DIP Episode 468 - USMLE Step 2/3 Rapid Review Series 98

Welcome my name is divine this is episode 468 of the divine intervention podcasts into this podcast I'm going to be continuing the rapid review series for the USM list at Juicy Cancer Tip 3 exams This is going to be series 98 So let's go ahead and jump right into it. So what if they give you a question about a patient They tell you that for the last two hours he has been having a very severe headache and they tell you that he has vision loss in both eyes In fact, it is mentioned that he has lost vision in the other half of both eyes If you see something like that what should you be thinking about Well I would hope that you'd be thinking about some kind of stroke In fact, if you wanted to maybe be smarter about looking at it I would think about an anterior communicative artery stroke The person basically has bytemporal hemianopsy So what's the deal there?

Well the deal here is that this person probably had some kind of aneurysm In the circle of Willis and then that aneurysm ruptured And then as a result of that you had like bleeding in the anterior part of the brain You have like a bytemporal hemianopsy In fact, if you even have just an aneurysm of the anterior communicative artery That can certainly compress The optic chiasm you can get a bytemporal hemianopsy Remember when a person has a bytemporal hemianopsy The high you'll think to know is that You're going to lose your outer visual field in both eyes Your outer visual field in both eyes So like the outer half in both eyes That's going to be bytemporal hemianopsy So now the big question then begs who are the people that typically get Aneurysms in the circle of Willis Well, I mean normal people can get aneurysms in the circle of Willis What are friends at the USMLE's they also love If you know certain diseases that have these associations So like for example people that have morphines Is associated with people having aneurysms in the circle of Willis Or a Zomodominant Policistic Kidney Disease Is also associated with people having aneurysms in the circle of Willis All these things can cause aneurysms And again, these aneurysms can pop And that can cause a lot of problems Now, what if they give you a question About a 29 year old male And they tell you that He is brought to the hospital by his wife Because for the last two days he has been having very severe headaches He has been having some visual difficulty He has been having next stiffness And then they give you a bunch of vital signs You notice that his temperature is like 102 degrees Fahrenheit He is blood pressure is like 90 over 60 He is tachycardic He is tachypnic And he has a fever as I've already mentioned And then they say which of the following is the most appropriate Imperial therapy for this patient's re

presentation I really hope in that situation you're saying Oh divine I think it would be wise For me to give this person some element of Cephtriaxone And some element of Vencomisin And I'll see plus or minus steroids in this circumstance So what's the deal there?

So this person Sounds an awful lot like they have bacteria in meningitis I know you may be like But divine Corino be viral Corino be fungo Corino be tb Again if we're just going with most common presentation That underlies what I just said But terminal in gyrosis is the thing that makes the most sense One thing I'm going to comment on here is We live in a world Especially of USML attackers Where people are so focused on getting the exact Oh what is the exact What is that one thing here that tells me Oh this is exactly what's going on That's not a wise way to take the USML exams The USML exams are almost like based on probabilities That's what we like to think of the USM Ls I think of it as a probability-based exam You ask yourself with a question that's been given What is the most likely thing that is being tested here What is the thing of highest probability That's being tested with this question That is placed right before me Right You see a person with crazy high fevers No courage to do Youngish person Acute presentation Again Is almost certainly like if they have to make you like play odds You're playing the lottery I would probably put my money on bad term in in gyrosis Because it's just the thing that makes the most sense In this circumstance So in this circumstance I would certainly be giving this person a combination of Ceptriaxon Vencomison and steroids That's what I'll be doing Like CVS Just remember CVS Like the drug store chain So why that Well the thing is the most common cause of meningitis Is going to be Stremming was the most common cause of meningitis So we're going to give Ceptriaxon Because it's going to cover it very beautifully But another thing we do is We're going to say Okay let's go ahead and give Let's go ahead and give Venk Because Venk Can also cover stuff Orius Although also don't forget that Ceptriaxon Can also cover nice germinanitis Beca

