DIP Episode 632 - Travel Medicine B (super HY with lots of integrations, for Step 1-3)

Alright, welcome to episode 632 of the Divine Intervention Podcast. In today's podcast, we're going to be continuing the series on travel medicine. This is going to be part B. Again, if you missed part A, strongly encourage you to go back and listen to it. It is a very high-year podcast, and I know it may be titled Travel Medicine, but it's not just Travel Medicine, I discussed there. I made a lot of very useful integrations that I think you're going to find to be helpful for you, exact. Alright, let's jump right into it. So what if they give you a question about a patient? They tell you that this patient, you know, can even be traveled within the US actually, or traveled outside the US. Remember, you're taking the US Emily exams. And you know, over the past five days, the patient has been having like very high fevers, and the fevers have worsened over the course of the week. You know, they tell you that the person has been having a, you know, that on Monday, their temperature was like 101 on Tuesday, was 102, Wednesday, was 103 points, something. You just have this progressive increase in the person's temperature over time. And then they tell you that you see these faint macules on the person's lower abdomen. And then, you know, they give you that, oh, the current vital signs, you see the person's temperature is 104. And you notice that those persons heart rate is 45, right? The person's heart rate is 45.

And you tell you that the person has not had any bowel movement over the last two days. If you see something like this, and it's probably going to be in a child on your exams, what should you be thinking about? I hope you're thinking about typhoid fever, right? So this child has infection with someonella typhoid, right? And the thing is, again, just like I did in the previous podcast, there are so many different integrations they can make with this stuff on your exams. So like, for example, they can ask you like, how did this person acquire this infection? Well, obviously it's going to be by way of a fecal oral transmission, right? You consume contaminated food, you consume contaminated water, you're going to increase your risk of contracting a someonella, right? And the thing is someonella, what kind of that, if you were to cause diarrhea, what kind of diarrhea would it cause? It's actually going to cause bloody diarrhea, it's going to cause bloody diarrhea, right? Because it's an invasive organism, right? So basically what it does is there's these M cells, I believe they're called microfold cells that we found in finding the GI tract. It's very in the terminal helium, right? Like in the terminal helium area, we find it. It's a very important thing in pyres patches, right? So it invades those cells, right? It survives in those cells, I believe those cells are kind of macrophage, right? And then from there, it gets into the bloodstream, right?

And then once it gets into the bloodstream, it loves the reticulo endothelial system, it just absolutely loves your reticulo endothelial system, what do I mean by reticulo endothelial system? And this is something I want to lock down in your mind for you exams. This is a term that keeps coming up. The thing is when you understand this term is going to make certain things that you previously memorized, make sense to you, right? So what's the reticulo endothelial system? It basically includes essentially like four things, liver, spleen, bone marrow, and gobladder, right? Lever, spleen, bone marrow, and gobladder, right? Bone marrow and gobladder, right? So the thing is, if this thing likes to invade these organs, it shouldn't come as a big surprise that the person may have a pardospelino megalith, right? They may have a pardospelino megalith, right? And the thing is, I know many people have memorized some onella. Someonella causes bloody diarrhea, someonella causes bloody diarrhea. That's true. It does cause bloody diarrhea, but the thing is typically you're going to have constipation to start, right? That's why if you notice, I let in the question by saying that hey, this person hasn't had a bowel movement for like two days, right? So just be careful about that. The USML is they know what you have memorized. Again, these people are not stupid. It's not like they just live on their rock in their MBM headquarters and they don't have any idea of what people are learning.

No, they do have ideas of what people are learning. So just be careful about that, right? Constipation is typically more common than diarrhea in the early course of someonella infection, in the early course of someonella infection, right? And again, typically how do you diagnose this? You're going to do a blood culture, especially if they've had symptoms for just like seven days or less. You're going to go ahead and do a blood culture, although you can also, you know, after like seven days or thereabouts, you should probably go ahead and do a stool culture or a urine culture, right? A stool culture or urine culture. But if you don't see an answer choice that says blood culture, you know, again, blood cultures are going to be yet within like the first few days, you know, five to seven days. But after that, you want to consider a stool or urine culture. But if you don't see an answer that says blood culture or an answer that says stool or urine culture, can I tell you one thing you can do? Bone marrow culture, right? Bone marrow culture. Bone marrow culture is extremely helpful if you really need to make the diagnosis of someonella, you know, some someonellosis, right? Because again, remember, it seats to the end of the reticulo endophilial system. So if you check the bone marrow, you're going to find it there. You're going to find it there, right? And how do you treat it? You're going to treat it typically with, you can do like a fluoroquinolone, right?

You can do a fluoroquinolone or you can use tetraaxone, right? But again, remember fluoroquinolone, there's a lot of resistance. It can explode your Achilles. It can prolong your cutie interval. It can cause a bunch of problems, right? So you may want to consider macroly like is it through my sin? Is it through my sin is a good idea when a person has someonella, right? And it's resistant to a fluoroquinolone or you don't want to give that child a fluoroquinolone, right? And again, remember, the USML is these days about 5% or more of your exam questions have this preventive medicine bent, right? So you need to consider that, hey, how could you have prevented this from happening in this person that traveled? Well, you could have given one of two vaccines. And I believe I highlighted that in the previous podcast, you could either have given the oral vaccine or the injectable vaccine, right? The oral vaccine is live attenuated. It is live attenuated, right? But again, remember, in the previous podcast, I talked about some populations where it may not be smart to give a live attenuated vaccine. So if you cannot give the oral live attenuated form, you can give the injectable form. The injectable form is a polysaccharide, right? And it's safe in people that I may not compromise, right? In fact, the injectable form, you only have to give one dose versus the oral form they have to give four doses, right? Four doses, right? And again, the vaccines have roughly equal efficacy, right?

