DIP Episode 292 - NBME Endocarditis and Myocarditis (For Step 1-3)

Okay, welcome. My name is Divine. This is episode 292 of the Divine Intervention podcasts. In this podcast I'll be discussing some topics that are actually very high-yout for the US Emily exams and there are two cardiology topics but again they just show up all the time. I feel like people keep getting them wrong. So we'll see. We'll see. So let's just jump right into it. I don't want to give up the topic because they all pretty much give up what I'm discussing. So okay. So what if they give you a question about a patient and they tell you that this is a 35-year-old guy and that he had a pacemaker that was placed in his heart like two weeks ago. But that over that like the last ten days he has been having a lot of fevers, he's been having a lot of chills, he's been having a shortness or breath and that they tell you that when you listen to his heart you can hear like a new murmur in the e-bex. If you see all these things what should you be thinking about? Well I would really hope that you're thinking that this person potentially has endocraditis. Endocraditis. So I know you may be like wow divine pacemaker come on divine are you kidding? So the thing is again you may notice that some of the podcasts that we're making recent times have been reflecting a mantra that our friends at the MBME you know tell a care about these days right. The go after things that are common topics but they just go after them in uncommon fashion.

So that's one thing you need to almost like begin to adjust to so that you don't have any unpleasant surprises contesting right because yes don't get me wrong is the MBME testing some very new concepts absolutely right. They're testing new concepts November 2020 that was last year the middle of these changes I've made tons of podcasts on that stuff but they're also beginning to make a lot of changes just from oh how do we test this same knowledge kind of deal right. So I'll encourage you to kind of keep those things at the back of your mind as you as you study. So what are some things that are important with regards to endocraditis? Well the first thing is you want to know some risk factors right. Obviously we know about the IV drug user right but again the IV drug user is not something it's again it's something that is pretty classic but it's not something that we pop up on exams because they know that again probably everyarchy they're known to man has that somewhere right. So who are some unusual patients that can have endocraditis on MBME exams. One it can be people that have prosthetic heart valves right especially with those people with stuff epidermidus because remember stuff epidermidus loves to form biofail. Two it can be people that are on dialysis right.

People that are on dialysis again they have a very high risk for like really weird bizarre bacteremia which can ultimately again leave those people to get in endocraditis but also another new kid on the block is people that have electronic pacemakers right. Electronic pacemakers have a very well-established association with people unfortunately ultimately developing infective endocraditis right. And again usually these people on exams right they will have like some kind of new heart murmur right and you'll have like skin ptki right. Now when you're thinking about endocraditis right what are the different types right. Obviously there is going to be acute endocraditis many of us have also heard of like subacute endocraditis but there's actually such a thing as chronic endocraditis right. So what are the timelines that help you to find these things really is just like how long you've had symptoms for right. So if you've had symptoms for less than six weeks for the most part people call it acute endocraditis. If it's from six weeks to three months people call this subacute if it's more than three months people call it chronic but let me tell you this if you see a person that has had symptoms over like a two-ish week period think more about think more about like acute endocraditis on MB exams but if you see a person that has gone past that two-week period in terms of symptoms think more in terms of subacute endocraditis okay.

So there's the official definition of oh less than six weeks acute six weeks to three months subacute greater than three months chronic but if you see less than two weeks on MB exams think about acute endocraditis if you see more than two weeks think more along the lines of subacute endocraditis and obviously if you're thinking about acute endocraditis I mean what's the poster child bug that causes the stuff. I hope you're telling me it's stuff for you. Stuff for you is the most common cause of acute endocraditis and one thing that's relatively unique about stuff for you is it can actually damage a valve that is normal. In subacute endocraditis which is something that will seem more severe it ends you need to have like a pre-existing abnormal valve for you to get endocraditis on that valve right. Again it's a subtle point but it's a floridly higher point to know. If your valves are stone-cold normal at baseline in general on MBM Es the only kind of endocraditis you will get is acute endocraditis from stuff for you. Stuff for you can damage a valve that is completely normal at baseline or a valve that is abnormal at baseline but severe it ends which is the most common cause of subacute endocraditis torches valves that are abnormal at baseline if your valve is normal at baseline you have a very low risk of getting subacute endocraditis right.