use yes Nitrogen meningitis is not necessarily the most common cause of meningitis But it's pretty common as well So you want to basically cover all your basis When you're given a person in buried therapy That's why we give Ceptriaxon Venkomysin and we give steroids Ceptriaxon and Venk We'll pretty much cover most of the notable Gram positives And gram negatives That can cause meningitis And then steroids are generally indicated When you're worried about strep pneumo meningitis When you're worried about strep pneumo meningitis You've got to add steroids in those circumstances And then obviously As you then get like a Lumber puncture And you Get like gram Sting results Csf culture results You can then reorganize your therapy accordingly But empirically believe it or not You will get questions on your exams Where you have to treat a disease empirically Imperic treatment of meningitis Very very high you to know In general you want to do strep triaxon and Venkomysin They may not throw in steroids as part of the answer But for sure You want to give strep triaxon and Venkomysin Now remember the empiric treatment of meningitis is different If you're talking about like a neonate Or you're talking about a person over age 15 When you're dealing with a neonate or a person over age 15 Then in addition to giving strep triaxon and Venkomysin You also have to give an pyselin Because people that are neonates people that are over age 50 They are pretty supposed to get in meningitis from Listeria Listeria the most effective drug for covering Listerial infection Is an pyselin So it's pretty helpful in those circumstances To give those people an pyselin Just to empirically cover Listeria Because Listeria meningitis I believe Has a really bad mortality If you pretty much don't treat it and treat it on time So it's just one of these weird things that you kind of need to keep in mind For yo

ur test Okay Now what if they give you a question About a What if they give you a question about a child And they tell you that this child you know for the past 70s this child has been having like really high fever And they tell you that this child has also been having like some chest pain In fact over the last two days the child has been having chest pain And they tell you that or that you listen to the child's chest And you hear a holosis stomach murmur You hear a holosis stomach murmur At the apex You're like hm holosis stomach murmur at the apex You're like hm that's kind of weird And then they also tell you that in the cue stem that this child Has cervical lymphatic anopathy And what they tell you that this child does not have any A dima of the throat Doesn't have any infiltrates or exudates on the throat And then you're also told that this child has significant right upper quadrant pain Um If you see and you know they'll say like in the question that who are the doctors visit like a month ago There was no murmur heard in this child's chest Right and then you may see they may give you a picture of like the tongue in this child or whatever When you put all these things together what are you thinking about?

I really hope you're saying oh divine This sounds an awful lot like a Kawasaki's disease Maybe like wait what Um In fact, I kind of want to break down this this topic because it's something that people could really wafer on On exams and I would want you to wafer on this the stuff but They could give you a question about a child With just these disparate set of symptoms Um you see cervical lymphatic anopathy You see these very high fevers that have been going over a couple of days You notice that the child may have like given some volume of issues like like a mitral regurg Um you may notice that they may have like coronary artery aneurysms You can even see this right upper quadrant pain because sometimes in Kawasaki's disease The inflammation spreads to the right upper quadrant and when it spreads there Um you can basically have like a demon of the world of the gold blotter That's what's called gold blotter hydrops like a strictly happen And then Remember these people can also have a rush on their palms and souls although the one always mentioned it like that They can in turn that rush to a demon They can say this person has a demon of the hands and feet When you see stuff like that you want to think about Kawasaki's disease When think about Kawasaki's disease Now what are some things that you could have completed this with Well one of the things that I've completed with this with is rheumatic fever In fact, I kind of figured that if I mentioned the valve lifting Oh people will just eat up wrap up in in in in in in up rheumatic fever Just be careful just be careful right rheumatic fever right usually They would have given some kind of group A strep and tisident in the question Group A strep usually causes some kind of fire angitis So you're going to see like some throat findings Like in literally inside the throat That's just something I want to keep in mind So they'll

tell you some information about a rapid strep test And although we could have also screwed this up is thinking about mono Right because people are like oh mono mono The vine right up record trend maybe Hit puddle something something megaly Yes, it could also be mono But again mono causes a fire angitis Mono causes lymphatic not with it with this child had But you know this child you don't have fire angitis And again, I didn't really mention anything about an age or a situation Where the child could have kissed someone Right like mono is going to be something that you're going to be seen in A teenager or older on your exams So say for example a person is like five or six years old I will probably not pick mono for that person It doesn't really make sense to pick that kind of an answer There has to be some very significant Extend waiting circumstances in a question for you to go down that pathway So Kawasaki's disease So what are some big things to keep in mind with Kawasaki's disease But what would have Kawasaki's disease Typically you're going to see them They're going to have like fever for a couple of days You're going to see them have Sometimes they can have cardiac abnormalities That can be an actual your presentation Believe it or not an MI can be a presentation of Kawasaki's disease I'm going to say that again An MI in a little child can be a presentation of Kawasaki's disease Be very very careful about that Be very very careful about that An MI can be a presentation of Kawasaki's disease in a little child So you see a little child with an MI And you see the child has like a fever with the MI One of the first things I want you to think about is Kawasaki's disease Or you see a child that has a fever They have an MI And you see like mitral problems Like mitral insufficiency that develops acutely I also want you to think about Kawasaki's disease Okay I know some o