So this is something you want to keep at the back of your mind for your exams. And then what is one amazing thing that our friends at the MBM Es can test? They can say, hey, you know, this person traveled, you know, they have the faint colored macules on their abdomen, right? Those are the real spots I kind of referenced in the question. Those are the real spots. And you may notice, right, you know, as I developed this new vignette, right? The person had a high fever, but they had a pretty cardiac, right? That's kind of strange. That's kind of strange. Typically, when people have fever, they tend to have tacky cardiac with it, right? Even like a mom, when a mom is pregnant and she has a fever, the fetal heart rate is typically going to be over 160, right? Maternal fever has a strong association with fetal tacky cardiac. Right? So it's kind of weird when you see a person that has this thing called a pulse temperature dissociation, right? Pulse temperature dissociation. Your pulse and your temperature should be associated as your pulse rises, your temperature should rise. But so it's kind of bizarre, like your pulse is rising and your, you know, I mean, your temperature is rising and your pulse is falling. That's a dissociation, right? Dissociations in medicine just mean that, hey, there are two things that are supposed to go in tandem and they don't seem to be going in tandem, right? Your temperature is going up, your pulse should go up.

But one is going up, the other is coming down. That's a pulse temperature dissociation. That's very common with salmonella, right? Another dissociation you may have heard of is abumino cytologic dissociation that we think you're in beret, right? Typically, the normal association is as you see an increase in CSF protein. You typically see an increase in cells, like inflammatory cells within the CSF. But in Guillembris syndrome, you see an increase in protein, but you don't see a commensurate increase in cells. That's a dissociation, right? So again, coming back to typhoid, right? So in typhoid, right, you have the pulse temperature dissociation, you have the raw spots, right? Those things, you know, some uncolored macules you're going to see on the lower abdomen on the trunk, right? It doesn't have to be lower abdomen, it can also be on the upper abdomen. But again, that's not the, you don't always find it. In fact, you probably find it in like less than a third of people that have salmonella, right? And then they tell you that you know, this person has been having bloody diarrhea for the past like, you know, few days. But that over the last three hours, the person has been completely no severe, worsening abdominal pain. The person's fever is higher, right? And you notice that the person has like rebound or guarding on a physical exam. When you see something like that, what's going on? They've exploded their GI tract, they've literally exploded their GI tract, right?

And they may ask you which of the following is the most appropriate next step in management? I really hope you're picking the answer that talks about exploratory laparotomy. I bet you never thought that there would be a question on salmonella on your exams where exploratory laparotomy is the next step. Well, you've just heard one from this podcast, right? So guys, please, like this stuff is actually pretty high yield to know for your exams. Again, the USML is, they love to integrate, you know, because they know that all of you have memorized, uh, uh, penetrating trauma to the abdomen, X lap, free air under the diaphragm, X lap, right? Uh, signs of parietanitis, X lap, right? So again, how do they test it these days? It can just give you a person that has something that can lead to bowel rupture, right? So like, for example, if a person has salmonella, right? Again, salmonella is pretty invasive. That's why it causes bloody diarrhea. It literally invades your intestinal mucus. When you are an invasive bug, right? When you are an invasive bug, you tend to cause bloody diarrhea. When you are not an invasive bug, you tend to not cause bloody diarrhea, right? So this, they invade. So they cause bloody diarrhea, but all that invasion, right, can ultimately lead to intestinal perforation. And this is something that tends to happen when you've had your symptoms for like two weeks, three weeks or stuff like that, right?

So that's something you want to keep at the back of your mind for exams, right? Now, what if they give you a question about a patient? And you tell me that this patient, you know, again, visited some foreign country, right? But again, you don't have to visit a foreign country to have travel medicine problems. You could also have travel within the US, right? And you're told that this person, they say that, you know, that for the last, how do I put this? I want to frame this in a way that will make it make make it make sense for you. Yeah, I want to frame this in a way that will make it make sense for you. Um, let's see. So what if they tell you that a person traveled, right? And that for the last four or five days, you know, they've been having fevers, you know, feeling nauseous, they have jaundice, right? But the person is not an IV drug user. The person is not even compromised. The person doesn't have HIV, right? And the person's LF Ts are elevated. And to be honest with you, they just give you a travel history or like, oh, you just ate a bunch of foods from different vendors, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, right? When you see something like that, what should you be thinking about on your exams? I would really hope you think about hip A infection, right? I'd really hope you're thinking about what hepatitis A infection.

Again, it is something that is pretty high yield to know for purposes of your exams, right? And just one thing I want to make. So because the USML is, they're not very big on giving people a lot of clues. Again, typically they give you a decent number of clues. But sometimes they can write these non-specific questions where they don't give you many clues, but they still magically expect you to arrive at the right answer, right? So the thing is you see a lot of food exposure, a lot of traveling, high LF Ts, John Dis, right? You know, you know, some red upper cordon pain, you really want to be thinking about, you really want to be thinking about hepatitis A, right? And the thing is sometimes on your exams, instead of putting hip A as the answer, they'll put a PCORNA virus as the answer. Again, you've heard me say this on this podcast many times about the concept of a derivative, right? So the USML is again, they know many of you probably can recognize hep A. So how can you just create a new hep A question? Well, one of the ways you can create a new hep A question is just keep the same vignette you've always used in previous years, right? But just switch up the answer. Why put hep A when you can just put an alternate name for hep A, like the corner virus, right? It's a PCORNA, PCORNA virus, right? Or why put yellow fever as an answer when you can put flavy virus as an answer, right? Why put, let's see, what's another common one? They love to tease people with on exams.

Why put parvo virus B19 on your exams? Where you can put single stranded DNA virus on your test. So guys, do you see why you need to know the classifications of these organisms? Yeah, that's why you need to know those, right? Because those are common sources of derivatives on your exams. Those are common sources of what of derivatives on your exams, right? So just kind of keep that at the back of your mind for your test. So again, going back to hep A, right? So again, you know, typically it's going to be a person that traveled, you know, half of the exposure like a month ago, right? You know, so typically the incubation period is about a month, right? About a month. And then the person is going to have like fever, you know, anorexia, you know, malaise, John, this, you know, that stuff, right? The left is elevated, right? And the thing is typically as you get older, you tend to have more severe infection. This is one of those strange things. You're like, oh, gives it to have more severe infection. No, not for hep A for hep A, things are kind of different. In fact, many times kids that have hep A infection, they tend to be symptomatic. But as you get older, the severity tends to increase, right? The severity tends to increase, right? And then our friends at the MBM Es, this is something I was actually kind of, almost like preaching like a sermon in one of the classes I thought recently, that hey, prognosis is a big thing on the US Emily exams, right?

