DIP Episode 586 - Quick and Dirty Microbiology Associations for Step 1-3 (Extremely HY)

All right, welcome. My name is divine. This is episode 586 of the Divine Intervention Podcasts. Into this podcast, we're going to be examining some quick and dirty microbiology associations for the USML exams, quick and dirty microbiology associations for the USML exams. So let's go ahead and get started. Again, this podcast is going to be a pretty high-yield podcast. I think it's going to help you a lot on your on your test. So, and again, this is not going to be in any particular order. Things are going to be kind of strung over the place. But again, it's really going to help you if you keep these things in mind. There's going to be many questions you're going to get right just from paying attention to this podcast. So what if they give you a question about a person and this person, you're told that the person has a history of some kind of prosthetic valve. And the person recently had a dental procedure when they went to a foreign country. And then now for the past two weeks, they've been having fevers, they've been shot of breath, they've been having some malchés pain, they've been having night sweats, and they tell you that their ESR and CRP is elevated. And they're telling you that you're hearing like increased sounds around where the person had the previous prosthetic valve. I'd really hope in this case, you're thinking of this person having some kind of some kind of endocraditis, right?

And they're having this endocraditis because they've recently had a dental procedure and now they've got an in trouble. So remember that typically if you're talking about just infectious endocraditis overall, the most common cause is generally going to be stuff-or-us. But some time you can get endocraditis from dental procedures as really things like strep mutants, for example. Strep mutants can certainly put you in trouble. And typically strep mutants is going to cause issues for you when you have a bad valve at baseline. If you have a normal valve, you know, these dental Florida usually do a number on you. But if you have a valve that is a normal baseline, then you can get in trouble. Contrast this with stuff where as they can go after obviously a bad valve at baseline or you can go after a completely normal valve. Remember, stuff where it's endocraditis, we usually find it in IV drug users. Because again, look at the name IV and usually what valve may you see with IV drug use and endocraditis. At least which one is pretty specific many times for stuff where it's, I hope you're saying divine, it's usually going to be like tri-cost-bit valve endocraditis. Well, why is that the case? Well, if you think about it, if you have an IV drug user, IV intravenous, you literally inject drugs into your veins. When you inject drugs into your veins, where do veins drain into? Where do all the veins in your body for the most part drain into?

They drain into the right side of the heart, right? So since they drain into the right side of the heart, the first valve that, if you inject box into your veins, the first valve they're going to encounter is going to be the tri-cost-bit valve, right? It's going to be the tri-cost-bit valve. So that's why they can get tri-cost-bit valve endocraditis. Something you want to keep in mind. I guess bringing another logical thing with the right side of the heart, many people memorize that centrovino pressures are surrogate for your righty trail and right ventricular pressures. And that's true. And some people have memorized that man, centrovino pressure. How do I remember this? Well, again, think about it. Your righty trim is like a central hub for all the veins in your body, the veins in your body drain into the right side of the heart. So it makes sense that centrovino pressure is going to be your right-sided heart pressure. All right. And again, since we're, I guess we're kind of talking about that, hey, if you have a dental procedure and you get into a creatitis, especially if you have an abnormal valve at baseline, think of a strep mutant, think of strep mutant, think of strep very dense. I guess let's talk about some of the normal flora we see at different parts of the body. So remember, for example, your nose, your nose many times is going to be pretty well colonized by staphoreus. Your nose is going to be pretty well colonized by staphoreus.

In fact, they can give you a question on your exams about reducing risk of MRSA infection in a person that has like a misal colonization upon admission to the hospital. And you want to consider using the answer that talks about topical muperosin in those people. Use the answer that talks about topical muperosin in those people. Although you can also find staphepidermides in the nose, but typically on the USML Es, they like to go after staphoreus, right? Staphepidermides we tend to find it more in the skin. We tend to find it more on the skin. And then remember, your colon, your GI tract, what are the bugs you're going to find a ton of in the GI tract? Well, you're going to find things like anaerobes, bacteria, these species, bacteria, these fragilists. You're going to see a lot of E.coli, right? You're going to see a lot of E.coli. In fact, the thing is if you have some of these microbiological foundations, you'll notice that it's no big surprise where, man, for a lot of GI infections, we tend to use it like septryaxon plus metronidousal to treat it or ampeicillin gentermycin ametronidousal. You know, I know many people memorize these drug regimens, but to be honest with you, they are not necessarily things, I mean, I guess you have to memorize them. But if you really think about it, these regimens make sense, right?

If we know that anaerobes and E.coli are the big, big, big things that sting your GI tract and you have an infection of your GI tract and you want to treat empirically, it just seems like a wise decision to cover gram negatives like E.coli. E.coli is a big time gram negative. So something by giving some of the septryaxon is phenomenal for covering gram negative infections. And the metronidousal is pretty amazing for covering gram negative infections as well. So as the septryaxon also happens to cover gram positives, you know, and one thing I'm just going to say about metronidousal, you know, many people learn this crazy thing about anaerobes above the diaphragm, clean the mice in anaerobes below the diaphragm, etronidousal. Yeah, that's a good route to know, works for the most part. But it doesn't mean that you cannot use clean the mice in for infections below the diaphragm and it doesn't mean you cannot use metronidousal for infections above the diaphragm. Just be careful about that. It's not like metronidousal, like when you give metronidousal, it stays below the diaphragm, it doesn't ascend past the diaphragm, that's pretty ridiculous, right? So just something you want to keep at the back of your mind as you prepare for exams. And then one association I want to talk about here, again, I told you that this is going to be, this is basically going to be like a rapid review of micro podcasts. But again, lots of questions you're going to get right from this on your exams.

But what if they give you a question about a person that just takes anti-bi, recently took anti-biotics like two, three weeks ago. And then now this person is having like a discharge from the vagina. What box should you be thinking about? I hope you're thinking about candidises. I hope you're thinking about candidises. The thing is, many people do not realize this. Many people are just aware of, hey, post anti-biotic diarrhea with CDIF. But many people forget this that I like to think of candidises like the CDIF of the vagina actually. Candidates the CDIF of the vagina. Whenever you alter the micro environment in terms of just bok flora and in terms of sugars in the, you know, persons like vagina or whatever, you're actually going to raise your risk of candidile infection. And make sure you can identify those pseudo-high features that you love to throw on the US Emily exams. But if you really think about it, if you take a bunch of anti-biotics, you kill off a lot of your vaginal flora, then candidat can have a field day, candidat can overgrow, and you can get in a lot of trouble. So the person will end up having like a vaginal candidises. And remember, obviously, you're going to treat that with an oral isle of some sort. Now remember, it does not the only thing that raises your risk of vaginal candidile infections. You can also get that if there's just too much sugar in your vagina. Why can they, why would you have too much sugar in your vagina?