f these things I'm saying may sound like unusual presentations But I promise you these are very high yield presentations to know for the purposes of your exams Now Kawasaki's disease What are some other things to know here Well again as I've said These people can have a coronary artery on the rhythms In fact this is one of the reasons why these people get aspirin and IVIG Okay This is one of the reasons why these people get aspirin and IVIG Right aspirin and IVIG aspirin and IVIG aspirin and IVIG Because Kawasaki's disease is an example of a kind of a vasculitis Right And remember they also have like a russian poms and soles Now one thing I also want to bring up here And honestly I don't know why this is the case Well this is something definitely need to know for exams Is that Kawasaki's disease has a pretty solid association with thrombocytosis I'm going to say that again Kawasaki's disease has a pretty strong association with thrombocytosis With thrombocytosis with thrombocytosis That is super super super high yield to know For purposes of the USMEL exams People can have Kawasaki's and have thrombocytosis Why?

Honestly I've not really found a good explanation in all my reading But that's something that I would strongly encourage you to know for for exams Stronger encourage you to know for exams Now one thing I want to comment on here is What are some causes of acute mitro regurg Because the pattern of development of acute mitro regurg Sorry the part of development of mitro regurg can tell you certain things On your exams In fact let's discuss mitro regurg from a few different perspectives Because it's one of these things that It's just one of these like innocuous concepts Just kind of pops up out of the blown exams And people kind of shake shake with those those states I don't want you to be one of those people So if you see acute mitro regurg Especially in a very young child Are you noticed that they have a fever One of the things I want you again to think of is I certainly certainly certainly want you to think of Either a dramatic fever or Kawasaki's disease But again I've already explained to you how you can differentiate a dramatic fever from Kawasaki's disease Now if you see a person develop acute mitro regurg And the person has like a bad medical history They're obese They have like hypertension They have smokers Blah blah blah blah And you see that this mitro regurg develops like super soddently Like literally within like a few hours You see them develop pulmonary dima I want you to think of that person having an MI So what exactly is happening there Well the thing that's happening Is that they have a papillary muscle rupture They literally ruptured their their papillary muscles They've literally ruptured it Right And sometimes on exams Instead of calling a papillary muscle rupture They'll call a rupture of the cordy tendon They'll call a rupture of the of the cordy tendon rupture of the cordy tendon Those are structures that support the papillary muscle So if those

things rupture They're going to have this acute onset mitral regurgitation Again it's just one of these weird things You want to keep at the back of your mind for exams And then if you see a person develop chronic mitral regurg You notice that man over time It's developing mitral regurg Developing mitral regurg Then I want you to think of that person having some kind of dilated cardiomyopathy Dilated cardiomyopathy Dilated cardiomyopathy So why does dilated cardiomyopathy cause mitral regurgitation that is chronic Well the thing is that if it cardiomyopathy will cause mitral regurgitation that is chronic Because so again what exactly does it do Basically what is going to do is You're going to have a dilution of the left ventricle When you dilate the left ventricle You're essentially going to pull the mitral valve leaflets apart When you pull the mitral valve leaflets apart What the thing that's going to happen is that Blood is then going to be refluxed back into the into the left eater Right and over time that can that can present as mitral regurg Okay mitral regurgitation can be a presentation of Dylated cardiomyopathy on exams And again remember our friends at the USMEL Es They can give dilated cardiomyopathy many different names They can call it eccentric hypertrophobic exams They can call it chronic volume overload on exams Again remember this is one of the hallmarks of the USMEL Es these days Is taking what you know and just being more descriptive Or putting it in other terms Right because again I feel like the USMEL Es these days They're trying to fair it out with people that truly understand what's going on They're trying to fair it out people that have modules blindly memorized their way through things But can actually like critically think and reason through what they have memorized Through what they have learned So again I'm just going to sound I have sounded t