Now one of the things that you may hear a lot again because I feel like one of the reasons I'm also making this podcast is just to clear up some misconceptions that people have and then they take that stuff away and then they end up getting questions wrong on exams right.

Like for example you hear this and it's thought sadly many med schools oh if your glucose is more than 400 the pressing has HHS if it's less than 400 you have DKA folks that's not true in fact the MBME actively capitalizes on this information and writing questions as you see me see many times the only thing that determines if you're in DKA or H HHS on MBME exams is not your glucose number it's your bicarb if your bicarb is low doesn't matter what your glucose number is you have DKA if your bicarb is roughly normal let's see if it's above like 21 okay let me even see 20 if it's above 20 your name me exams doesn't matter what your glucose number is you have HHS that's very important to know right again many people screw that up so the thing I would just say is many times you hear people they say oh contra negative endocraditis contra negative endocraditis contra negative endocraditis he's sacognisms and that was the thought before right but the unfortunate thing is that still being thought very commonly many resources but it's wrong right culture negative endocraditis the most common cause of culture negative endocraditis is that you've gotten antibiotics before you took the blood cultures to treat the person for endocraditis right so the thing is that's why many times before you start antibiotic therapy for any case of endocraditis on MBME exams you're usually encouraged to go ahead and get a blood culture right many times before you start antibiotics on endocraditis folks get a blood culture right so that you don't get into that culture negative territory right the most common cause this is actually very high you to know the most common cause where they can meet this a risk factor question the biggest risk factor for a negative blood cultures in a patient with endocraditis is actually the administration of antibiotics and it's kind of a weird question but it's very hi

gh you to know for exams right so really like whenever you see resources referred to a culture negative endocraditis it just means that the endocraditis that the person like the bog causing the person's endocraditis is a very difficult bog to grow right so things like again those he said cognizms I think the he said means like if I'm not mistaken like the he stands for hemophilus the he stands for achteno bacillus the c stands for cardio bacterium the he stands for iconella and then the case stands for king gala if a mom is speaking I'll be remembering correctly but I believe it's hemophilus achteno bacillus cardio bacterium iconella and king gala right those things just take time to grow that's that's all right the cultural alternative at some point right so but if you know everyone is not a patient right to meet wait for those things to grow also as perjilosis also something that causes again these things we call cultural negative endocraditis even coxiela coxiela is becoming on nbm is a big big big cause of endocraditis right and remember IV drug users right whenever they get endocraditis what side of the heart is usually affected it's usually going to be the left side of the heart I mean sorry the right side of the heart right usually going to be the right side of the heart because think about it IV drug user intravenous drug user right so that means you'll literally inject the drugs into veins while we're doing all the veins of the blood draining of the body draining to are they draining to the right side of the heart right so an IV drug user is like that infected blood very likely hit the tracospid valve first right that's why tracospid valve endocraditis is very common on nbm exams and people that are IV drug users right but in general most cases of endocraditis is on the left side of the heart the most common overall site of endocraditis in if you're taking al

l comers it's going to be the left side of the heart right what IV drug users think about tracospid valve endocraditis right and again just kind of piggybacking on this all the veins in the body draining to the right side of the heart there is a reason why the right it's your pressure is called the central venous pressure the CVP because again all the veins ultimately drain there right so it's like the central hub for all the veins in your body right that's why it's called central venous pressure right because again the mbme if they put ready for pressure for all these arrow questions the new everyone will get it right so they don't do that right so they can call ready for pressure central venous pressure on your test right so again you see an IV drug user staff orders is the likely cause of the endocraditis and then don't forget that again for patients a prosthetic heart valve right you want to think about stuff epidermitis especially they got the prosthetic valve less than two months ago right that's something that's called early prosthetic valve endocraditis if you see prosthetic valve endocraditis you'll always want to think about stuff stuff epidermitis again especially when it's less than 60 days since they got said valve right so again what are the classic symptoms you see for a person with endocraditis on mbme it's again they'll have feverers fever is probably like the most common clinical symptom in people that have endocraditis on mbme exams right but you know they will be fatigued right you'll have a new heart murmur that's always high up to now right and then they can also have this thing called a septic emboly right you'll have this thing called septic emboly basically these septic emboly they are just pieces of the vegetation that break off and then they begin to occlude things right so they can give you a person having gangrene right especially on step