Well, if for example, you're taking an SGLT2 inhibitor, like a canagly flossing, the pagly flossing, and impagly flossing, those bugs, I mean those drugs, whoops, those drugs, they work at the level of the proximal convoluted tubio. They inhibit the reabsorption of glucose in a person's proximal tubio. So by doing that, you're going to have sugar urine. So they actually raise your risk of UT Is, but it also raise your risk of a vaginal candidises. And then also just being a diabetic, if you ever see vaginal discharge in a person that's a diabetic, always think of candidile, right? Always think of candidile. Because again, if you're a diabetic, you have a lot of glucose urea that can strictly cause quite a number of problems for that individual. So again, too much sugar in your vaginal area, or you're taking an SGLT2 inhibitor, or you've recently taken antibiotics, those are all high-yield associations to know with vaginal candidises. Because remember, normally in your vagina, the numplera that's usually there is going to be like lactobacillus, you can see E. coli. And I guess if you're pregnant woman, or about 25% of women, group B strap, group B strap. Group B strap is a big time colonizer of most women. Let me not say most women about 25% of women's vaginas. So about a quarter of women's vaginas for sure colonized by group B strap. So something you want to keep at the back of your mind for exams.

That's why between 35 to 37 weeks gestation, we're going to go ahead and screen you for group B strap for stripping galactia. And if you come back positive, you're going to have this temptation on your exams to immediately go ahead and treat the group B strap. Don't do that. If you do that, you'll be wrong on your exams. You want to wait until the woman is intro part of it. We don't tell she's in labor. And then after that, you can go ahead and give her group B strap or philaxis. I guess in that case, you're actually trying to treat. Although I'm not really treating for the mom or treating for the newborn, so the newborn doesn't get in trouble. So we're going to treat with, you know, you can use them picellin, you can use them oxycelin, you can use penicillin, you can use any of those things. That is totally fine on your exams. And one thing I'm also going to say is this, if you see any major infection in a newborn, right, especially like in a new unit, like first 20 days of life, beat like pneumonia, beat meningitis, or whatever, you really want to be thinking about group B strap, stripping galactia as the cause, right? And again, they can tell you, hey, how did this newborn acquire this infection? You want to pick the answer that talks about, you know, passage through the birth canal or passage through the vaginal canal, right? Something you want to keep at the back of your mind for, for example, right? Again, don't, don't, don't, don't, don't forget this.

And I guess since we're kind of talking about fluorine newborns, another association you want to keep at the back of your mind for your test is why we're told, what if they give you a question about some child, you know, and they tell you that this parents are, you know, I gains getting vaccinations, you know, which is not wise, which is very unwise. And then they tell you that, well, this child for the past two days has been having like a decreased cry, has been having a, having a decreased cry, not doing very well. And they tell you that the child has diffuse hypotonia on physical exam. When you see something like that, I really hope you're thinking about, and they tell you that, oh, his mom recently started giving him a, you know, to soothe the baby because the baby has been having an increased crying. The mom has been giving him his pacifier, deep, in a sweet substance or whatever, you know, sweetener. If you see that, I really want you to think of botulism, right? So this child, I try to master the question as much as possible, as the NBM is doing right now and then, right? But this child has botulism, right? And the thing is, many people don't realize this, but our friends are the NB Ms. They do actually care about how people get botulism, right? They do actually care about how people get botulism. They care about the mechanisms. Many people tend to ignore this. Many resources do not cover this. It's actually pretty high yield to know for exams, right?

So the thing is, if you see a newborn getting botulism or a person within the first year of life, getting botulism, it's going to be from honey on your exams. Because if you really think about it as a newborn, you pretty much have like no GI floor. So because you have no GI floor, any bog that is able to set foot be a first settler in your GI tract, it actually has a pretty easy time. It can just overgrow quick and have like no problems, right? Because in a normal adult that has a pretty abundant GI floor, if that normal adult consumes honey, why is it? I mean, I consume honey. I mean, I'm not a big honey consumer, but I consume honey every now and then. Why did I not get botulism? Well, the thing is, you know, I'm an adult, you know, and I have like an actual GI floor. So it's not like C botulinum can just come in and just, you know, fill out home in my GI tract. No, because there's other bogs that will keep the crowd in a population of C botulinum down. Something is pretty high yield to know for exams, right? So a newborn does not have enough GI floor. So because this newborn does not have enough GI floor. This newborn, if they're exposed to anything that contains Clostridium botulino, they're going to get in trouble. They're literally going to get in trouble, right? Because it's like there is very limited competition in the newborn's GI tract, especially that first year of life. Because think about it, your food is not very diverse when you're born, right?

You're just chugging a bunch of milk. There's not much floor you can get from chugging a bunch of milk. Yes, that's probiotics and all that fun stuff. But again, there's not much floral diversity you can get from chugging a bunch of milk. So the thing that can happen in those circumstances is that you give that and the spores just overgrow in the child GI tract, a laboratory, a ton of, you know, toxin and stuff and the child gets in hot water, right? But it's from spore overgrowth. It's going to be an overgrowth of spores for a child. For an adult, that gets sea botulinum, right? The way they're going to get it is from improperly canned foods, right? Impripply canned vegetables and whatnot, right? The thing is the clostridium botulinum is growing in that improperly canned food and it's elaborating the toxin. And then you as the adult, you consume the actual toxin and that's how you get in trouble. It's the toxin that gets you in trouble, not necessarily the bug. I'm going to say that again, for an adult, it's the toxin that gets you in trouble, not necessarily the bug. But for a newborn, right? For first year of life, right? The thing that's happening is you're consuming the bug. The bug can grow nice and easy in your GI tract and laboratory toxin and you're going to get in trouble. Again, you'll be saying divine. Okay, you've talked about this for two minutes. We get it.

Again, if you see me spending a lot of time on one topic, it's probably a topic you should know pretty well for your exams. And I guess since we're on this again, whole topic of GI flour, right? Let's not forget that people can also get into trouble with that. That's why when you're newborn, before you leave the hospital, one of the first shots you get is a vitamin K shot. Why do you get that vitamin K shot? Makes sense. You get a vitamin K shot because again, vitamin K is literally produced by your GI flour. Vitamin K is literally produced by your GI flour. Again, when you're when you're newborn, you literally have no GI flour. If you have no GI flour, you cannot make vitamin K. And vitamin K is very important for the gamma caboxylation and activation of factors 279 and 10 protein CNS. So if you cannot gamma caboxylate and activate those things, you're going to be your cloning factors are not going to work, right? And because your cloning factors do not work, you're going to have a high risk of bleeding because basically, you know, secondary hemostasis, essentially not working, right? In fact, our friends at the MBM is they can literally give you hematology question involving newborns and ask you which of the following will be expected. You should expect, you know, for a newborn, that their PT and their PT should be elevated. Why? Because again, they are pretty much in an anti-quagulated state because their cloning factors are not, you know, active, especially 279 and 10.