his call out to people many many many times Among this podcast there is nothing wrong with memorizing stuff But make sure you understand and can reason through stuff And not just understand or reason through stuff But ask yourself what is the story behind this thing Many people will be well served to learn things in the story format On USMEL Es exams Like as they are studying they are learning the story behind the pathology When you learn the story behind the pathology Then it will be very easy for you to recognize those things on on exams That's just the truth When I go ahead and continue So as I wrap up today One thing I think I want to focus on Is to discuss some of the uses of aspirin on exams Because you know sometimes people wonder When can I use aspirin on the USMEL Es exams Believe it or not they're actually a myriad of weird associations with aspirin That I will still be pretty helpful for you to know for your test So the first one we've kind of talked about You can use aspirin for Kawasaki's disease You know in general you try to avoid giving aspirin to little kids But in Kawasaki's disease you throw that rule out the window You can give aspirin to little kids that have a Kawasaki's disease Now what's the second association on Kawasaki's disease When a person has an ischemic stroke That is not of a cardiac origin Because remember you can get these ischemic strokes On USMEL Es exams in general for two major reasons You can get it from the carotids Or you can get it from the heart Usually put that get it from the heart Which is less common People that have a feb of had a recent M-on But if you have like ischemic an ischemic stroke because of a carotid problem One of the treatments you should strongly consider is aspirin Obviously if you are less than four and a half hours from symptom onset and is an ischemic stroke The first thing you're going to give is TPA Kin

d of like the smart play But once you're done giving TPA In terms of what the person should be on long term I was strongly encourage you to consider putting those people on aspirin Strongly consider people to put in those people on aspirin When people have ischemic strokes They need to be on anti-plet lead agents When they have ischemic strokes of carotid origin Which again is the most common kind of ischemic stroke Go ahead and put those people on anti-plet lead agents Like aspirin or acropodogryl or dipiridomol Usually aspirin is the go-to on exams But remember if a person has a stroke from a cardiogenic source Let's say they have a feb or they have my trust and noces Or they have whatever Please do not put them on an anti-plet lead agent Put them on an anti-coagulant Something like wafery Something like apics about something of that nature Just be wise be smart Okay?

It seems like a subtle difference But it's a common difference I've seen many my students Kind of with Basically mess up on on exams You don't want to be one of those people That was a third use of aspirin A third use of aspirin is in peripheral arterial disease Actually every single person that has peripheral arterial disease Has to be on aspirin Because again peripheral arterial disease Is basically like atherosclerosis Atherosclerosis of a person's Low extribute vessels That's more of a thrombotic phenomenon Those people certainly should be on an anti-plet lead agent like aspirin And they remember when you've had an MI One of the first drugs you're supposed to get is aspirin Is one of the drugs you get in the acute phase of an MI But also after a person has had an MI And they get a stem placed in their hearts They need to be on dual anti-plet lead therapy That dual anti-plet lead therapy Is usually going to be aspirin and some other drug Typically something like Lupido Gryl The P2 Y12 inhibitor Now another thing to keep in mind with aspirin for exams Is that you can use it as a clumsy uprofielaxis Right?

So if someone has had like a clumsy And a previous pregnancy you're like Hmm, she had to want this one to have this problem again In future pregnancies When she gets pregnant again Go ahead and put her on aspirin Go ahead and put her on aspirin And then don't forget that aspirin can cause tinnitus Asprin can absolutely positively cause tinnitus It can cause tinnitus That's something you want to keep in mind on exams And then what are the AC Bs that normally you can get when you take aspirin Or you overdose on aspirin Well the AC Bs that normally you can get Is you can get a respiratory alkalosis And a metabolic acidosis at the same time Many people for the purposes of the US Emily exams Actually many resources have thought people this Is this whole concept of If I may have thought this in the past But this is something that I've pretty much kept Suddenly in mind for years That those two provincial parties at the same time Right? Many people learn that Oh wait, you get the respiratory alkalosis first And then get the metabolic acidosis later That is not true Okay? Because you see some people They'll get these arrow questions involving AC Bs problems on aspirin And then they'll only pick the answer that shows respiratory alkalosis alone And then they won't pick the one that reflects respiratory alkalosis and metabolic acidosis Please let me tell you right now Both of those problems crop up when you have aspirin toxic濕 Right?