one they can give you like a gangrene question in a person that has infected endocraditis again it's just that embolyce or those little bits of the vegetation that have broken off right and they are occluding blood vessels in the in the legs in the toes right they can even give you a stroke question again septic pulmonary septic emboly right those things are basically like just think like parts of the of the vegetation breaking off and going on occluding blood vessels right and again remember these people can also have these genuillisions right you know genuillay right painless right it's a painless lesion on the palms and soles right you can have all these splinter hemorrhages they can have these they can even give you a question ready see that all they do like angiography right and then they find like a wet shaped area of non-enhancment right in the wall of an organ like the spleen again that's embolyce phenomenon right so basically right people that have endocraditis they tend to get infarctions of the spleen especially right but again remember blood vessels branch branch branch branch branch so whenever pressing has an impact is usually like in a wet shaped form okay because the vascular territory of that central blood vessel that splits off into two right no longer gets blood supply right sometimes they can even tell you that oh they perform on geography right and then they find like a mushroom shaped extension or expansion of the yodic wall if you see that you want to think about something called amicotic aneurysm right amicotic aneurysm again they know that most of these angi-dex contain the term my cotic aneurysm you've heard me say this at nasim in fact like my step two ck course courses or in general when i'm tutoring people i teach them like the multiple ways the mbimic can see the same thing right the multiple ways the mbimic can see the same thing sometim

es the mbimic can see my cotic aneurysm well glory be to god that means your life is easy that day but again sometimes they can just describe it they can just say oh angiography or you know city and geography of the of the chest shows a mushroom shaped expansion of the yodic wall if you see that you want to think about amicotic aneurysm right again it's just that infection that is tearing eating eating eating away at the wall of the aorta right and when you enter the wall of the aorta that is skimmy causes the aorta to begin to dilute right if it dilute in a mushroom shape that's what's called amicotic aneurysm right that's what's called amicotic aneurysm and you don't need only getting in the yodic and get it pretty much in any vestor you can even get like cerebral my cotic aneurysms right and then remember these people can also get like osler notes right so remember those things are painful remember genway lesions are painless but osler notes are pain for right and again instead of seeing osler notes on the test you can see oh this patient has painful nodula erythema on the hands and feet right they can see open full nodula erythema on the hands and feet right and the thing is again these genway lesions they actually are more vascular based versus these osler notes that tend to be more immunologic phenomena right because remember one of the hallmarks of inflammation right there's tumour, dollar, rubour, color, blah blah blah blah blah right so like pain right pain is one of the hallmark things that happens when a person has inflammation right so actually these osler notes if I'm not mistaken one of the reasons those things are painful is because there's a lot of inflammation that creates those lesions those painful lesions you find on the palms and so's right and then don't forget on the retina they can have these rough r-o-t-h these rough spots right so again obvio

usly if a person has endocraditis what are you gonna do for them well you're gonna do some kind of diagnostic testing right you're gonna get a blood culture that's always the first thing you do before you even give anti-bodies don't matter you always always always have to get a blood culture and then after you've got into blood culture you can start the antibiotics but one thing your friends at the Mbimi love to do is what kind of imaging would you want to go for for the heart remember always go to TEE a trans esophageal echocardiogram do not go to TTE which is a transphoracic echocardiogram right TEE is better than TT Es in people that have endocraditis right I mean like the TEE the sensitivity I believe is almost like 90% versus the TTE where the sensitivity is about 50% right so I just get in a much better study right and again that should make sense one because most cases of endocraditis involve the left side of the heart two when you put an ultrasound probe in the esophagus which is what happens in a TEE right you're pretty much smack dab against the left atrium so you're gonna just get much better views right so it would make sense that that's the right thing to do and again the most common cause of endocraditis is just in general right again it's gonna be stuff for us right the second most common cause actually strep very dense right strep very dense and again the thing is your friends at the Mbimi realize that most people oh strep very dense strep very dense like every onky deck known to man right a onky b onky c onky again I'm not gonna say anything here right onky is a great resource but I feel like my only quip with onky is I feel like many people they memorize stuff mindlessly but then they have like zero understanding of what they are memorizing and then they notice that man I've done this onky deck I've matured this onky deck and somehow I'm not doing I'm