I guess, pretty high you to know, for example. I know is a micro podcast, but again, I love to make these integrations. So you can see all these connections. And then what if they give you a question about a person that, you know, consumes food, right? Again, I'm trying to focus on patterns here. You see a person that consumes food. And within a few, like an hour, few hours, they have like really nasty gastroenteritis. They have like a lot of vomiting. They have a lot of diarrhea. If you see something like this, I want you to think of food poisoning. And there are two bugs you should target on your exams. So what are those two bugs you should target on your exams? Number one, should target staff warriors, especially when you have like food has been left out, you know, like mayonnaise, cheese, you know, picnic associations, it keeps those in mind. But if you see anything about like rice, fried rice, jolof rice, right? The people that are Nigerians listen to this podcast of Canadians. And by the way, if you're going to listen to this podcast, Nigerian fried rice is better than yours. Just, yes, Nigerian fried rice is better than yours actually. It's an ongoing war between Nigerians and Ghanaians about who has the best fried rice. But anyway, okay, let's get back on top. Right? So you see reheated rice and you see a person having a rapid onset gastroenteritis that comes right after think of the Sylas series. Okay? So what's the pattern I'm trying to emphasize here?

I'm trying to emphasize the pattern of rapid onset and offset gastroenteritis. So it's like not too long after exposure, you get the gastroenteritis. Not too long after the gastroenteritis starts. It stops. Think of gastroenteritis from staff orius and gastroenteritis from the Sylas series. I'm going to say it again, staff orius be serious. If you see anything about, so how are they going to test these? Right? If you see like a picnic association, food that has been left out for too long and all those things, think of think of, think of staff orius. It's going to be the most common one they're going to test on examples. Now, if you see a reheated rice association, you know, rice that has been left out, right? And then, you know, obviously, right, we live in the world of microwave, right? You microwave the rice, you eat it, you get gastroenteritis, not too long afterwards. You only think of Bacillus series. Now, one devious thing our friends at the MBM Es can do is they can give you a question about a food that has been left out for a long. And you'll notice that, you know, it'll be a picnic association. And you notice that staff orius is not an answer. If you get that kind of question, that'll be another situation where Bacillus series is not a bad idea to pick. Okay? That will be another situation where Bacillus series is not a bad idea to necessarily pick. Okay? So please kind of keep that at the back of your mind as you prepare, as you prepare for examples, right?

You see this pattern of rapid onset, rapid offset gastroenteritis, think of staff orius or B-series. What B-series, the more classic association you're going to see on your exams, probably more than 90% of the time is going to be with reheated rice, right? I'm pretty sure I've had this before. I was some family member of mine, a cook rice for me. And I really love the rice, right? I really love the rice. So I just eat it. I don't like, gee, I'll have like, die afterwards. Gee, eat it die afterwards. I didn't get the point until a few times, you know, you think that man, the vinewood kind of learning is less than, but I guess I didn't learn the first, second, third. I think I ate that rice like four or five times. I was like, yeah, it's probably the rice that's causing these problems. And then I stopped. But, you know, you got to do what you got to do. Sometimes the love for rice exceeds the problems with the die rate. But anyway, okay. So let's go ahead and continue. Now, what if you see like, reheated meat? What if you see a reheated meat association on your exams? Then you want to be thinking about close-tradium per fringes. You want to think about close-tradium per fringes, right?

I guess if we're, since we're talking about meats, if you see on the cooked meats on your exams, especially if you see a person having like, bloody die rare, after eating under cooked meat, or they give you a question about a person that has bloody die rare, you know, they've been exposed to under cooked meat. And then they give you other things, right? They give you things like the person having like, they show you like a blood smear, and you see fragmented erythrocytes. You see, she's those sites on your exams, right? And the person's bleatlet count is extremely low. Then you want to think about this person having exposure to E coli, O157 H7. E coli, what? O157 H7, right? Has a very strong association with under cooked meat, very strong association, under cooked meat on the exams. And why did they give those other laps that I just kind of started mentioning? Well, in that case, I'm thinking about a hemolytic uremic syndrome, right? Remember, HUS, it can be caused by microbes that make the sugar toxin, like E coli O157 H7 or shegella, right? E coli O157 H7 or shegella, right? Although the one that is way more common is going to be E coli O157 H7, right? So remember, they're going to have very high fevers, they're going to have anemia, and that anemia is going to be a micro-anjupathic hemolytic anemia, right?

So they're going to have things like she's those sites on a blood smear, you're going to notice that they will have an increase in indirect bilirubin, you're going to notice that their LDH is going to be elevated. Remember, LDH, whenever I see high levels of it, you may see that in inflammation, right? You may also see that when a person has a lot of hemolysis going on. So they will have a maha, they'll have a micro-anjupathic hemolytic anemia, right? They'll have thrombocytopenia, right? They can have like renal issues, so you may see elevated creatinine in those kinds of circumstances, right? Again, just going to keep those things at the back of your mind, for example, right? HUS. Remember, HUS is supportive care. You don't give antibiotics, right? Your classic error on the example is to give antibiotics. Again, it's the toxin that's causing the problem. If you give antibiotics, you kill more bulk. As you kill more bulk, you release more toxin. As you release more toxin, the child is going to get in some very serious trouble, right? Because you're pretty much going to sentence that child to really, really awful, awful, awful outcome. So don't do that, right? That's not a smart thing to do. All right, and then I guess I kind of talked about shegella and I said that, ooh, shegella is like probably going to be the second more common cause of hemolytic uremic syndrome on your exams. I said E. coli 157 H7 is the big one. What's I guess the cling to fame with shegella?

Well, shegella just like E. coli 157 H7 can cause HUS, right? Remember, shegella can also cause bloody diarrhea. It can also cause bloody diarrhea. Now, one high ill but weird microbiological association you want to know for your exams is that as few as 10 organisms can give you trouble, right? You don't have to be exposed to a ton of shegella to get in hot water, right? Literally, if you have as few as 10 shegella, you can get in trouble, right? The thing is again, one of the easy ways they can test that to kind of mess up your head on exams is use the term ID50, ID50, right? So it has a very, very low ID50. I like to think of ID50 as being pretty similar to KM. If you're kind of thinking in terms of mechalismenting kinetics, remember KM relates to how much of the substrate you need for the enzyme, for the reaction to be going at like 50% of Vmax, right? So the thing is ID50 is kind of a similar term, right? It's like, hey, how much bog do you need to deliver symptoms in this patient, right? So the ID50 for shegella is very, very, very low. The ID50 for shegella is extremely low, right? As few as 10 can literally get to in hot water very, very quickly, right? And then since we're, I guess talking about mechalism, remember, there are other books that are sort of like poultry, meat and eggs, right? Think of salmonella in those circumstances. Salmonella, right?