Is a big thing on the US Emily exams. So what can I do prognosis here? Well, we know that most people that have hep A can recover, right? Most people recover and it's not a big deal. But one thing our friends at the MBM Es love to do is what if you, they can give you a question about a person that has hep A infection, right? And the person has a history of, you know, like hep C or the person has a history of some kind of liver disease or whatever, right? And then they will ask which of the following factors in the patient's medical history most increases the risk of developing a fuminant hepatitis, a fuminant hepatitis? Well, you want to maybe go ahead and pick the answer that talks about the liver disease, the preexisting liver disease that the patient has, right? Again, this is something the US Emily's love to do, right? So they'll usually give you many things in the person's medical history. The person who have like some kind of liver disease, the person who have high blood pressure, maybe heart failure, whatever, right? If a person has preexisting liver disease, that is one of the biggest determinants of their prognosis, if they have an acute hep A infection, okay? And remember, hep A does not cause chronic infection. It causes an acute infection, right? So like typically if you want to diagnose hep A, just check the anti-HV IGM, right? If it's the IGM that's positive, it tells you that it's an acute infection.

If it's the IGG that is positive, it means that this person has probably had a past infection, right? Or they got a vaccine against hep A because there is in fact a hep A vaccine, there is in fact a hep A vaccine, right? So you may wonder like divine, why is it that IGM indicates an acute infection? Well, think about this. What is the first antibody you make to an infection? It's going to be IGM, right? Literally by default, the first antibody immune system mixed to any infection is IGM. And then after that, this process called class switching is going to happen. Isotype switching is going to happen. And then you're going to go from IGM to IGG or to IGA or to IGE, okay? You may again be wondering like, divine, why, why, why, why, tell me why? Why is IGM made first? Well, the thing is when your body is making antibodies, the first part of the genome that it can tapping to that it can access is literally the IGM part of your genome, right? It literally has no access to the other parts, right? So it has to work with what it has current access to. That's why IGM is the first antibody that's made. Now, there's more genetic underpinnings there, but that's kind of beyond the scope of this podcast. I'm going to move on from from that, right? And again, preventive medicine is the big is a big thing on the exams, right? So you can ask you, oh, which of the following measures would have increased this person's risk of infection? Well, the person could have gotten the vaccine, right?

The person could literally have gotten the vaccine, right? Remember, you get the vaccine as a two doses, right? And it's extremely effective, right? You get it as a child, right? You get it as a child. You get it in two doses, you get it in two doses. You give the first dose and then like six to 12 months later, you give the second dose. It's extremely effective. The immunity stays for a pretty long period of time. So it's just something you want to keep at the back of your mind for your exams, right? But one thing our friends at the MBM Es can also do is they can ask you about post exposure for relax is actually for for hep A. These are one of those things that you almost never find in any resource, but it's actually very, very high you to know for your exams. It's actually what very, very high you to know for your exams. Right? So they can ask you like, you know, let's say there was a let's say there, there's been an outbreak or you're aware that the person was exposed to hep A recently, right? Especially within like the past like two weeks, right? After like two weeks, all bets are kind of off. And then they ask you, you know, which of the following is the most appropriate next best step in in management? In that case, go ahead and give the person the hep A vaccine, right? In general, post exposure profile access, when you've been exposed to hep A, especially if you're asymptomatic, is for you to get the hep A vaccine. Okay? Is for you to get the hep A vaccine. Right?

But if a person is immunocompromised, right? Or let's say the person has some kind of chronic liver disease, let's say they have cirrhosis, then you don't just give the vaccine alone. You can actually give the vaccine plus the immune global plus hep A immune global, right? And also that's something we may do in people that over age 40, but generally people that are even over age 40, doesn't matter. You can still give them the vaccine alone. That's fine. That's fine. Okay? But please do not forget this for purposes of your exams, right? For most people, just give them the hep A vaccine, right? That's fine. But if the person is immunocompromised or they have chronic liver disease, then you need to try to give them not just the vaccine, you also need to give them the immune globular, right? So basically you're giving them active immunity and passive immunity, right? So again, our friends at the MBM is they know some people may have memorized or activity, they may have memorized the vaccine plus immune globular. So what's another way they can literally ward the exact same thing on your exams? They can ward the exact same thing by putting an answer that says, active immunity alone. Passive immunity alone, active plus passive immunity, right? So obviously for persons getting the vaccine alone, they're only getting active immunity. But if the person is getting the vaccine and the immune globular, you're getting not just active immunity alone, but they also getting passive immunity.

They also getting passive immunity. All right. So keep that at the back of your mind. Remember, fecal or transmission, right? And you can also get person to person spread, right? Person to person spread. That's why we do this thing called post exposure perphylaxis, right? And again, you consume contaminated food contaminated water. You're going to get in trouble. You're going to get in trouble. All right. Now, what if they give you a question about a patient? And this patient has, you know, fevers, you know, really nasty headache, right? And they tell you that, you know, that they were bitten and they have like this, uh, you know, that they went to a foreign country and they were, in fact, like they were bitten by a dog, right? But they thought nothing of it. But now this person has been having fevers, headaches, this person is having a parastegias where they were bitten, right? And then they tell you that this patient for the last four days has not taken a shower, right? For the last four days, hasn't taken a shower, right? And this person has been very, you know, having like very hyperactive symptoms, has been having a lot of hallucinations. When you see something like this, what should you be thinking about? I hope you're thinking about rabies, right? I hope you're thinking about rabies, right? Our friends at the NBA means one time on our thing they love to do is to test rabies in the context of travel medicine on your exams, right?