not getting two seventies on my practice exams it's because the understanding is not there again the Mbimi they're not novices they are aware of what exists out there they know that there are people that oh memorize memorize memorize right so again I'm nothing you should have memorized you need to memorize to do it on the usml's or does just one of the steps you also need to understand what in the world you are memorizing I'm telling you I can literally because I love writing questions I can literally write a bunch of questions where memorization won't do you didly squat you actually need to understand what's going on to get those answers correct so again I encourage people to use onky onky is great it is phenomenal it's fantastic it's probably one of the best inventions in medical education but make sure that you are understanding what you are committing to memory if you can do that then your use of onky is a lot more prudent in those circumstances right so again Star 4 years is the most common cause second most common cause when do credit this is trevary dance but again trevary dance you need to know the alternate names right there are many things that can be strevary dance on your test right you can have like strep or aless or are al is strep mightis m its strep sanguess s a n g y s right so I remember that with the mnemonic school of medicine s o m the s for sanguess the o for or aless and the m for mightis okay that's the way to keep that straight on exams right and the third most common cause of indogridate is actually is these interococcal species right interococcal species but again if you see an ivy drug user think about staff staff or is right and again people can get these things from again they can get like especially like these viridance and ducatitis they can get it from like a tooth extraction of some sort right or you can even get it as an ivy drug us

er if you lick your needles if you mix it with saliva right because your saliva very likely contains strep very dance right or if you go for like a procedure where the manipulative geotract your genital urinary tract or your GI tract again those things in general tend to have this nice association with interococcal endocarditis right so if you see a GI procedure or a geopersidure on mb me exams and the person has endocarditis afterwards I want you to think about interococcus right or they can give you a question about a person that has endocarditis from a foot puncture right so they were punctured by a needle in their feet if you see that you want to think about sudumonas as the cause of the endocarditis right or you see a person that has endocarditis and they have colon cancerous right there are some bugs you want to think about you want to think about strep bovis strep bovis is a common one on exams but another common one on exams a new kid on the block is something called close tridium septicum right close tridium septicum close tridium septicum close tridium septicum yours hear me repeat it over and over again I'm not repeating it for fonzies okay it's very high you to know close tridium septicum and I know many of many people may say like divine why is it that these bugs have an association with like where oh let's say a person has endocarditis you do blood culture you grow strep bovis or you grow close tridium septicum why would these things be associated with with with colon cancer the thing is the thought at least from my research is that many people believe that people that have colon cancers those colon cancers can kind of break down the barrier because the thing is there is like a pretty decent amount of mucosal layers or whatever that exists between the lumens of the colon and the blood vessels that drain the bowel and send the blood back to the liver so t

he thing is whenever a person has an invasive malignancy especially an invasive colon cancer that invasive colon cancer can pretty much tick over the walls these mucosal surfaces right and it can basically like leech leech leech leech leech the mucosal surface all the way to the blood vessel right and then getting to the blood vessel right so bugs that you normally find in the lumen of the colon like strep bovis or clostridium septicum can translocate through getting to the blood stream and then going deposited on hard valves right that's why again for presence endocarditis and you grow strep bovis or clostridium septicum then you're worried about those people potentially having colon cancer okay so that's the mechanism there right and again if you see endocarditis in a presence that's super immunocompromised think about candidaeal becancer I remember just like stuff epidermis candidae actually is also able to form biofilm right so that's one of the reasons why it's a very nice risk factor for endocarditis and people that have in people that have a prosthetic prosthetic valve so whatever but again the first thing you think about for prosthetic valve endocarditis is going to be a stuff epidermis it is the most common cause of prosthetic valve endocarditis on any mucosams but if you don't see that as an answer all in court you'll also consider candida albequins especially in a person that is super immunocompromised like a person that's on immunosuppression because they got a transplant or something of that of that nature right and then one of the things that you want to think about right is wow divine why is it that people that have some of these heart defects tend to get endocarditis right so let's see like for like having like a VSD for example the thing is when a person has like a VSD or a PDA right or an ASD or whatever those heart problems tend to cause turbulent b

