DIP Episode 183 - Comprehensive NBME Emergency Medicine Shelf Review Series 3

Welcome. My name is Devine, I'm a resident. This is episode 183 of the Divine Intervention Podcasts. In this podcast I'm going to be continuing the comprehensive review series for the 30 year or I guess 4th year depending on where you're in that school. MBM emergency medicine shelf. I know the first installation I talked about cardiology pretty much and then second one I talked about the endocrine emergencies. So then I'm going to be talking about the infectious disease things that you classically see on the image show. So let's jump right into it. So what if you get a question about a young female or let's say a young male you know presents with like he tells you that he's been having like like a pureland penal discharge. No, not he's been having like a penal discharge right or let's say this is a guy says that he has like painting a testicle or he says that yeah let's see painting his testicle and mouth fevers and again they then tell you that oh the obtainers swap from his penis and they don't see any organisms. What's your diagnosis? Well I hope you're saying Clamidia right? Clamidia right? I mean young male maybe like a new sexual partner uses condoms inconsistently. You want to think about Clamidia trachomets right? Remember Clamidia can cause many kinds of things on the test right? So you can cause like you can cause like a urethritis, you can cause like an epididimitis. Remember epididimitis in young people you want to think more about gonorrhea and Clamidia.

In order people you want to think more like E. coli of things of that nature right? And remember that Clamidia also has an association with a writer syndrome. Right? Remember these days it's called a reactive arthritis where people have like the triad of can see can pee and can't claim a tree right? So they'll have like a urethritis, you'll have a conjunctivitis and then and then they'll have like an arthritis right? So that's the way we activate arthritis presenting again it has a very probably the strongest association you see on MBM exams is with is with Clamidia for the reactive arthritis right? And the classic thing the MBM loves to do is they'll tell you that oh they swapped something and then they don't see any bugs. If you see that you really want to think about that Clamidia and really on the exam if you want to diagnose Clamidia right? You know you can do like you can do like a nucleic acid amplification test right? So like essentially PCR some finds like some weird questions you can see them do like an ELISA or for the most part the nucleic acid amplification test is what you do and if it's a woman that has Clamidia right? You can like do like a swallow for vagina. But if it's actually a guy do we actually diagnose Clamidia as you do like a clean catch like a urine specimen from a guy. Now for the most part if a person just has Clamidia you can treat them with a z-throw Mycin right?

You can give it actually as a single dose or you can do like doxycycline for like seven days. Typically many people prefer z-throw Mycin because it's one dose because many of these people that come into the ED right? For these kinds of complaints they may not be very compliant with their medication regimen right? So you can give z-throw Mycin or doxycycline and then if I'm to since I'm talking about Clamidia I guess I might as well talk about gonorrhea right? So gonorrhea can cause many things right? You can cause again in men it can cause like the urethritis, epididimitis, but in women it can cause like PID right? So like vaginal, purulent vaginal discharge. So Clamidia doesn't usually cause a purulent discharge but I wouldn't hang my hat on that as the only source of the diagnosis on an exam. But gonorrhea it tends to cause you know like a purulent discharge it can cause PID right? So you see the purulent discharge cervical motion tenderness at bilateral and mix of tenderness right? So if you see those things and then they tell you that oh they do a gram stain and you see like gram negative de bloc oxide you definitely want to think about gonorrhea and then one other thing you want to think about which regards to like disseminated at gonococcal infection right? is that these people almost always tend to have skin findings on in-beaming exams right?

So they can have like BTKI they can have like PIPRA and believe it or not these rashes can actually shop on the palms and soles okay? But usually have those problems on the extremities right? So that's like a classic sign of disseminated gonococcal infection and really the way you diagnose gonorrhea is you do again the nucleotacid amplification test and if a presence diagnosis gonorrhea you need to concurrently treat them for nice serious right? So you typically give safe triaxone to cover the gonorrhea plus easy thromising and you can actually give both as a single dose right? Or you can give dosy cycling for seven days okay? So that's how you target those. So you can give safe triaxone plus easy thromising or safe triaxone plus dosy cycle right? and this is gonna be like a common theme so I'm just gonna say it only once here but in general for STI you usually try to treat the partners right? So the person doesn't get the infection back again and then typically you tell the person that you're treating to avoid sexual contact for about seven days after they've completed antibiotic therapy okay?