Can cause bloody diarrhea, can absolutely cause bloody diarrhea, especially when again, you eat like, you know, chicken products, right? Poultry, meat, eggs and things like that. Although remember, another thing that's associated with like meat and poultry is going to be Campilo Bacterge, a Junai, right? Ceege, a Junai. Remember, that's the thing that grows that I think is like 42 degrees or something like that. I'll probably talk about that later, but it's Ceege, a Junai, right? It can cause bloody diarrhea as well, especially when you're exposed to like meat and poultry products, right? The thing is you may wonder, divine, how do I differentiate one from the other? The thing is, thankfully, the USML is many times, they will not put all these stains, they will not give you like a poultry question and put like Campilo Bacterge and answer and put like Ecoli O157 H7 as an answer or put like salmonella as an answer. They are usually loath to do stuff like that. The only time where they will do stuff like that is when they give you some kind of memory hook that you guide you in one direction versus the next, right? So, say for example, they give you a question about a person that has bloody diarrhea, poultry products and you're seeing antecedents of like thrombocytopenia, renal failure, you know, maja, then in that case, they are clearly getting you towards Ecoli O157 H7 or shigella, right? You may be like divine. Dude, you said that memory hook.

Well, HHS can be caused by both shigella and Ecoli O157 H7. Well, that's where PD Mialogy comes in, right? Ecoli O157 H7 is a more common cause of HUS than shigella. So, Ecoli O157 H7 is going to be the correct answer, right? In that case, even if they give you both those answers, right? Salmonella, right? Causing bloody diarrhea after exposure to poultry. You know, they may again put Salmonella alone as the only thing then and then you're like, oh, of course, it has to be Salmonella. Or if they give you a stack with other bugs that cause the same issue like Ecoli or whatever, then they will have to give you some hooks. So, what's the hook that should guide you towards Salmonella? Well, there's a few things you may see on your exams, right? So, there's this thing that Salmonella seems to have this kind of association with, called a pulse temperature variation, pulse temperature variation. So, you see this pressing, they have a very, very high fever, but they're kind of pretty cardiac. That doesn't really make any sense, right? Typically, whenever people have fever, they're going to be pretty tacky cardiac, right? If you've worked in hospital, right? Or if you even see this with uBigan questions on the USML Es, you see how fatus that is tacky cardiac, right? So, the fetal heart rate is over 160, and mom has a fever. Mix sense. Whenever your body's cooking, right? Your heart really usually kind of goes up, right? Because that's kind of like an indicator of sepsis, right?

And typically, when you have sepsis, your cardiac output actually rises, especially in early sepsis. But again, I don't want to go deep in the cardio discussion right now. That's for different podcasts. But, so whenever you have fever, you should have a tacky cardiac, right? So, in that case, there is no dissociation, there is no dissociation between your pulse and your temperature, right? Your pulse is pretty high, your tacky cardiac and your temperature is pretty high. But with Salmonella, things are a little different, right? There's this phenomenon. It doesn't always obtain with every Salmonella question on the USML Es. But if you see something like this, you really want to think about Salmonella. This concept of again, pulse temperature dissociation. The person is febrile, but they are not just febrile, they are pretty cartic. That doesn't make any sense. When you see that in a person that has bloodied area, being exposed to poultry products, then you absolutely, positively want to think about Salmonella in that circumstance. Another thing you may also see with Salmonella on your exams, may be a person that has sickle cell disease, right? You see a person that has sickle cell disease, they have bloodied area after exposure to poultry products. They want to think about Salmonella. Because remember Salmonella tends to cause quite a number of problems in people that have sickle cell disease. The one I'm sure many of you are used to thinking about is osteomyelitis, right?

Salmonella on the USML Es is going to be the most common cause of osteomyelitis in a sickle cell patient. There are a bunch of resources these days that are the same things that are otherwise. They are same old stuff or stuff or stuff or stuff. I wish all the best if you go with that. You're going to be getting a lot of trouble on your exams. The most common cause is very high yield. This is divine saying this in 2025, April 2nd, 2025. The most common cause of osteomyelitis for USMLE purposes in a sickle cell patient is going to be Salmonella. Keep that in mind, please. Keep that in mind, please. All right. We've talked about, hey, what's going to be the memory hook for Shigella? We've talked about the memory hook for Salmonella. We've talked about the memory hook for E coli 157 H7, and honestly, they just give you a bloody diary after a poetry product and they really don't give you much of any hook. E coli is probably going to be a pretty classic cause there. Let's talk about the memory hook for Campilo Bacter. If they give you a lot of neuromuscular weakness, especially that symmetric A sending paralysis, they want to think about Guillembori syndrome. Campilo Bacteria Junai has a very strong association with Guillembori syndrome. Now remember, though, it's not only Campilo Bacteria Junai that can cause Guillembori syndrome.

In fact, friends at the NBM is they know that many people have memorized, bloody diary, and symmetric A sending paralysis, Guillembori syndrome, Campilo Bacteria Junai. So these days, they started getting a little more creative. So remember, you can actually get CJ Junai after UTI. You can get CJ Junai after an upper respiratory infection. All right. So again, if you just generally see a mucosaline infection and you see a symmetric A sending paralysis, all right. In afterwards, then on your exams, I was really, really strongly, strongly encourage you to consider Guillembori syndrome on that those circumstances, on that those circumstances. All right. Let's continue. Okay. Now, what if they give you a question about a pregnant woman? And they tell you that she's at 36-digestation. And they tell you that she has a fast-melancholy amniotic fluid. And you're told that the woman has been, she went on a vacation recently and ate a lot of like delimits or a lot of assorted cheeses, right. And she has a fever. If you see that, you want to think about Listeria. You want to think about Listeriosis on your exams, right. This is why when you're pregnant, you shouldn't eat delimits, you shouldn't eat soft cheeses, right. Because that can get you in a lot of trouble with Listeriosis, right. Listeria can cause corromionitis, right. Listeria can cause a lot of, you see the fetus being stillborn. And they have abscesses in many, you know, they have like infection in many body cavities.

So many of you have heard of Granulumatosis infanticepticum. That's pretty strongly as your Listeriosis, right. And what's the drug of choice for treating Listeria infections? And the drug of choice is going to be ampicillin, right. The thing is ampicillin is the way you treat Listeria infections, right. If you have a Listeria infection, especially Listeria of the brain, and you don't, you don't get ampicillin, you're probably going to die actually, you're probably going to die actually, right. So it's pretty high you to know that for exams, right. So what's another hook you may see with Listeria in your exams? You can be mom that consumed delimits, soft cheeses, you know, maybe like two, three weeks before she delivered a child or during pregnancy. And then now she has delivered a new born and this new born has meningitis, right. You absolutely want to give ampicillin. In fact, this is why when you see a new born with meningitis, empirically, you're going to treat with cephotaxym or septriaxym. Usually we're going to do cephotaxym because septriaxym can kill it, calcium and cause intraeparic holostasis, especially newborns, right. But that's a different discussion, right. But you give cephotaxym or septriaxym plus vancomycin plus ampicillin. We do that because we specifically want to cover Listeria because again, if you have Listeria meningitis and you don't treat it, the mortality is almost 100% with that, right.