Is to text, is to test rabies in the context of travel medicine on your exams, right? So typically, how do you get rabies? Well, you're going to get it from a bite or a scratch, right? So they may not use the word dog bite. They may use the term that the person was just scratched by some animal, right? So a dog bite or a dog scratch, just be mindful of that, right? From an infected animal, you know, a dog, right? A dog, right? The literally like dogs are the most common vectors for, for rabies globally. They're literally the most common vectors, right? The virus is in the saliva of that dog, right? The virus is in the saliva of that dog. So when the dog bites or scratches you, then you're going to acquire said, said virus, right? And this can happen in, you know, African countries, Asian countries, but again, it can also happen within the US. It's not like the US is like immune to rabies, just FYI, right? So typically, how do these people progress over time? Well, they usually start off with like fever, headaches, right? The place where they were bitten or scratched, they have parestidias there, right? But then over time, they start having things like hydrophobia, a fear of water, right? Aerophobia, a fear of air, right? They are very hyperactive. They're having these hallucinations, right? In fact, sometimes that is called like a furious rabies. I like to call them, you know, and the name is very descriptive, furious. Think about if divine is furious with you.

It means very angry, right? So the person is like, right? So furious rabies, right? But over time, you know, it then progresses to paralysis, right? They start having like a like an ascending paralysis that actually looks a lot like Guillain-Barré syndrome, right? And then over time, they're going to die basically, right? The final common pathway, once you generally become symptomatic of rabies, you're probably going to die. Once you start having symptoms, you're probably going to die. The mortality is like 100%. Rabies is one of those things you don't mess around with, right? If no, the person is going to die. The person is going to die, right? The person is going to die, right? So once they start having the hydrophobia, aerophobia and stuff, kind of all bets are off. You know, you can do ICU care, whatever, but they're probably going to die. They're probably going to die, right? So how do you treat rabies? How do you treat rabies? It is super high yield. And our friends at the NBM is just amazing. How diverse they can be with the questions they test, right? So they can literally let me give you like the different variants of questions you may see on your exams with rabies. Number one, you can give you a question about a person that was just bitten by a dog like a few minutes ago or a few hours ago, right? And the dog status is literally not known. The dog status is literally not known, right?

And then they ask you which of the following represents the most appropriate next step in management? And they will give you an answer that says to give the techno's vaccine. They will give you an answer that says to give the rabies vaccine. They will give you an answer that says to give the rabies vaccine and the immune globally. I'm going to talk about all these things. And then they give you an answer that says to irrigate, irrigate the wound with soap and water. What answer should you pick? Please, guys, pick the answer that talks about irrigating the wound with soap and water. That's literally the first thing you should do. That's literally the first thing you should do. That is a phenomenal way to do source control, right? So if a person has like a fresh wound, irrigate that one with soap and water. That's a very smart thing to do, right? Thoroughly wash that wound where the person was bitten or scratched with soap and water, doing it for about 15 minutes, right? In fact, it literally reduces your risk of the rabies progressing by like 80 to 90%. That's probably one of the most important interventions you can do for those people. So wash for about 15 minutes, wash for about 15 minutes. You're literally washing the rabies out, right? That's an amazing way to do source control, right? And then what else should you do? What else should you do?

Well, the thing is if a person has never been vaccinated against rabies or you don't know their vaccine status, then the thing you want to do is you want to give them the immune globally and the vaccine, okay? You want to give them the immune globally and the vaccine, right? So their vaccine status is unknown or, you know, they've been on vaccinated. Give them the immune globally and the vaccine. And the place you give the immune globally matters, you want to give the immune globally directly into the wound, right? Infiltrate the wound with the immune globally. Why in the world are you going to do that? Well, the reason you're going to do that is because is because like the rabies virus is within that wound. That's why the early, the earlier you give it the better, it's literally within that wound, right? So if you give the immune globally, the immune globally will literally bind up the virus. That's very helpful, right? But then remember, give the vaccine elsewhere. Please do not give the vaccine. Please, those shall not give the vaccine at the same place where you give the immune globally. If not, that vaccine ain't going to work. Why? Because the vaccine will literally be bound up by the immune globally, right? So literally give the vaccine at a distant intramuscular site. Don't give it at the same site where you give the person the, the, the immune globally. Just don't even want to keep at the back of your mind, right?

And then and the vaccine is like four doses, but you didn't to worry about that for your test, right? But if you've been, well, maybe you need to worry about that for your test, actually, right? But if you've been previously vaccinated, right? Let's say you've got in the vaccine against rabies, then you don't need the immune globally. All you need to do is just give the vaccine, give two doses of the vaccine, and that's, that's it, right? That's it. Now, what if a person, so we've talked about post exposure, what if he's like, man, I'm kind of putting myself in a high risk situation. You know, I have a high risk of getting rabies. What can I do so that I don't develop problems in the first place? On your exams, go ahead and give those people the vaccines, right? Go ahead and give those people the vaccines, right? Go ahead and give those people the vaccines, right? Give them the vaccine, right? And the good thing is once a person gets the vaccine, then post exposure prophylaxis is just going to be the vaccine. Again, remember, please don't make the head be mistake, right? What do I mean by the head be mistake, right? Obviously, if you've got in the head be vaccine, then if you're exposed to head be like needle steak, you don't need any kind of post exposure prophylaxis. You don't need the immune globally. You don't need the heavy vaccine, but that does not necessarily work with rabies, right? That literally does not necessarily work with rabies, right?