So they've completed the entire therapy the symptoms are resolved wait for seven days before you start doing it in the bedroom again okay now what if they give you a question about 24-year-old female presents with like severe tenderness in how vulver area they may even say that she has like a strawberry cervix although they really do that these days on exams and then they'll say that oh she has like a very false million greenish or they may call it like a thin watery discharge and she can see that oh she has this burning sensation right? What are you thinking about there? And let's say the vaginal pH is greater than 4.5 what are you thinking about? Well I hope you're thinking about trick right? So trick among us are vaginalists right? So this person has a trick right? So how do you diagnose trick? Well for the most part trick right you you do a wet prep and then you look at whatever under like microscopy and then you make the diagnosis that way and then if you're looking for treatment on exams right go ahead and give the patient like metronidousol you can give metronidousol something just a little point metronidousol you may try to mess with your head by giving a put in the term tine d'azol tine d'azol is basically metronidousol okay remember metronidousol you don't want to take it with alcohol so that you don't get that I saw from side effect because metronidousol has some ability to inhibit as a tada high behind drow genies.

Now what if they give you a question about what if they give you a question about like like a 20-year-old guy you know let's say he either has sex with other men or you know he's very loose from a sexual perspective and then he comes in and tells you that he has like a painless ulcer like a maybe they show you a picture like you say like a penis picture on your test you say like a single painless ulcer on the penis what are you thinking about? Well I hope you're thinking about syphilis right and syphilis.

Remember syphilis is caused by trapponema right so it's caused by t palidum and syphilis I mean he kind of has like three stages right there's like primary syphilis there's secondary syphilis and stachery syphilis primary syphilis the big thing you want to think about is the painless shanker right so it's like a painless ulcer in the red blooded borders that's it right and then secondary syphilis typically those people tend to have like the congeloma lada right where you have like a rash on the palms and souls right it's usually like a like a it's almost like like like like it's like red dots right you'll have that rash on the palms and souls and typically the way it happens is for the most part it usually starts like it can start on the trunk or it can start like on the upper like the upper parts of your extremities right so like let's say for example like before you have the rash on the palms it starts on like the arms and then you'll spread to the palms that's a classic distribution of the way t palidum kind of moves on exams right and then when the person has tertiary syphilis right syphilis they can have like the gomas they can have like the t-d is dorsalis where you scrub the posterior columns of the dorsal columns of the spinal cord so they'll have like problems with like fine touch vibration perception they have like a positive rumberg right or they can have like like meningitis from syphilis right or those people can also have like an erotitis right so syphilis tertiary syphilis can present as like an erotidis section on inbiming exams right so if you see all those things think about the different stages of syphilis and really the thing is how do you diagnose syphilis well the thing you can do is you can typically do like the non-traponimo test first right so whether the non-traponimo test right so if you do things like vdr or rpr right you use those as almos

t like your screening test for syphilis with the thing is if those screening tests are positive you don't need to follow follow it up with a confirmatory test and your confirmatory test right will be a trapeonimo test is essentially like a test that detects antibodies against t-palida and these trapeonimo tests tend to have like some weird names like mhatp or like ftaabs you do need to actually memorize these things I just said those are the classic trapeonimo test they are confirmatory tests for syphilis and occasionally you may also see them refer to like dark field microscopy you can actually use that field dark field microscopy just in general is good for detecting spirochetes right so like if a presidium has trapeonimo pallidium the spiroket it's a spiroket it can be detected pretty easily by doing a dark field microscopy especially for like primary syphilis or like secondary syphilis or if a presidium has like congenital syphilis it's like a newborn with sniffles like very bad like run or ran all that stuff you can actually don't touch that stuff with your hands right like you know take a swap put it on the dark field microscopy and you know we actually see that you'll actually see whatever you swap a teaming with a spiroket so how do we treat syphilis well syphilis if it's primary or secondary syphilis you can give them like penicillin G maybe the if I want to be a little more specific like benzettin penicillin G you give them like intro you give an intramuscular like one-time dose and that's it now one thing that you want to keep in mind is when a person gets that's like such a large dose because of the huge bird budding right as those bugs die and expose their contents right to the to like your bloodstream right massive inflammatory response can be mounted and the patient may have like fever's headaches they have like myalgias if you see that you want to thin