It rests up your respiratory rate So you're going to blow CO2 You're going to get a metabolic Sorry respiratory alkalosis from that But you're also going to get a metabolic acidosis For two reasons One, aspirin is literally known as acidosale acetic acid Okay, it's an acid So just based on acid base You know right of the bat You're going to get a high anion gap in a metabolic acidosis But that's not all Aspirin is also an on-coupling agent It kind of works like dinatrophinal It's an on-coupling agent of the electron transport chain So basically you will not be able to make ATP You're pretty much wasting that proton gradient that you have In your inner mitochondrial In your intermembrane space Of your mitochondria So basically Yes, you're doing everything Most of your electron transport chain is happening But basically Aspirin on couples that process And when you're on couples that process You're pretty much just generating a lot of heat So your body is going to start depending on a lot On like colitis To give it any kind of useful energy like ATP So you're going to be making a lot of lactic acid That can certainly cause you to become acidolic So please Aspirin Please I want you to disband this from your mind of Ooh, respiratory acylosis first Metabolic acidosis down the line No Is respiratory acylosis and metabolic acidosis At the same time I'm going to say that again At the same time That's pretty high you to know for for example That's pretty pretty high you to know for for example Okay, so I think I'm going to go ahead and stop here I think those are Well, I guess maybe there's throwing one more aspirin A fact right here Right, so you see a person that You know they've been taking aspirin for like pain or whatever And then you notice that you know they've been having asthma stout symptoms They've been having nasal polyps This is pretty easy right This is aspirin in

duced asthma I believe these days is called aspirin exacerbatory respiratory disease But what's the pathophys behind that Well the pathophys as you know Aspirin is a cox inhibitor It's an irreversible inhibitor of cox-1 and cox-2 Well guess what?

If you shut down cox-1 and cox-2 Then arachidoneic acid needs to be useful in life So is it going to get useful? It's going to get useful By getting shunted down the lipoxygenates pathway Into making local trines When local trines they can cause bronchospasim They can cause asthma like symptoms Right? So that's actually the pathophys behind Aspirin exacerbated respiratory disease Because basically by shutting down the cycloxygenate pathway Then the only fit for arachidoneic acid is like Okay, I'm going to go down the lipoxygenate pathway And you're going to make all these local trines Again, which can cause a lot of airway problems That can certainly cause asthmatic symptoms Aspirin exacerbated respiratory disease Has a classic association with nasal polyposes Okay? Has a pretty strong anesthesia with nasal polyposes Right? And again, by the way, if you ever see nasal polyposes I'm, I'm, okay, let me take a step back real quick So that, um, aspirin exacerbate Aspirin exacerbated respiratory disease How can you treat it?

Well, obviously a white thing needs to probably stop taking an aspirin It's probably not a smart idea That's one But the second thing I would say to keep in mind there Is maybe using a local trine antagonist Like a literal trine receptor blocker Something like Monte Lucas Or Zafriloquist Or you can use lipoxygenase inhibitor Like Ziluton for example ZILUTON Those are very effective therapies for managing aspirin exacerbated respiratory disease Okay, and then with nasal polyposes I don't know just all these higher things Just kind of flying into my brain Uh, but nasal polyposes Remember your exams Think of aspirin exacerbated respiratory disease Think of cystic fibrosis Cisdifibrosis is a very common cause of nasal polyposes On exams And then also think of just chronic rhinocyanusitis With nasal polyposes That's also something that causes nasal polyposes on exams Which lead out with with inhield colicosteroids And then a fourth cause of nasal polyposes on exams Believe it or not Is vaginus granulomatosis Remember vaginus these days with coli GPA Granulomatosis With polyangiatis We that that can also present with nasal polyposes Just something you want to keep at the back of your mind for For exams Okay, something is strictly want to keep at the back of your mind for exams And then don't forget that aspirin can also precipitate Gouda attacks Why?

Because it can raise your euricastic levels Okay, so if a person has a history of like Goudt Aspirin is not maybe the smartest I game those In those people It's only if they really really need that aspirin For like a really really big reason Like say for example, if had like an An MI for example And remember as well Aspirin is the drug we use for paracoditis And people that have had MI For the first six months after if had an MI You cannot take any other inset But aspirin But aspirin But aspirin Why? Because again you can have a pretty high risk of myocardial rupture So again just be smart be wise Right?

Aspirin is the inset you can take for paracoditis Really again for the first six months after an MI Don't go taking any of that kind of inset like I will profane I just going to rupture myocardium And that's going to be a very bad very bad thing Okay, so I think I'm going to go ahead and stop here Again, thank you for joining me For those of you that are studying for step two Step three or step one I have a bunch of classes that are coming up Actually starting like two more Yeah, tomorrow Right, so I have a testicking strategies class It's two and a half hours long It's for step one or the way to step three That's tomorrow On Friday I have a bio statistics class If you struggle with bio stats You're taking step one to step three That class is exactly what you need On Saturday I have a five hour class That covers quality improvement Social sciences Healthcare systems Ethics And what not Let me tell you this These classes are not lectures They are all based on stories They are all based on scenarios They are all based on clinical presentations Because that's exactly the way your USMLE exams will be Right, so that's one benefit of my review courses I would say is You're not just learning the concept But you're learning the story You're learning the context Behind that concept Is a much more efficient Much more effective way To learn and prepare for exams And then if you're taking step two or step three Next week Monday, Tuesday Thursday and Friday It's a four day course I am actually going to be having the 20 hour Step two step three review It's also helpful for people that are like preparing for a shelf exam So if you're interested in any of these courses Just shoot me an email And I'll give you some more information They're all held over Zoom Most of them are in the evening So you should be able to partake from all of them And then I also offer one A one-tutor in for s