lood flow right so like a VSD for example people can have turbulent blood flow the thing is whenever you have turbulent blood flow that increases the risk of the deposition of organisms because the thing is when blood moves a certain way it actually makes it much harder for bacteria to kind of like settle on surfaces those bacteria usually get just pushed along they keep moving forward they keep it moving they keep it moving they keep it moving but if a person has a lot of turbulent flow that can prevent bacteria from keeping it moving in the appropriate way they can begin to hang out on things right like a VSD right like oh around a VSD a ton of turbulent flow those things are always factors for for endocarditis right so the thing is in general for endocarditis right how do you prefer relax right like again remember if you're getting like a GI procedure or a GI procedure or you know like an invasive respiratory procedure or dental procedure in general right the people who want to prefer relax that people that have you know like maybe hide endocarditis in the past so they have a prior history of endocarditis or it can be a person that has like an unrepaired sanodic congenital heart defect right or people that have prosthetic valves and usually you just give these people like a moxicillin or ampicillin just give them some kind of penicillin based product like a moxicillin remember a moxicillin is oral or you can give an picillin or whatever right like which is more IV ampute remember ampicillin has a ton of isinit right so it's IV a moxicillin has an or we need so it's oral right so that's a nice way to kind of keep those treated and for the most part you just give those like an hour before the procedure starts and those patients should be good to go for the for the most part right but again if you want to empirically treat while you're waiting for blood culture result

s so remember the drugs I talked about have a perfect relaxes but for actual treatment are you give the combination of septriaxone and vancomycin right you give the combination of septriaxone and vancomycin septriaxone and vancomycin so I think maybe let me go ahead and pause here because stimuli just focus on this and the credit is business the thing I will just say is oh you know what let me talk about my credit is real quick again many of us know my credit is on exams right for the most part the big thing is it'll be a person that had an upper respiratory infection and then a few days or weeks later and they'll tell you that oh the URI resolved without treatment or whatever fancy story to give and then they'll tell you that oh this person you know has been having like heart failure symptoms right so they'll have like opniac,poxism, noxional dyspnea they'll have like a demine the lower extremities they'll have crackles in the lungs and usually your name being means they'll tell you that they have a new S3 heart cell that's very high your channel they have a new S3 heart cell if you see that you want to think about myocarditis right now what is the most common cause of myocarditis well that's easy it's usually a viral infection right especially like oxachibii so please do not conflict or I guess confuse oxachibii with oxachie a on him being exams oxachie a causes hip and china right that's in the menu for the affectionately called hand-full mouth disease right they can have remember oxachie a right is one of those things that cause lesions on the palms and souls right remember the numonic will you drive Kawasaki cars with your hands and feet right so Kawasaki's disease oxachie a reketi reketi and syphilis right secondary syphilis lose all cause lesions on the palms and on the souls right so the thing is um coxachie a causes hand-full mouth disease what coxachie b is

the thing that causes viral myocarditis right viral myocarditis and the treatment of myocarditis right you basically treat it like a treat heart failure right you give like an ace inhibitor you give a bitter blocker you give a diuretic right just remember you'll a bd we're pretty much keeping a C right so an ace inhibitor a bitter blocker a diuretic those are all things you give for for myocarditis right you treat them like heart failure right and again you'll have a recital respiratory infection and sometimes the mimicant try to trick you on exams right they will give you like the troponins elevated but again if you see the temporal association with recital respiratory infection you see heart failure symptoms don't think of an MI again is not everyone that has an elevated troponin that has an MI right and the thing is myocarditis the timeline right is more like these slash weeks of symptoms not hours or minutes of symptoms that's one thing that will help you differentiate between an MI and endocarditis I mean myocarditis on exams right so you remember MI sodium onset severe chest being relating to the jaw to the arm or something like that right versus a present that has myocarditis where again you'll be like at least a few days of heart failure style symptoms they'll have the new s3 heart sound okay you'll have the new s3 heart sound so that's again very very high you to know for exams right very high you to know for exams the CRP will be elevated yeah yes are be elevated um because again they have the chronic inflammatory inflammatory state and usually on MBM Es when the give you an eke eche for a person that has myocarditis they'll have inverted two waves right they'll have inverted two waves they'll have inverted two waves now what is the most common cause of endocarditis I mean why do I keep seeing this so remember I say the most common cause of myocarditis in the