Rabies, if you've been vaccinated and you're exposed to an animal, you know, billion scratched or whatever, you still need to get the vaccine only as the post exposure prophylaxis. So again, the pre exposure prophylaxis is to get the vaccine. Literally get the vaccine, right? So you may be wondering to find what kinds of patients may I see on the exams that should get the rabies vaccine as pre exposure prophylaxis. Consider a person that works with animals, a veterinary veterinarian, right? A person that works with animals, they should probably get the vaccine, right? That can be a question on your exams, right? They give you a question about a person that is, you know, starting veterinary medicine school, right? And they say, oh, which of the following, you know, they can literally make a vaccination question out of a person studying vet med school, right? In that case, the person should get the rabies vaccine, the person should get the rabies vaccine, right? And also if you're going to a place, if you're traveling to a place where rabies is endemic, yeah, you should also get the vaccine, right? Or you're going on an adventure, you're going to be exploring a lot of caves, right? You're going spill on kin. You should probably go ahead and take a take the rabies vaccine, go ahead and take the rabies vaccine. All right. So I think those are all the things I think I want to say about rabies. Those are all the things I think I want to say about rabies.

You know, I just want to give a few more quick hits on some minor things that pop up in travel medicine and then we'll go ahead and I think I want to try to see if I can compress everything else into this one podcast, right? But don't forget on your exams. Again, this maybe pops up every few years, right? Pretty much everybody gets it wrong. But again, you don't have to join those people to get it wrong if you just kind of pay attention, right? But again, you know, they can give you a question about a person that visits rural Asia. So how is this going to present on you exams? It's going to be a person that visited or visits rural Asia, rural Asia, right? So like rural India, rural Japan, right? Or you see Papua New Guinea. If you see Papua New Guinea, person that visited like a Papua New Guinea or like a rural part of Papua New Guinea, right? Papua is PAPU A new is new, you know, any W and then Guinea, G U I, any A, right? So person that visited there, right? And then they have, they have, they've been having fevers, they've been having headaches, altered mental status seizures, right? They even have like signs of Parkinsonism, right? They have like a positive of movement and all those things. You want to think about Japanese and civilitis. You want to think about Japanese and civilitis, right? That's the way they're going to present it on your exams. Right? I remember it's carried by the Kulex Mosquito. Right? Not so cute after all, right?

So Kulex, C U L E X, the Kulex Mosquito, right? And especially like if they tell you that the person went to a rural area, where a lot of rice is grown. A lot of rice is grown. Think about Japanese and civilitis, right? Because he likes to breed in these rice parties. So those strange things you want to know for your exams, right? Or let's say the person had a lot of exposure to pigs, because pigs are a big time race over of this, right? Keep that at the back of your mind for exams. Pigs, birds, think about this, right? And this is another flavy virus, right? Kind of like what's the other thing I've discussed to you? That's a flavy virus yellow virus, right? Yellow virus, right? So this bog is a flavy virus, right? And it's neurotropic. It likes to go to the brain. Why? Because it literally can cross the blood brain barrier. Crosses the blood brain barrier, infects, inflames your neurons, right? And then the person has a civilitis, right? That's why they have like, ornamental status, they have seizures and things of that nature, right? Things of that nature, right? And sometimes on your exams, they can ask you which of the following is the most common clinical presentation of Japanese and civilitis? Most people are going to be symptomatic. They're not going to have any symptoms. But some people can have very, very, very nasty and civilitis, right? Very, very nasty and civilitis, right? Very, very nasty and civilitis.

And once a person has a civilitis, there is a lot of dynos almost like one third, right? There is a lot of dynos almost like one third, right? And even if those people survive, even if those people survive, many of them are going to have like permanent, neurologic damage, permanent neurologic damage, right? And the way you're going to diagnose this is just look for the IGM, again, acute infection, right? IGM in like the CSF in the serum, you can even do a PCR of these fluids, right? And then there's no, it's a virus. There's no much in the wheel of treatment that's available, right? There's literally no much in the wheel of treatment available. But the vaccine, you can give an inactivated vaccine, right? So again, if a person is visiting Papua, New Guinea, or a person is visiting a rural Asian country, right? Our person is visiting a place where they're going to be exposed to a lot of pigs. Again, especially in a rural Asian country, or a place where a lot of rice is grown in a rural Asian country. Those people should get the Japanese and Sepulitis of vaccine, right? It's an inactivated vaccine, it's an inactivated vaccine. All right. It's an inactivated vaccine. All right. So what are some other high yield things you want to keep at the back of your mind? We travel medicine. Well, you see a person that travels to Egypt or sub-Saharan Africa, right? Sub-Saharan Africa or travels to the Middle East, right?

And then you notice that the person has been having fevers or equeria, right? They have a pardosclenomagally, right? You notice that they have like, they may have hematuria, right? And you notice that their Eocenofil County is really, really, really, really high. That's a parasite that she's to somai assets, right? That's she's to somai hematobia, right? It's going to be a person that was exposed to water, you know, they swam in the mouth or they swam in some body of water, right? And again, they know that everybody has memorized the Egypt association, right? They know that everybody has memorized the Egypt association. So since they know that, oh, many people have memorized the Egypt association. Do you know what they do these days on the exams? They test other countries, right? They test sub-Saharan Africa, right? Sub-Saharan Africa are countries like Nigeria, like Ghana. So guys, guess what? You can get she's to somai assets traveling to those countries. You can get into the Middle East, going to like Libya, Qatar, right? Going to Saudi Arabia. These are all countries where you can absolutely get that problem from. So you're just going to keep that at the back of your mind, for example, right? And again, how you're going to get this problem by swimming in fresh water, right? That contains the Sekaria, right? A Sekaria spelled as C-E-R-C-A-R, right? I-A-E Sekaria, right? So again, keep that in mind, right? From snails, from snails, right?

I don't know if I'd ever travel to a foreign country and swim in the water. At least, maybe a pool, but that's just a lot of things that I'm pooled, man. And you know, just something to keep in mind, something to keep in mind, right? And remember, she's to soma has two major species you should worry about for your exams, right? So there's she's to somai Hima Tobium. Hima, right? Red, Tobium, right? So this thing kind of causes, you know, bladder infection, right? It goes after the bladder, it goes into the venous plexus of the bladder. So it literally attacks the blood vessels that feed the bladder, that, I mean, sorry, that drain the bladder, the venous plexus, right? So they can have hematuria, they can have like blood, you know, fibrosis of the bladder, it can cause squamous cell cancer of the bladder, right? Be careful, guys. Squamous cell cancer of the bladder. Oh, man, the USML is just swimming with, they can get people. Guys, squamous cell cancer of the bladder is not the same thing as transitional cell cancer of the bladder. It's not the same thing. Squamous cell cancer of the bladder, right? Most bladder cancers are transitional cell. If you see a person that has squamous cell cancer of the bladder, it's probably a she's to soma, she's question of your exams. All right. And then what's the other species of she's to soma you should know for your exams? Well, think of she's to soma mansunai or she's to soma japonica, right?