And also this same CVA numonic of septriaxym, vanque and ampicillin for meningitis also applies to people over age 50. If you want to empirically on the USMLE strip meningitis and personal age 50, you want to give them septriaxym, vanque and pizzeria because ampicillin is also found in increased quantity in people that are over the age of 50. Okay, now what's another memory hook you may want to keep at the back of your mind with Listeria infections? Well, if you see a person that has meningitis and this person is on a TNF inhibitor, TNF inhibitor. People that take TNF inhibitors, they can get very serious Listeria infections. It's one of these kind of weird random associations. You may not see many resources, but it's very, very high yield to know for you exams, right. So you see a person that has meningitis and they take TNF inhibitors. It is florically high yield to know that whenever regimen, you're giving those people until you get cultures and sensitivities back, you better make sure that those people are getting some kind of ampicillin. They're getting some kind of ampicillin because again, ampicillin covers Listeria and Listeria causes issues in people on TNF inhibitors. People on TNF inhibitors, they can get very, very serious infections with Listeria, right. Very, very serious infections with Listeria. So one of these are random things I cover in one of my review classes that I teach for step two, step three. All right, let's continue.

All right, so what are the, again, just in quick summary, Listeria, Listeria, Listeria, what are the big associations? pregnant woman, daily meat soft cheeses, bad idea, right. Pressing taking TNF inhibitors, right. And then pressing over age 50 with meningitis, new needs with meningitis, you absolutely want to cover Listeria with those things, right. So again, just kind of keep those at the back of your mind. And one thing I guess I want to say, since I was very, I guess, astute in making this connection with toxins, because the USM is the love to test toxins from time to time, right. I said that hey, it's the toxin that will cause a person to have botulism as an adult if you consume undercooked, if you consume a polycan't good. Well, remember I said rapid onset, rapid offset gastroenteritis. The reason that it's rapid onset, rapid offset with stuff worse and bacillus serious is that the toxin has already been made. So it's almost like you have like a ready to go problem, right. It's not like the bug got a grow and then the bug has to make toxin and cause all these issues. No, the toxin is already there, right. And then you just kind of get in trouble quick, right. Remember, like bacillus serious mix this toxin, I think he's known as serial light. I spelled as C-E-R-E, sorry, sorry, C-E-R-E-U-L-I-D-E serial light. Serial light is a toxin that can cause the gastroenteritis. And stuff worse has like a bajillion toxins, right.

It can make different kinds of toxins that can cause a gastroenteritis, right. So kind of keep that in mind as you prepare for your exams, right. And then what if they give you a question about like a like a serotic, a serotic, right. You see a serotic with really, really nasty gastroenteritis, especially after they've consumed seafood, right. Or they've gone to a sushi restaurant on your exams, you absolutely want to think about these vibrio species, right. You want to think about the vibrio species, right. Vibrio parachymolyticus and vibrio-vonificus. Although usually on the USML Es, for gastroenteritis, they tend to focus on parachymolyticus. And then for vonificus, they tend to focus on like neck fascia of the skin, right. Like a necrotizing wound infection, necrotizing skin infection in serotics that have been exposed to seafood, right. Seafood shellfish contaminated water. So let's say you went like swimming in a bay of some sort. That's usually not a very good idea, especially if you're a serotic. If you're a serotic, many people do not keep this in mind. But serosis actually compromises you from an immunologic perspective. So just going to be careful about that, right. Like you're a serotic, you're a diabetic, be very careful. You can get some very, very, very, very gnarly infections, right. So serotics, you see like neck fascia of the skin, you see like an acrotic infection, you see like gangrene on their skin.

After exposure to contaminated water, seafood shellfish, think of vibrio-vonificus on the those circumstances. Again, I just said that diabetes compromises your immune system. There are many different ways they go after diabetes and infections on the USM in the exams, right. Like for example, I already gave one association in this review, right. I talked about vaginal candidiases with being a diabetic, right. And also I guess the diabetic association of you taking an SGLT2 inhibitor, you're getting trouble there. I've explained those already. But don't forget diabetes, right. You can see them getting the short end of the stick from many different kinds of infections, right. So like for example, you see a diabetic poly-controlled diabetes, they have like a lot of facial pain, they have a lot of facial pain, and they have very high fever, they have like insane lucositis. In those circumstances, what should you be thinking about? You want to be thinking about mucomicosis, right. You want to be thinking about mucomicosis for your test, right. Cosby like those rise up or species. Remember, you want to be make sure you can identify those wide branching up high feet, right. Branching up at wide angles. Again, make sure you can identify those pictures on the USME Ls, something that absolutely love to test on on exams, right. And then I guess to talk about the diabetes, remember, typically, you know, if you see a person that has like flunk pain and fever, right.

We know that we're talking about flunk pain, fever, you know, you see piouria, you see a wide blood cells in the persons that you're in. Sometimes you see a wide blood cell cast, right. Lucositis casts. You're thinking about acute pylon and Fridays. I remember the most common cause of acute pylon and Fridays is going to be equal, it's going to be equal, right. But typically if you give a person antibiotics for pylon and Fridays, the person is going to recover very, very quickly, very, very quickly, very, very quickly, right. It's one of these miracles of modern medicine within like a day or two. You've turned a corner, right. And typically pylon and Fridays, we're going to treat you like safe triaxone or a fluoroquin alone or a minoglical side, very amazing coverage there, right. But you notice that a person is a diabetic and it's like three days, four days, five days, they're not getting better. When you see something like this, you want to think about that person developing some kind of nasty complication of pylon and Fridays. They may have this thing called emphysemaidous pylon and Fridays where they have like air in the wall of the kidneys, like a very bad gangrenous infection. That thing's actually pretty deadly. In fact, you actually have to reseg those people's kidneys in addition to giving them IV antibiotics, right. Or they can actually get an abscess of the kidneys, they can get a perinephoric abscess, they can get a perinephoric abscess, right.

Or you see a diabetic that has like infection under the breast, that can actually be kind of diocese, right. Intertragal, right. Candid diocese, intertragal, like infection under the breast, we tend to see that in diabetics on the USMLE exams, right. Or you see a diabetic that, you know, it's probably on chemotherapy. So the person is neutropinic. And then you notice that they have like neck fascia of like the skin. So I'm not focused on the face now, I'm focused like on the skin. You see that thing about a pseudomonal infection. We call that ect themagangrenosa, mect themagangrenosa. We tend to see it in a diabetic patient that is neutropinic, right. We're going to manage that with IV antibiotics, actually a very serious infection. So you can give something that covers pseudomonas. So what are the drugs that covers pseudomonas? Well, think of things like IV cephepim, right. That's a fourth gen cephalosporin that covers pseudomonas. Think of IV ceph tazidim. Remember ceph tazidim is the only high yield. Third generation is, basically, is the only third generation cephalosporin. You need to know for your exams that covers pseudomonas, right. And then remember, you can also give an IV carburet penem, right. I remember, like meropenem, immunopenemodal stents. I can give a monobachem like astrionym, for example, you can give a fluoroquine alone. Fluoroquine alone is good for covering a pseudomonas.

