bad. No, it actually has the best prognosis of all the melanomas. Okay, now for all the melanomas, which for which one is UV exposure, not a risk factor? For which one is UV exposure, not a risk factor? UV exposure is not a risk factor. I hope you're picking the one that talks about acral lentichinus, acral lentichinus, acral lentichinus. Okay, next one. Which one is pretty common in people of color, right? I mean, you won't find them the sole of the foot on the sole of the foot. I hope you're also saying acral lentichinus, acral lentichinus. Okay, now which one has the worst prognosis and is the second most common? Remember, I say the most common is superficial spreading. Which one has the worst prognosis and is actually the second most common? It's going to be nodular. All right, now which one has a long horizontal growth phase? Which one has a rapid initial vertical growth phase? All right, so let's talk about these growth phases. Right? I really, I'm telling you this. Some of these rapid reviews that I put out, right, is just like, oh, in summer, rapid review, it's like one out of the other 137 divine has made. I'm telling you these, these rapid review series, they're no things to ignore. These things are like super, super, super high-yale things that can naturally a lot of really amazing points on your exams, right? And the theme is, if you're a person that is like shooting for like, hey, I want to get like in the 270s, right? It can just be questions like these where it's like, there's no testicking strategy that can save you. You've not seen it in any resource. You just randomly remember divine, spending like two minutes talking about like some random factor and that's why you got it right. Right? So again, that's the thing, right? Like every question counts, right? But let's talk about these things. Right? So the thing is melanomas, right? They have this phenomenon of growth phases, right? You can have a horizontal growth phase. We can have a vertical growth phase. Right? Now, let me ask you this, which growth phase you think is really bad? Well, it's actually going to be the the vertical, right? A vertical growth phase means that, oh, that thing is going deeper and is beginning to a metastasize, right? But if it has a horizontal growth phase, it means that the thing is just going horizontally. It's not going deeper because remember the official layers, right? You have like your mucosa, your sub mucosa and whatnot, right? As you begin to go deeper, you begin to get to the blood vessel layer of your skin. And once you get to that blood vessel layer, right? Thins, cancer cells can enter the bloodstream and begin to metastasize. They can begin to get to lymphatics and begin to metastasize. Right? So if your person has skin cancer, you want one that has a very, very long horizontal growth phase, right? It means that, oh, it may be locally destructive, but it's not going to cause many problems because it's not going down vertical. Remember, I said that's the biggest determinant of prognosis in a person that has melanoma is the brislow depth, is the brislow depth, right? So the thing is, uh, superficial spreading melanoma has a very, very long, very, very long horizontal growth phase. So it doesn't metastasize very easily, right? That's why it has a pretty decent prognosis. So though remember, the prognosis is not as good as lintigo maligna, right? But what did I see was the second most common skin can, second most common melanoma and had the worst prognosis of all? I said nodula, right? nodula has a very rapid initial vertical growth phase, a rapid initial vertical growth phase, right? So again, keep these things at the back of your mind, right? This can be a very easy way for them to test metastatic potential on your exams, very easy way for them to test prognosis on your exams. That's why I'm emphasizing this. The USML is these days, they really, really love prognosis, prognosis, prognosis, prognosis. They love these things on the exams, right? So please make sure you bank these things in your brain, make sure you bank these things in your brain, right? And, um, uh, just some other, I guess, maybe like random things I just want to throw in here, uh, since where I guess we're kind of talking about derm, right? Since we're kind of talking about derm, right? Um, metanomas, right? Just quick general management, right? Again, they don't go very deep on management here, right? But if it's a small lesion on your exams, you can just do some kind of excision of biopsy, right? If it's a cosmetic, if, you know, you're kind of worried about like cosmetic, uh, issues with resecting the lesion, or it's a large lesion, at peak, the answer that talks about an incisional biopsy, right? So for small lesions, excision for large lesions or lesions where like it's going to be in an era of cosmetic consequence, you want to do an incisional biopsy, an incisional biopsy, right? Uh, I would encourage you to almost never pick punch biopsy for metanomas, punch biopsy, metanoma questions, not, not a good mix, right? And one answer is you should definitely not pick with metanomas is a shave biopsy. Uh, shave biopsy, picking a shave biopsy as your answer from metanoma is like consulting the ethics committee for an ethics question. That's not going to end well for you on your exams, right? Now, one other thing that you may also see, right? Because again, they know that many people have memorized like the brislo depth for prognosis in metanoma. One other thing that's also pretty high yield to measure actually in the work of a melanomas is the LDH, the lactate dehydrogenase, the lactate dehydrogenase, it's actually a prognostic indicator, right? In fact, that may actually be an indicator of liver metastasis. Uh, um, the, the reasoning behind that is well, well, well, beyond the scope of the USM exam. So I'm not going to talk about it, but don't forget that measuring the LDH, the lactate dehydrogenase is also a very good prognostic indicator and it may be an indicator of a potential liver metastasis in a person that has a metanoma, And then again remember we've talked about how many of the skin cancers like the diesel cell, of course, enoma, the scrimal cell cancer, or you can treat them with topical chemotherapy, or you can do like topical five if you, right, five floor of your cell, right, you can use a make way mod, I M I Q I M O D, right, a make way mod, a make way mod, right, a make way mod, right, some skin cancers, like diesel cell, scrimal cell, you can do a electro desiccation and curatage, right, these are all words you may see on your exams, but do remember from the lanova, you pretty much always do surgery, you pretty much always do surgery, you pretty much always do surgery, right, you pretty much always do surgery. And