This one's tend to go after the intestines and the liver, right? So they leave your eggs, those eggs get trapped in the portal circulation. You found a lot of granulomas, they can start fibrosis in their liver, they can develop cirrhosis, they can have portal hypertension. Right? So again, how is this going to present clinically on your exams? Again, person is going to, like, you know, like two weeks up to two months, right? So I like the two and two rule, right? Two weeks up to two months after you've been exposed, right? The fever, the body carrier, a lot of eocenophils because it's a parasite, right? And eocenophils help us deal with parasites. Remember, eocenophils they have this protein called major basic protein that is very good for helping us kind of deal with parasites. It's one of the strange factoids that's basic science that they love to put on step one, step two, and step three, right? Major basic protein, right? And it's a, you know, it's pretty much a type three hypersensitivity reaction, right? And then, you know, so that's how it's going to present acutely, but chronically, right? You're not going to get cancer like within a month of getting infected with she's to soma hematobium, right? That makes no sense, right? That literally makes no sense. No, it's going to be months to years later, right? Presence can, you know, again, like the she's to soma man sonai or japonica, you can have fibrosis of your intestines, of your liver, right?

You can get cirrhosis, they can develop poor hypertension, right? They can have a palospelino megalith, they can believe it or not, they can actually give you as a vojol varicies. Oh my goodness. As a vojol varicies as a question in a person that has she's to soma ises, she's to soma man sonai or japonica. So they can give you a question about a person that has a remote history. It's going to be that, oh, they traveled to Egypt like 10 years ago and you know, they had like some abdominal pain when they came back, you know, but they never followed up with a physician and this is like 10 years later. And now they've been coughing off blood, right? They've been having a lot of prochlorine pain, they've developed a sideys. That's poor hypertension because of the intestinal and hepatic fibrosis that we see from she's to soma man sonai or she's to soma japonica. She's to soma man sonai or she's to soma japonica, right? And again, remember from the hematobium end of the spectrum, ready? You can have hematuria, you can have blood cancer and all those things, right? And again, how do you diagnose this again? Just look for the over in the stool, look for the over in the stool, but that's for man sonai or japonica. If you want to, if you want to find she's to soma hematobium, you should check the urine. And again, maybe like, oh, to find this is so hard to memorize. Well, guess what?

It's going to be hard to memorize if you pin no attention to just basic common sense and pathophysiology. What do I mean by basic common sense and pathophysiology? What did I say so far about the parts of the body that are infected by she's to soma man sonai or japonica? What did I say? I said that they infect your GI tract and your liver. So things from the liver, GI tract, where are you going to find them? You're going to find them in the stool, guys. You're going to find them in the stool. So look for the over in the stool, but where does she's to soma hematobium go to? He goes to your liver. Yeah, he does go to your liver. I mean, sorry to your bladder. What did I just say? Go to your bladder. So because he goes to your bladder, where are you going to find it? It's going to be your urine, right? It's going to be your urine. So look for the over in the urine for she's to soma hematobium. Look for the over in your GI tract and your stool, right? For she's to soma man sonai or japonica, right? And again, your sonophilus is going to be high, right? You can also do serologies and how do we manage this? You're going to give crazy quantel, right? You're going to give crazy quantel. You're going to give crazy quantel. Okay. You're going to give crazy quantel on your exams. So again, another disease. I'll just talk about really briefly. Don't forget chicken guñía, right? Chicun guñía, chicun guñía, chi, chi, cun, kun, guñía, g-u-n, y-a, chicun guñía. Right?

Remember, this is carried by the 80s mosquito, right? It's carried by the 80s mosquitoes, right? And those people are going to have like just very severe prolonged polyathrologist, right? So many joints are going to hurt and this is going to last for a month. You're not going to get on and get off the hook in like a week. No, right? So in the last for months, right? It's going to last for months, right? And many times those people are going to have a fever. They're going to have a rush. They're going to have fever. They're going to have a rush. And there's no specific treatment. And all you're going to do is an insides, right? Zika, right? Especially a person that travels to like Brazil or something like that on your exams, right? Think of Zika. Zika is also carried by the 80s mosquito, right? And you can actually also get it sexually. Ooh, right? You can get it sexually, right? Or you can also be transferred from mom to the fetus, right? Critical transmission, right? Again, the big thing you should worry about on your exams is congenitus Zika syndrome, right? Congenitus Zika syndrome, right? The kids will have a big head. You have my micr, sorry, a small head, sorry. They'll have microcephaly. Sorry, not a big head. They'll have a small head, microcephaly, right? They can have all these brain problems, vision problems, hearing problems, right? Vision problems, hearing problems. Although they want to present a Zika to an adult, many times they will present it as Guillembré.

It can actually cause Guillembré syndrome in adults on your exams, right? And the thing is, basically, if you're pregnant, you should not if you're a woman that's pregnant, you really should not travel to an endemic area. Please, that has a Zika. It may not be a very smart idea, right? And again, they can give you a question about a person that, you know, travels to some foreign country, right? And then they did a lot of swimming, a lot of swimming, right? They tell you that, oh, I went white water rafting, right? So they went like rafting or they went exploring caves, right? So again, you may not just be a water exposure, although that's the classic thing. You can also get this from soil exposure, right? And then they tell you that the person has like very high fever, headaches, my allergies. And then they use the term on your exams, conjon tival, suffusion, conjon tival, suffusion. The person's eyes are red when you see this thing called leptospirosis, right? Sometimes on your exams, instead of putting leptospirosis as the answer, they will put a spirochet as the answer because leptospiror is a, is a spirochet. So you're just going to keep that at the back of your mind. You see, I've been emphasizing things like flavy virus, be corner virus, singles trying to do any virus. Again, keep these things at the back of your mind for your exams, right? And you see I'm emphasizing the mosquitoes because they do test these things on the exams, right?