US is coxacabee right the most common cause of myocarditis all over the world right all over the world is actually tripe when I saw my cruziar remember tripe when I saw my cruziar I lost to cause big things right again you can cause uh um uh what do I want to say it can cause dhalithecaryomyopathy right wettberry you can cause like uh yeah it can cause dhalithecaryomyopathy just leave it at that uh it causes a big heart right and then it can also cause uh it's not wettberry bear wettberry bear is more for an alcoholic it can also cause a big esophagus right it can cause a ekelesia and then it can also cause a big GI tract right it can cause a herchprone's disease right it can cause like a mega colon essentially right because it can be pretty much consume your nerve flexi that's in the distal colon right and again um it's not just bugs that cause that cause um myocarditis right you can also get it from certain drugs and one thing I will just establish whenever a person has myocarditis or name him exams always think of those people as um having a dhalithecaryomyopathy right so just in your mind mentally translate myocarditis to dhalithecaryomyopathy on tests right and again remember that the drugs that can cause these myocarditis right will be things like clasapine right so you can give an answer as a colleague question with that um another one could be uh alcohol right I mean the more alcohol you take right alcohol in pairs gluconeogenesis it impairs ATP production so if ATP is not being produced adequately right then the thing that's gonna happen is um your heart whatever you know because think about it like why do people get into problems with an amine right it'll close blood flow so blood is not flowing to certain regions of the heart so nutrients and energy are not flowing to those regions of the heart right and then the heart doesn't function well kind of like th

e same thing here right alcohol impairs ATP production so even if blood flow is normally in your coronary vessels that blood is not rich in ATP right that can begin to cause the heart to become ischemic right so those are two big things to keep in mind but other drugs remember your unsicyclined right so things like uh docks and don't know what they're missing right those things can also cause myocarditis right again they cause inflammation by virtue of the fentine reaction because they are very powerful iron key leaders right so they can cause a lot of free radical damage to a person's heart that's why when you're taking those drugs you need to take dexeroxin right I'll say that again dexera zoxin DEXRAZOXIN so dexeroxin dexeroxin is an iron key leader that you can use to prevent the the myocarditis or you know the delytheric cardiomyopathy that comes with these anthracycans and remember docksodona rubissin everything cause delytheric cardiomyopathy it's irreversible right contrast this we trust to zoom up trust to zoom up is a monoplonal antibody against her too right it's used as treatment for people that have brisk answer right so the thing with a trastuzumabis it can also cause delytheric cardiomyopathy right but it's reversible so many times when imbi makes them the can ask you a question and say oh prior to initiating like an anthracycline or trastuzumab what is your next best step in management i'll hope you're picking the answer that involves to get some kind of echocardiogram to estimate the ejection fraction right just to monitor them throughout disease and follow the the atreatment the atreatment course so hopefully that hopefully that that that makes sense right now the last things i'll just share is how do you diagnose myocarditis well that's actually pretty easy you pretty much perform like some kind of coronary like you take them to the cath lab and usu