So though these days, we try to avoid fluoroquine alone because they cause a bunch of problems, you know, they can prolong your cutie interval, they can explode your Achilles, right. So if you're an athlete, you can have fluoroquine alone is a terrible idea. So just kind of keep those things at the back of your mind, for example. And also remember, I mean, no glycosides like gentomizing can also cover pseudomonas. They can also cover pseudomonas. All right. Now, I think one thing that's kind of helpful is let's kind of talk about the most common cause of certain things from like a kind of a bog perspective, right. Kind of a bog perspective, right. So again, if you see a new born, right. So these kinds of questions when they present them on exams, they won't give you many clues at all, right. They'll literally give you, they won't give you many, many, many clues at all, right. But you notice that who they'll give you a bunch of bugs that all cause the same issue. But because they expect you to know the most common cause, you gotta pick the right answer, right. So for example, right, you see like ringworm, right. Or you see like, so like tinia corpus, or you see like tinia involving like the head, tinia capitals, or you see like tinia involving the nails, only comicosis, right. And then they give you like, hey, it was the most likely cause or whatever. And they give you like a bunch of answers. And you know, one of the answers has track of fighting in it.

And then they also put micro spore and then they also put epidermal fighting. You want to pick the track of fighting answer, track of fighting species at the most common cause. Very high yield. They're the most common cause of tinia on the exams, right. The second most common cause are going to be the micro spore species. The third most common cause are going to be the epidermal fighting species. So trichofighting is number one. Micro spore is number two. Epidermal fighting is going to be, it's going to be number three, right. Okay. Now what if you see again, a newborn, like most infections in a newborn, what's going to be the most common cause, like meningitis, pneumonia, sepsis in a newborn, right. Especially again, the first four weeks of life, the neonatal period. You want to think about group B streps. Treppe Galactia again, the acquired it from passage through the vaginal canal, right. If you don't see group B streps as an answer, quite a big answer that says E coli, big answer that says E coli. If you don't see E coli as an answer, then consider pickinglysteria as an answer, because look pickinglysteria as an answer, right. Okay. What if you see a child within the first two years of life having like gastroenteritis? Then what should you be thinking about? I really hope you're saying, ooh, divine. I should think about a root of virus infection on the US Emily exams. Think of root of virus infection on the US Emily exams.

I remember if you're caring for a child that has root of virus, what kind of precaution are you supposed to take on the US Emilys? Well, you want to wash your hands with soap and water, right. They'll try to tell you to pick, they'll give you an answer that says to pick an alcohol based solution. Don't do that. Don't do that. If you do that, you think as an adult, you cannot get root of virus. Boy, you could not be more sad, lean is taken. You can absolutely positively get that, right. An alcohol based solution is don't do deadly squat to root of virus. You need to wash your hands with soap and water. You need to wash your hands with soap and water, right. So you see a gastroenteritis in a child. Think of root of virus on the exams. Think of root of virus on the on the exams. Although, root of viral gastroenteritis, the incidence of it amongst kids has started decreasing because there is more and more vaccination going on there, right. There are certain things that we're beginning to see a decrease incidence of these days because of vaccination, right. We're beginning to see a decrease incidence of hepatocellular carcinoma, you know, secondary to HB, just because of HB vaccine. In fact, they can throw a question on your exams. I'm sorry, I'm going to get back to the most common cause. Just give me a moment here. I don't want to forget these associations that kind of bubbling in my brain right now.

So the intervention, the most effective intervention for decreasing the risk of a paracelular carcinoma on your exams, they're actually getting the HB vaccine. Believe it or not, this is something the absolutely test on the US Emily exams. Believe it or not, this is something the absolutely test on the US Emily exams. I'm telling you, this podcast is extremely high yield. This podcast is extremely high yield. There's so many questions you're going to get right from this, right. If you see the, the ask your question, they literally will free me. That's an epidemiology question. They can kind of formulate something and again, they're not going to make it a direct question. They're going to give you like a bio-starts question, right. You'll say, oh, hepato-cellular carcinoma, you know, like incidents in the 50s, you know, they can say 500 per per million in the US. And then they say in the 1990s, 400 per million in the US. And then they say in the 2000s, 150 per million in the US. And then they'll see which of the following interventions has most likely explains the trend in the observed data. The answer is going to be HB vaccination. The answer is going to be what? HB vaccination. The answer is going to be what? HB vaccination. It's something you want to keep at the back of your mind, for example, right.

So that intervention, because when you get HB vaccine, when you get the HB vaccine, it massively, that's why you get it before you leave the hospital, you get like your first shot of HB before you leave the hospital, right. By getting the HB vaccination, you're reducing your pretty much your lifetime risk of getting HB infection. So you're highly unlikely to get hepato-cellular carcinoma, at least from that. I mean, if you drink or you have hemocromatosis, then objects are off, right. But then also when you get the HB vaccine, you're also protected against HB. Don't forget that HB can also cause hepato-cellular carcinoma. But the thing is HB for each to survive, it needs some components of HB. So you're going to need to be co-infected with HB to get a HB infection. So by literally protecting yourself against HB, you're also protecting yourself against HB. So you will not get hepato-cellular carcinoma from those things. All right. So remember, so again, we talked about, hey, reduced incidence of stuff, right. Reduced incidence of rutovirus gastroenteritis in kids because of vaccines. Reduced incidence of hepato-cellular carcinoma because of the HB vaccine. What's another weird thing they can test, reduce the incidence of, on the USML exams. They can also test, reduce incidence of ear infections from hemofluos influenza type B. And just infections in general, from hemofluos influenza type B. Because we now have a vaccine against it. We now have a vaccine against it.

Again, that's something you certainly want to keep at the back of your mind for your exams. All right. So now let's go back to the most common causes. So we stopped at, oh, most common cause, they give you like, orderly diary in a child. You want to think about rutovirus in those circumstances. But again, what if they give you a question about a child that has, you know, they had like, you are right symptoms for a few days. And now they're having a lot of whizzing, right? They tell you you have to see something infiltrating the lungs, especially like a child within the first like two years of life. I want to think about RSV, right? RSV broncholitis. RSV is like the most part of the most common cause of like interstitial pneumonia, especially in a little kids. It's pretty within the first two years of life, within the first two years of life, right? And then, remember, in general, once you become like an adult, most pneumonia's, most meningitis, you're going to get it from strep pneumo. Once you become an adult, most pneumonia's, most meningitis, you're going to be getting that from strep pneumo on your, on your, on your exams. You're going to be getting that from strep pneumo on your, on your exams, right? So kind of keep that at the back of your mind for tests. Although, if you see an adult with walking pneumonia, right? So those people, they have like low grade fevers. You see a lot of interstitial infiltration. So it's not going to be low bar.