So I talked about the 80s mosquito, right? I talked about the 80s mosquito for chikungunya, talked about it for zika virus, right? Again, please make sure you know these things for your, for your exams, right? Make sure you know these things for your exams, right? So again, if you're coming contact with water, contaminated water, or contaminated soil, right? That's been contaminated by animal urine, right? rats cattle. That's why you can get this from soil, right? I don't think you're going to see cattle grazing in the water. This doesn't really make any sense, right? So that's how you can get it from soil, right? So keep that at the back of your mind, for example, right? Again, fever headaches, myalgyus, right? conjunctival, so fusion, su, double, f, u, s, i, o, and keep that at the back of your mind, for example, right? Think of leptospirosis, right? And the thing is this can get really bad and it can form a thing known as a wills disease, right? Wills disease, right? What happens in wills disease? Basically, your liver and your kidneys and your lungs go up in flames. Your liver, your kidneys and your lungs go up in flames, your can, your L, right? Think of the alphabet, i, j, k, l, right? Your kidney and your two L's, your kidney, your liver and your lung scoping flames, right? So they have like, they have like pulmonary hemorrhage, they have like jaundice, they have renal failure.

When you see that thing of wills disease, wills disease, it's a very nasty complication of leptospirosis will is spelled w, e, i, l, and then apostrophe, yes, right? Wills disease, you know, if you go to Cornell for your med school, you should hopefully never get this from you exams, right? I guess Cornell, the will, Cornell medical school, it's a double L instead of single, but different discussion. All right. So keep that in the back of your mind for exams and how do we manage this? We're going to manage this with doxycycline, right? If a person has just like the basic conjunctivir, suffusion, fever, headaches, just give them a tetracycline, like doxycycline, they're going to be fine. But if they have very severe disease, they are beginning to have like renal involvement, kidney, you know, so renal involvement, liver involvement, lung involvement, those people are going to need a tetracycline, they're going to need IV tetraxone or IV penicillin, IV tetracycline or IV penicillin, right? And then what if they give you a question about a person that again traveled, right? Traveled and the person, you know, went on the beach a lot, you know, or, you know, or they played with a lot of dogs or cats and then they have like this intensely parodic rash, you know, serpigenous rash on the skin, right? And you can even see like these trucks on the feet, especially on the feet of the bodox, right?

These trucks on the feet on the bodox, especially in a person that walked bare feet, then you want to think about a person that has cutaneous lava migra, right? Cutaneous lava migra. So you pretty much have a warm infection. Many times they are, you'll see no field count to be elevated, right? So this is something from like the dog or the cat hookworm, you know, so like dogs or cats, you play with them, right? And the hookworms literally hook into you, right? Or you walk bare feet on the beach. Those are all classic ways these kind of shop on the exams, right? Again, it's going to be from this, this bog, you may see the bog on your exams and see lost them and see lost them. Ah, ANCY LOS T O M A and see lost them, right? Kind of penetrates the skin. That's why you see this intensely parodic, you know, serpigenous rash. You can even see like literally the, the worm literally trucking through your skin, right? How do you treat this on your exams? We're going to treat it with Ivermectin or Albandazone, okay? You're going to treat it with Ivermectin or the, uh, the bandazone on your exams, right? You, you, sorry, Ivermectin or Albandazone, right? Just use your bandazone, speak a bandazone answer or Ivermectin on your exams, right? So now just to kind of wrap things up, I just want to give a few quick hits. Uh, again, that should help you think of certain associations on your exams, right? So again, if you see sub-Saharan Africa, right?

Nigeria, uh, which is run from Nigeria, um, Togo, um, Chad, Ghana, places like that on, you know, Benerri Public on your exams, uh, you, you want to think of things like malaria, think of yellow fever, think of Shistus or my SS, right? Um, keep that in mind for your exams, right? You see a pressing going to like Southeast Asia, right? Think of things like Japanese and Sephalides, especially like rural areas, right? Uh, think of, uh, typhoid fever, think of leptospirosis, right? Think of dengue, dengue is not only in African countries, right? Just keep that in mind for even malaria, right? In fact, let me tell you this guys, if you see fever in a returning traveler, fever and anemia in a returning traveler, that's malaria until proven otherwise. That's literally malaria onto proven otherwise, right? And then, um, if you see, um, you know, South America, right? If you see South America, again, think of yellow fever, but you can get yellow fever from South America, yellow fever, but you can get malaria, they can get dengue, right? You see a person that visits South America and then they develop heart failure after, it's like, I come back from South America, I have heart failure. I come back from South America, I have a so-called job problem, right? That's sugar's disease from Trappin' and Somar, uh, cruziac, right? Keep that in mind for your exams.

You see the middle east, middle east especially on your exams, think of shistosomiasis, think of shistosomiasis, think of shistosomiasis. If you see a lot of it, you'll see no fields, right? Think of a parasite, right? Think of shistosomiasis, think of, uh, the hookworm infection, right? If you see thrombocytopenia in a person that is a returning traveler, thrombocytopenia, again, think of dengue, dengue, dengue, dengue, think of dengue, dengue, dengue, right? If you see thrombocytopenia in a person that travels within the US, and they have like very severe headaches and all those things, you should think of rickets here, rickets, I actually, Rocky Mountain spotted fever. Just keep that in mind, a person that travels to like North Carolina or something crazy. I think of Rocky Mountain spotted fever, right? So, and then what if you see John Disson a traveler, right? Again, think of hep A, viral hepatitis, think of yellow fever, right? Think of leptospirosis, especially when it's gone to the will's disease phase, or malaria, right? Malaria is gonna cause an indirect hyperbular minimia, because it literally infects your rib-bloat cells and causes himolises. Whenever you have himolises, you're gonna have an increase in your indirect bilirubin, right? And then if you see a lot of hemorrhage, a lot of bleeding, bleeding, bleeding, right? Think of yellow fever, think of dengue, there's a reason why dengue is literally called dengue hemorrhagic fever, right?