I will encourage you for me, lanova is usually not a smart idea to pick moles surgery, M O H S, right, is usually not a good idea to pick moles surgery for me, lanova you exams, I don't know for whatever reason, I friends at the M B M's, they don't like that being the correct answer for me, lanova, right, for me lanova, right, and then sometimes, right, although this pops up not very frequently, but every few years you're going to see this pop up, right, but remember, for diesel cell curse, you know what, what are the surgical margins you want, right, you won't like to get the surgical margins you want, right, you won't like 3 to 5 millimeter margins, right, and for Scum and Cell course, you know what kind of margins do you want, you want like 5 to 10 millimeter margins, 5 to 10 millimeter surgical margins, maybe like, oh, divine, how do I remember which is which, well, just remember that the larger number, the larger margin goes with a bigger letter, right, the larger margin goes with a bigger letter, the larger margin goes with a bigger letter, right, and then, you know, don't forget, right, another skin thin, right, don't get a big, right, remember, you know, diabetics, who are the classical bull that get necrotic infatuation right, diabetics, IV drug users, right, you may see bull, you may see creptidus, you may see hyponitremia, right, the legions tend to be violacious, you may see gas bubbles on imaging, right, when you see this thing of neck fascia, remember neck fascia needs to be of polymicrobial infection, right, tends to be of polymicrobial infection, okay, tends to be of polymicrobial infection, don't forget your SGLT twin inhibitors that can cause a neck fascia of the perineum, right, which we call phony's gangrene, right, and again, remember if your culture, a strebobovis or clostridium septicum, where you need to go ahead and do a colonoscopy, right, to screen those bull for colorectal cancer, right, a lot of colorectal cancer, and sometimes when a person has neck fascia, right, if there's a lot of muscle involvement, if there's a lot of muscle death, you eventually need to consider amputation in those people, right, in those people, but again, remember, how do you handle neck fascia, right, dibraidmen, dibraidmen, dibraidmen, dibraidmen, and anti-biotics, brospectrum, anti-biotics, right, brospectrum, anti- antibiotics, okay, and now there's this kind of strange thing our friends at the MBM is love to do with cellulitis, right, because many of you can probably recognize cellulitis pretty easily, but I've noticed one strange thing that you love to do these days is they can ask you what layer of the skin is involved, you're like, wait, what? What layer of the skin is involved? If you notice for cellulitis, don't forget that is the deep dermis and subcutaneous tissue that is involved in cellulitis, okay, it's what it's the deep dermis and subcutaneous tissue that is involved, the deep dermis and subcutaneous tissue, all right, and then the last thing I'm just going to talk about, these are rapid reviews series, I don't want this to go too long, right, but what if you see us blackest crying apostle worker, what are you thinking about? Repostal worker, what him optizes, why do you need this time, it's going to be anthrax, right, it's going to be anthrax, it's going to be anthrax, all right, so I think I'm going to go ahead and stop here, again, I'm telling you this, this is going to score you so many easy points on your exams, right, things that people get really, really good at it, right, and I'm going to get wrong, right, things that people get wrong, you don't have to get them wrong, if you be attention here, now, do you love the way I teach, then you're going to love my classes, have a battery of classes that kind of start into day actually, right, so I have a 25 hour basic science review, it's for people taking step one or people taking step two, step three that have poor, poor foundations, right, this class will benefit you tremendously, it's a case based review, right, it's not like a review where it's just like, oh, what's the definition of this? No, no, no, no, no, right, I use cases, I use clinical scenarios to purchase the points, right, so you're learning it in the context of an MBAme exam, and then after this week, the 25 hour basic science review, starting next week, I have a CCS cases class for step three, specifically, right, and then after that, I have a test taking strategy class for step one to three, it's a two and a half hour class, I have a biostat's class for step one to three to four hour class, I have a social sciences quality improvement, a hospital medicine, ethics review, it's a five hour class for step one to step three. Super, super, super comprehensive class, it's actually one of my most popular classes, many people take it and find these to be extremely helpful for their exams, right, and then after that, I have the last many reviews, specifically for step two and step three, it's a three hour class that shows you not just concepts that are commonly test, testable on the exams, but also just methods and approaches that the USMEL is used to test concepts, and then after that, I have a 20 hour step two step three review that is again, specifically for step two and step three, and then in the month of June, first weeks in the month of June, this is the only time this is going to take place this year, I have the 50 hour step two step three review, right, it's an epic, epic, epic, amazing, amazing, amazingly wonderful class, many people that have taken those classes have just found these weeks extremely helpful, and then I also offer one and once you're in for all the USMEL and complex exams and medical school exams, and then have these podcasts on Apple Google and Spotify, so check those out, I also have a YouTube channel that I post all the videos that I make, right, and some podcasts that I make as well, I throw those on there, and then many of you listen to this podcast, not a price follower, right, so I do have another website called divineinterventionlifelessons.com, divineinterventionlifelessons.com, every week I post like one or two podcasts, we're from a biblical perspective, I do address a life lesson, there's actually an Apple podcast associated with that called the divine intervention life lessons podcast, and then I also help with errors, applications, mock interviews, personal statements, recommendation letters, and things of that nature, I help with editing those things, right, editing those things and making them very polished to what admissions committees and residency selection committees are looking for, so thank you for listening to me today, I will see you in episode 654, but have a wonderful day, God bless you and bye for now. Thank you.