It's going to be interstitial infiltrates. Then on your exams, I was strongly encouraged you to think about like microplasma, right? Microplasma pneumonia, right? It's the most common cause of walking pneumonia. We're going to cover that with microly. We're going to cover that with microly. We're going to cover that with what with microly. So this will, they're going to have low grade fevers. They may have like a mildly productive or non-productive cough. And you're going to see interstitial infiltrates on a chest x-ray. Think of microplasma infection on those circumstances. If you don't see microplasma as an answer, then pick the answer that talks about like chlamydia pneumonia, right? Remember, chlamydia can also cause pneumonia or think of legionella, especially when you see associations with like contaminated water supply, right? Like contaminated water supply, humidifiers, and things of that sort. Think of legionella infection. And again, all these atypical organisms can be covered with microly. There's this nice demonic right? Like if you spell out the word microly. Right? Microly has an eminent, has a seed, it has an alienate, a surprise surprise. Guess what? M for microplasma, C for chlamydia, L for legionella. It's almost like microlytes have this manifest destiny of covering these atypical organisms. So kind of keep that in the back of your mind, for example. All right. So let's, let's, let's keep going here. Right?

So what if you see again, let's talk about some more associations, right? Again, remember I say that Campilo-Bacter, you know, Guillem-Barris syndrome, and he grows at 42 degrees Celsius, right? It's like a common-shaped organism. It's just one of these rare things you may see them thrown examples. And I know some of you may think that this will only be on step one. Until you see it on step two and step three, especially step three, and you're like, what? Yeah. So you're just going to keep that in the back of your mind as you're kind of preparing for tests. Okay. Now, what if they give you a question about a person that, you know, has a long history of GERD and the person was switched four weeks ago from having, person was switched four weeks ago from taking like, you know, from taking those, those histamine blockers to a new drug for their, for their GERD. And now this person has been having like very significant watery diarrhea. What should you be thinking about on other circumstances? I want you to think of CDIF, right? So the USMLE's, excuse me, the USMLE's, they're not stupid, right? They know that everybody knows post-antibiotic gastroenteritis and CDIF. Everybody knows that stuff. But don't forget that taking PPI's also raises your risk of CDIF. I'm going to say that again, taking PPI's proton pump inhibitors also raises your risk of CDIF. Why? Well, think about it, a PPI or proton pump inhibitor inhibits that hydrogen potassium ATP's pump that we find in the stomach.

So by doing that, you're pretty much not going to make acid. Acid is a very strong deterrent to preventing the growth, the overgrowth of CDIF. But if you're taking a PPI, then you're not making that acid deterrent because you've shut down that transporter. So that ATP is pump, it's not a transporter is a pump. So because you're not making that, because you're not making acid, then you don't have that deterrent anymore. CDIF can certainly overgrow on that those circumstances. And remember, CDIF does not only cause watery diarrhea. CDIF can absolutely cause bloody diarrhea on the USMLE exam. So just kind of keep that in mind. All right, now what if they give you a question about a person that has like a bloody diarrhea? But this person also has right-up pro-coronating pain. They have like significant right-up pro-coronating pain. And they tell you that you see like a space-ocupine lesion within the person's liver. If you see something like that, you want to think about intamibahistolidica. Intamibahistolidica. Amibiasis. Remember, many times it's going to cause bloody diarrhea. In fact, it's like the higher your protozoan you need to know for your exams. That causes bloody diarrhea. But in addition to causing that bloody diarrhea, it can also cause a liver abscess. It can also cause a liver abscess. The bloody diarrhea we're going to control it with metronidousol. Remember metronidousol can cover amibiasis very well.

There's this pneumonia, you probably know, get gap on the metral for the things that are covered by metronidousol. So the G4 Gardia, the E4 intamibahistolidica, the T4 trigomonidousis, so the GET. And then the gap, the G, the other G, I'm kind of wondering what that is. I don't know. And then the A stands for anerobs. And then I think the P stands for protozoans. metronidousol is pretty good at covering those things. It's pretty good at covering those things. And then don't forget that metronidousol can cause that dyso from effect from inhibiting as a toutedhyde hydrogen. That's why if you're taking a metronidousol, you shouldn't take alcohol at the same time. But again, different discussion. And then the liver abscess that you can get with amibiasis, how do you treat it? What are you going to use an intra-luminous agent like paromomizing or ayudo-quinol? Like paromomizing or ayudo-quinol? Again, paromomizing or ayudo-quinol. And then again, since we're talking about the liver, remember, there are certain strains of malaria, the plasmodium species, plasmodium, sorry, plasmodium species that can stay dormant in the liver. Plasmodium, vivax and plasmodium, ovali. Those are the plasmodium species that can stay dormant in the liver. If you want to eradicate those, remember you're going to have to use a primer queen. Primacoin kills the hypnozoid forms of those organisms, the hypnozoid, very high of the hypnozoid forms of those organisms, so that can help you out there.

So again, keep those things at the back of your mind as you prepare for for exams. Let's see. This podcast is, whoa, 50 minutes. This podcast is getting long. So we're probably need to shut things down pretty quickly here. But again, what if you see a person that has a kind of like a right upper quadrant and they tell you this person has a lot of vaginal discharge on your exams, right? They have vaginal discharge, they have like bilateral or abdominal tenderness. Then on your exams, you want to think about pelvic inflammatory disease, PID, pelvic inflammatory disease, PID, PID, PID. So what's the deal there? Remember PID, pelvic inflammatory disease is a kind of sexually transmitted infection, right? And we tend to find these in people that are sexually active on the exams. So many times they're going to have like vaginal discharge, like purulent vaginal discharge, and they're also going to have like bilateral at next cell tenderness. But sometimes the inflammation when a person has PID can spread to the liver capsule and cause a percusion pain. In that situation, we call it FITSU Curtis, Syndrome FITSU Curtis, Syndrome FITSU Curtis, Syndrome, okay? FITSU Curtis, Syndrome FITSU Curtis, Syndrome. All right. So just I guess kind of keep these things at the back of your mind as you prepare for your exams. I think this is probably a good stopping point for tests.