Or also, you see a person that has like Ebola, you know, a person that travels to like some African country, and they like have like DIC, mortise, organ dysfunction, think of like Ebola, think of lassa fever in those circumstances, right? In fact, what is one amazing way of friends that the MBM is can try to mess you up? Oof! Oh my goodness. The MBM is, they're not stupid. There is, is, let me tell you this. It is amazing, the kinds of questions they can create. It's literally amazing, the kinds of questions they can create. Do you know what they can do to you on an exam? They can give you a question about a person that works at a morgue. Woo! A person, you know, they'll tell you that a patient travels to some African country, right? Or some foreign country, it's probably going to be an African country came back and died, right? And then they wear a sense to the morgue. And then they tell you that one of the morticians, right, or one of the people that work at like a funeral power, like a funeral power, whatever, they tell you that this person, you know, has been having like nose bleeds, bleeding from the ears, thrombocytopenia and all those things. You want to think about Ebola, right? Remember Ebola is not only you that has the Ebola that can get in trouble. You can also get Ebola from handling a dead body of a person that had Ebola, right? So that's why if you're a person that works at a morgue or a person that works in a funeral home, you got to be careful, right?

See, let me tell you this, even if you handle the cremated remains of a person that had Ebola, you can get Ebola that way. So if you handle the cremated, so it's called cremated, C-R-E-M-A-I-N-S, cremated, or a person that has Ebola, that can absolutely be a USMD question. You can get Ebola. All right, so I think I'm going to go ahead and stop here. I think I have really hammered travel medicine pretty hard, right? So you should know these things for your test, right? You should know these things for your test. And again, if you love the way I teach, you're going to love my classes, right? And my classes, I'm the only one that teaches them. I don't like subcontracted to some person, right? I have classes for step one, all the way to step three, level one, all the way to level three. They start next week, actually, right? So I have a class on Monday. So two and a half hour test taking class for step one to three. Yeah, two and a half hour class for step one to three on Tuesday. I have a biostatistics class also for step one to three to four hour class. When's there have a social sciences and ethics review? So five hour class also for step one to step three. And then also I have a last minute review, but that's for step two and step three, specifically. I have a last minute review. That's for step two and step three, specifically. I have a 20 hour class. That's for step two and step three, specifically. Again, it's coming up within the next week or two here, right?

So if you're taking any of those exams, again, many people have taken these exams and found these classes to be extremely helpful. I get so many reports like literally, and this is not like a report from five years ago. No, I literally have reports from Buddha took the exams like within the last like month, took my classes and they got like very high scores, very high scores. By very high scores, I mean things like 250, 260, 270, right? I've actually had a, I think I've had like two, two eighties from my classes. I think, right? I think I have to go and check. But it's something, these classes, if you like the way I teach you like the way it's linked path of this, you're going to love my classes. I have a 25 hour step one class coming up within the next few weeks as well. And then I have a 50 hour class for step two, step three, that's taking place in the middle of this year. The first two weeks in the month of June. That one has very, very limited spots available. So if you're interested, shoot me an email. I can give you some more information. All these classes are over Zoom, right? And it's me teaching them. Again, I do a lot of integration pathophysiology. You're going to love these classes. I also offer one on one tutoring for all the USML and complex exams, Met School exams, residency exams, offered tutoring for those. And then I have this podcast on Apple Google and Spotify.

And then I also have a You Tube channel, Divine Intervention, USML podcast and videos that you can check out. And then another thing, you know, also another website I have is Divine Intervention Lifelessens.com. Divine Intervention Lifelessens.com. Many of you that listen to my podcast, you know, I'm a Christful or I do have a, you know, every week I make like one or two podcasts from a biblical perspective, address a life lesson. There's actually an Apple podcast associated with that. There's almost, what like almost like 400 episodes on there. Many people listen to those and find those to be very helpful. And then I also help with eras applications, mock interviews, personal statements and things of that nature. So thank you for joining me into this class. Again, I hope you found this, I mean, to not to this class today's podcast. I hope you found this podcast to be very helpful. But again, I promise you travel medicine, a travel medicine, B super high old stuff to know for your exams. There's just so many ways. There's probably like a hundred different vines they can generate from these two podcasts. So just make sure you listen to these very high yield. Most of the time these are things that you either know or you don't know. So if you don't know, you're going to for sure get the question wrong. If you know, you're going to for sure get the question right. So many times it's not things you can necessarily reason out. So just keep that in mind and share this with your friends.

So thank you for listening. Have a wonderful day. I'll see you in episode 633. God bless you and bye for now. Thank you.

Thoroughly irrigate the wound with soap and water for about 15 minutes (source control).

Anti-HAV IgM.

The vaccine alone.

S. mansoni and S. japonicum have eggs in the stool; S. haematobium has eggs in the urine.

Malaria.

Jaundice, renal failure, pulmonary hemorrhage, and multi-organ involvement.

Schistosoma mansoni or S. japonicum.

Culex mosquito bite, especially in rural areas with rice cultivation.

To locally bind and neutralize the virus at the site of exposure.

S. haematobium eggs are found in urine; S. mansoni/japonicum eggs are found in stool.

Cutaneous larva migrans (creeping eruption).

Aedes mosquito.

Leptospira interrogans (Leptospirosis).

Schistosoma mansoni or S. japonicum.

Culex mosquito bite, especially in rural areas with rice cultivation.

To locally bind and neutralize the virus at the site of exposure.

S. haematobium eggs are found in urine; S. mansoni/japonicum eggs are found in stool.

Cutaneous larva migrans (creeping eruption).

Aedes mosquito.

Leptospira interrogans (Leptospirosis).