ally you perform something called an endomaiocardial biopsy right so you take a biopsy of the endocardium and the myocardium right so you do an endomaiocardial biopsy right to to make the diagnosis and usually when you take a specimen and you look at it under the microscope right they may ask you oh remember again the imbi made all these things that i call pathophysiological answers where they'll give you a bunch of answers and it will be descriptions of pathophysiological processes so remember histologically for both the atmachocarditis you would see like a lot of microphagias a lot of lymphocytes and then you see a lot of a dima between the cardiac myocytes right because of that again that fluid build up right so again don't forget interstitial edema with tons and tons and tons of microphagias and lymphocytes those are the things you find histologically in people that have myocarditis so i guess i'll go ahead and actually wrap up now right so as i do again remember i do offer one on one tutoring for all the ulysses mal exams step one just step three also preclicula med school exams 30th shelf exams i you know tutor for if you're medicine resident and you're preparing for your boards like your ibi i m board exam or the entry exam i do tutor for those then again i have step one and step juicic courses my step one course is from the fifth to the ninth of April my step juicic courses i have the emimi testic in strategy scores that's that's on the 24th of this month right again we'll have a ton of questions learn how to teach in mimimi exams in a standardized fashion and again i'll teach you a lot of tips and tricks so that you can very confidently even if it's questions we're like i have no idea what's going on here you can still get them right and then again i have the 16 and a half hour course from the 25th to the 27th of this month again it's for step juicic and for

step three and then next month from the 5th to the 9th of April you know i have the step one course and then finally um please subscribe to the website again divineinterventionpodcast.com i have these podcasts also on google podcasts on apple podcasts and on Spotify so please subscribe i'll even have a youtube channel divine intervention usmly podcast and videos so um again any subscription helps any feedback or whatever definitely helps so i want to share a life lesson today i'm a life lesson it's going to be on the importance of arriving on time right this is sadly a big big big problem and again i'm even almost calling myself out although i try to be pretty early to most things right but i would just see that it's very important as individuals it's just uh it's just a behavioral thing and it's something that you can easily change is to just show up on time be the kind of person that shows up five minutes before time consistently right because when you do that you kind of show people that you are you care about them and you kind of show people that you respect them right you care about them and you respect them because the thing is many people are they always lead always lead always they the thing is this tends to bite people in the ass in residency when people know that you have the lead commonly commonly come at some times you can get retinop as a result of it and there are some good opportunities that you miss out on when you're just when you just show up lead right i mean even the bible says the bible talks about timing it says there is a time to reap and a time to show there is a time to give birth a time to die a time to this a time to that a time to this a time to that right so you won't go out like peace attention to timing right so you know you should probably pay attention to timing as well in your daily life so just show up for things on time it's always

helpful and again your seniors will love you right your seniors will love you when you shop on time so just something to keep in mind my next life lesson will hopefully maybe come in the next podcast so thank you for listening today again i'll encourage you to know this podcast pretty cold you'll be very unusual for you to take a step one step two ck or step three exam and not see some concepts that were covered pretty much today so thank you for listening i'll see you in the next podcast god bless you bye

Staphylococcus aureus.

Subacute infective endocarditis.

Transesophageal Echocardiogram (TEE), because it provides superior visualization of the left atrium/left side of the heart compared to TTE.

The tricuspid valve (right side of the heart).

Elevated inflammatory markers (like CRP) and often inverted T-waves.

Anthracyclines (e.g., Doxorubicin) or antiarrhythmics (e.g., Amiodarone).

Blood cultures, as administering antibiotics can lead to false-negative results.

Prior administration of antibiotics (which kills the organism before it can be cultured).

Janeway lesions (vascular/non-painful) and Osler nodes (immune/painful).

Bicarbonate ($\text{HCO}_3^-$). Low $\text{HCO}_3^-$ indicates DKA; normal $\text{HCO}_3^-$ suggests HHS.

ACE inhibitors, Beta-blockers, and Diuretics (ABC).

Candida albicans (fungal) or other difficult-to-culture species like Coxiella.

Blood cultures, as administering antibiotics can lead to false-negative results.

Prior administration of antibiotics (which kills the organism before it can be cultured).

Janeway lesions (vascular/non-painful) and Osler nodes (immune/painful).

Bicarbonate ($\text{HCO}_3^-$). Low $\text{HCO}_3^-$ indicates DKA; normal $\text{HCO}_3^-$ suggests HHS.

ACE inhibitors, Beta-blockers, and Diuretics (ABC).

Candida albicans (fungal) or other difficult-to-culture species like Coxiella.