I guess since I talked about the Vibrio species, I talked about Vibrio pyrimolyticus, I talked about Vibrio vanythicus, don't forget Vibrio cholerae, right? Vibrio cholerae causes diarrhea, right? It's going to be like a watery diarrhea, it's going to be rice water diarrhea. Many times on your exams it's going to be from you consuming infected seafood, right? And then you kind of get you in trouble. That's another bug that is common shaped. So remember we've talked about two common shaped organisms today. We've talked about Campino Bacteria Junai, right? And we've also talked about Vibrio cholerae. Remember people that have Vibrio cholerae, those people need oral rehydration therapy, right? They're going to need like a salt sugar solution to kind of help them out to help them out. They're going to need a salt sugar solution. I mean wonder, gee, divine, why? Why? Why? Again, our friends at the NBA means they can slap in some pathophysier. Sorry, I cannot stop this podcast and not talk about this, right? So remember when I talked about cannaglyphlosing, empathy, phlosing and that paglyphlosing earlier, right? I said that those are SGLT2 inhibitors that we used to treat diabetes, right? Remember just like this, SGLT2, there is actually SGLT1. SGLT1, sodium glucose, so look what is the SGLT stands for? Sodium glucose link transporter 1. We tend to find that in the GI tract, right? The thing is when you have cholera infections, right?

The cholera, one of its toxins is pretty much I believe an adenylid cyclist. So it's going to cause you to put a ton of chlorine in the lumen of your GI tract. Waterful lose, you have this rice water diarrhea. But don't forget that one of the few transporters that can help you, because these people are losing so much fluid, one of the few transporters that can still help you, it's going to be your SGLT1 transporter. It still works even if you have a cholera infection. That's why we give a sole trigger solution because that transporter uses the gradient energy of sodium. Remember, sodium is primarily an extracellular ion. So sodium flows down its gradient into the cell. Glucose is pumped in, right? Water is going to follow and that's going to help you kind of hold some volume, right? So that's why we use that sole trigger solution. That's actually the mechanism behind us using oral rehydration therapy. When a person has a gastroenoritis, I certainly remember when I was growing up back in the day, I definitely had to take or at times when I had like some cases of a gastroenoritis. All right, so just again, pretty high notes to know these things for exams. Again, I know this podcast may have seemed kind of discombined, but again, as I've explained on your USML exams, you want to be able to think in multiple dimensions. Many people get frustrated at my podcast making style where it's like divine. Can't you just say, okay, talk about diarrhea alone, talk about this alone.

And I do that from time to time. But the thing is, that may help you, if it may make you feel comfortable as you're learning, but I'm not helping you for your exams. I'm really not. Because the USML is they don't test things in a linear fashion. They test things in a multi-modal fashion. They test things in a multi-dimensional fashion. So if you can think in all these webs on your exams, you'll notice that most questions you see will look like a joke to you. Let me not say like a joke, but it will seem a lot easier on exams if you can make integration. So sorry again, that's the reason I don't just make these integrations because I like to make people's life hard or to seem disorganized. No, it's because this is what the USML is demand. This is the way they want you to be able to think. This is the way they want you to think. So don't get me wrong. I organize things a lot. But again, I like to use scenarios, vignettes, associations, integrations to get these points across. Because again, that's just a lot more realistic for what you're going to see on your exams. If you love the way I teach, you love the way I make integrations, you're probably going to be interested in the classes I offer. I have a bunch of classes coming up in the month of April. I have a, you know, for step one, two, step three, I have a test taking class, I have a four bio stats class, I have a social sciences ethics quality improvement and hospital medicine class. That's for step one to three.

And then for step two, step three, specifically, I have a 20 hour step two step three review and I have a last minute review. Again, many people of taking these classes and they found them to be extremely helpful. I literally had somebody that took the exams last week that took my class just before they took the exams and they were like, oh, divine, I wish I had known. I'd have taken it much earlier in my prep so I could have seen this material multiple times. This didn't really, really help me on my test again. I've had a lot of a few take my 20 hours step two step three class and they've gotten like 250's, 260's, 270's, very, very high scores on the exams. Obviously, I can't, I can offer any guarantees. But the overwhelming majority of people that take my classes, they do extremely well. And then there's this 50 hour class that's taking place in the first two weeks of June. It's going to be held only once this year, but oh my goodness. It is my most comprehensive class, extremely, extremely high class for step two and step three or level two and level three. If you're interested, again, there's still some spots. Shoot me an email and I can give you some more information. And then I also have this podcast on Apple Google and Spotify. And also, by the way, I have a step one review taking place in the first week of May, a 25 hour step one review. So it's about taking step one or level one, about taking step two step three and you have poor basic science foundations.

Because believe it or not, these step two step three exams, these days, test a lot of basic, a lot of basic sciences. So I also have this podcast on Apple Google Spotify. I have a You Tube channel where I post the videos that I make. And then I also help with, you know, do a lot of one on one tutoring and also help with your applications, personal statements, recliders and things like that. And then I also have another website called divine intervention life lessons.com. Divine intervention life lessons.com every week. Typically post like two to three podcasts, where from a biblical perspective, address a life lesson. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons podcast. All right. So thank you for listening to me today. Please, I will strongly encourage you. Don't ignore this podcast. A lot of high-yield stuff. Going a full, almost a full hour. But again, a lot of high-yield stuff here. A lot of easy points on your exams if you know this stuff. So I will see you in episode 500 and I think it is, it is seven I think. So have a wonderful day. God bless you and bye for now. Thank you.

Tricuspid valve endocarditis, because veins drain into the right side of the heart, and the tricuspid valve is the first encountered structure.

Recent antibiotic use (disrupting flora), diabetes/high glucose levels, or taking SGLT2 inhibitors (which increase urinary sugar).

Passage through the vaginal canal during birth.

Pulse-temperature dissociation (the patient is febrile but has a tachycardic pulse).

GETA (or similar variations): Gardia, Entamoeba histolytica, Trignomonodiasis, and anaerobes.

Ampicillin (or combination therapy including ampicillin).

The SGLT1 transporter uses the sodium gradient to pull glucose and water into the body, counteracting massive fluid loss.

Streptococcus agalactiae (Group B Strep).

Food poisoning from Staphylococcus aureus.

Elevated Prothrombin Time (PT) due to inactive clotting factors.

Campylobacter jejuni.

1) Pregnancy, 2) Soft cheeses/deli meats, and 3) Immunosuppression (e.g., TNF inhibitors).

The toxin (Botulinum neurotoxin).

1) Trichophyton spp., 2) Microsporum spp., 3) Epidermophyton spp.

Ampicillin.

Streptococcus agalactiae (Group B Strep).

Food poisoning from Staphylococcus aureus.

Elevated Prothrombin Time (PT) due to inactive clotting factors.

Campylobacter jejuni.

1) Pregnancy, 2) Soft cheeses/deli meats, and 3) Immunosuppression (e.g., TNF inhibitors).

The toxin (Botulinum neurotoxin).

1) Trichophyton spp., 2) Microsporum spp., 3) Epidermophyton spp.

Ampicillin.