tep one, step two, step three Preclinical medical exams, 30-assault exams I Also help people with your applications So personal statements, recommendation letters Editing those things, editing applications Editing supplemental applications Doing more interviews I do all those things with people And I have these podcasts on the major apps You know, Apple Podcasts, Google Podcasts and Spotify I have them on those major platforms I have a USML A You Tube channel called Divine Intervention, USML Podcasts and Videos That's where I post the videos that I make So you can go ahead and check those out And then you know many of you know I'm a Christian So I do have another website called Divine Intervention Lifelessens.com Divine Intervention Lifelessens.com Divine Intervention Lifelessens.com There's actually an Apple Podcasts So you know that called the Divine Intervention Lifelessens.com Many people have said that Oh, Divine, I love these little life lessons You put at the end of some of your podcasts So I decided to basically make a separate website Where every week I post like two podcasts About 10 to 20 minutes long Where I address a life lesson from a biblical perspective Again, many people have listened to those fondos To be extremely helpful So go ahead and check those out So I'll see you in the next podcast The one thing I'll just say to you today Whenever you face a tough circumstance So think of this as a mini life lesson Whenever you face a tough circumstance Be quiet and try to be constructive Be measuring your steps Because usually when people face chaos When people face catastrophe or disaster They start doing a lot of irrational things But I promise you, when in a situation of chaos Even in a situation of disaster You can make good wise choices Take a step back Be patient Be calm Be gentle When a tough circumstance comes And then think Process, ask yourself Okay, what

is the rational approach in this situation What do I do Right Many times quietness And even just doing nothing Is the best move In a chaotic circumstance Sometimes just doing nothing Because when you do nothing and take a step back It then causes you to wonder the situation rationally And begin to do like just wise Wise things Right Begin to do just wise things I mean you see this in many situations of life Where Catastrophe happens And people just like I must do something I must do something But in those things they do End up adding to the problem Instead of actually like solving the problem So again Just realize the importance Recognize the importance of Stopping Looking Listening Thinking In the course of a bad Bad situation Okay, well I'm going to stop blabbering for now I'll see you in episode 469 Bye for now God bless you

Bitemporal hemianopsia (loss of outer visual field in both eyes).

Ceftriaxone, Vancomycin, and Ampicillin (to cover Listeria).

Streptococcus pneumoniae.

Thrombocytosis and coronary artery aneurysms/MI presentation.

Antiplatelet agents (e.g., Aspirin).

Respiratory alkalosis and Metabolic acidosis.

The optic chiasm, often due to a mass like an A Comm aneurysm.

Ampicillin (must be added empirically in neonates and elderly).

Kawasaki disease.

Inhibition of COX enzymes shunts arachidonic acid into the lipoxygenase pathway, leading to excessive leukotriene production and bronchospasm.

Ischemic stroke of carotid origin, Peripheral Arterial Disease (PAD), or after MI/stent placement.

Thrombotic $\rightarrow$ Antiplatelets (Aspirin); Cardioembolic $\rightarrow$ Anticoagulants (Warfarin/Apixaban).

Aspirin-Exacerbated Respiratory Disease (AEARI) and Cystic Fibrosis.

The optic chiasm, often due to a mass like an A Comm aneurysm.

Ampicillin (must be added empirically in neonates and elderly).

Kawasaki disease.

Inhibition of COX enzymes shunts arachidonic acid into the lipoxygenase pathway, leading to excessive leukotriene production and bronchospasm.

Ischemic stroke of carotid origin, Peripheral Arterial Disease (PAD), or after MI/stent placement.

Thrombotic $\rightarrow$ Antiplatelets (Aspirin); Cardioembolic $\rightarrow$ Anticoagulants (Warfarin/Apixaban).

Aspirin-Exacerbated Respiratory Disease (AEARI) and Cystic Fibrosis.