k about something known as the jarish hexheimer reaction okay that's not a contraindication to still getting like penicillin in the future it's really not a real allergic reaction although if a person has like a penicillin allergy for whatever reason for like primary or like secondary syphilis or even like early latin syphilis you can consider giving like tetracycline like dopsycycline that works just what and the interstitial syphilis really it's kind of like the same regimen you give like benzene benzetine penicillin G where you can do it as a one-time dose you do for more like like like three weeks okay so it's a longer it's a longer course now what if they give you a question about like a 24-year-old guy right you know and it comes in he says that he's been having like this tingling this like burning sensation on this penis and then the on physical example they're like they should be like a peat again penis picture and then you see like these things that kind of look like vesicles and they are sort of like on a red base like an erythematous base and they tell you that these things all hurts they're like very painful what are you thinking about on the circumstances well I hope you're telling me that this is genital therapies right genital therapies I remember genital herpes because by that he says we want on he says we too but for the most part you want to think about he says we tone exams and really how do you and remember he says we are like you want to remember your classic causes of a painful ulcers right so like genital ulcers from herpes and also like a shank right from hemophilus do cry remember hemophilus do cry makes you cry those are those are all causes of painful ulcers on the penis on like in case you're like you're a really an external genitalia and really the way that no surface right you can do like a viral culture you can do PCR those are all accep

table on exams don't be Zank smear on your test you'll very likely get the question wrong Zank smear used to be done like back in the day essentially no one does it anymore right so don't pick Zank smear when you examine that's more like an artifact from step one and really how do you treat herpes right you give me psychrovere if the person you know doesn't have like systemic symptoms they're like relatively okay you don't need to admit them to the hospital so you actually need to be as you as I go through this podcast you know here we see certain things like oh admit the patient to the hospital believe it or not there's some in the exam questions where the right answer is to admit the patient to the hospital right typically patients who are going to a hospital that people that have like severe systemic symptoms they have vomiting so they cannot tolerate puing tick blah blah blah but meet them to the hospital you please them on IV antibiotic therapy right but if for example a person has like you know like getting the right to HSV they don't have any significant symptoms you just give them a psychrovere or you can give them like valley psychrovere or like fam psychrovere those things all work you don't have to admit them to the hospital but if a person has you know like very high fever they have vomiting they're not to the routine puing tick then you can admit them to the hospital and give them like IV acyclovere okay I remember for president has herpes that is resistant to acyclovere I want to consider giving those patients false carnage remember false carnage is a pyrophosphate and a lot now what if they give you a question about a patient 24-year-old male okay presents with like it tells you that he has this papill on his penis right and it hurts like a ton it hurts like a ton and it's like one single lesion not the multiple notice a key difference here in herpes I

said multiple vesicles right on an erythematospace but this person has like a single lesion right and he hurts real badly this very painful papill on his penis and then he tells you that they also show you they also tell you that oh that you know he also has like enlargement of his in green no notes and they are very painful what are you thinking about here well hope you're thinking about shankhurt right shankhurt remember shankhurt is caused by hemophlos ducry remember hemophlos ducry makes you cry and really the diagnostic testing I really wouldn't worry about it on your mbim exam the big thing won't worry about his treatment for the most part you can treat this with you can either give like a third genertion as a flosporing like septic triaxone or you can give the person like is it through my sin right or you can actually also like one time dose like one time dose septic zone or one time dose is it through my sin or one time dose um actually not one time dose but so septic triaxone is it through my sin can give it as one time doses you can also give them like a flu or quinolone but you have to take that for like three or three days or thereabouts so I will say really for you exam just remember septic triaxone is it through my sin especially the same drug regimen for for my siria gonorrhea right so it can give septic triaxone or not both septic triaxone or is it through my sin for shankhurt and again remember shankhurt is caused by heech ducry now what if they give you a question about you know like a 24 year old female you know let's see she's had a tampon in for like the last two days or you know let's say it's a person that has had nasal packing in for the last like two days and in this person presents with like a temperature of like 103 his blood pressure is like 70 over 40 he has like a rush everywhere right and he's also beginning to have like this like his sk

in is essentially beginning to fall off and you know he has like elvedic creatinine has eleptia abnormalities if you see that what are you thinking about on your test well I hope you're thinking about some kind of like toxic shock syndrome right the thing is toxic shock syndrome for the most part it can be caused by staff like staff warriors or it can be caused by strep pneumo right I mean sorry by strep pyrogenics so like group E strep it can be caused by any of those bugs and again the classic presentation will be a person that you know has like some kind of like indwelling foreign body right or it may actually be in a person that has like some kind of like ss t i or so like a skin and soft tissue infection so like cellulitis stuff like that and then they become like superfabral profoundly hypotensive they usually almost always have like a generalized rash on mb me exams and then they also have like signs and symptoms of like their organs feeling right this is almost like a septic shock kind of situation right if you see that think about a toxic shock syndrome right then again the symptoms almost always begin at you key right so again like I said staff warriors group a strep those are the two like big-time causes if you don't see staff warriors or group a strep as answer choices go with a super fringes glossulium perfringents typically for post glossulium perfringents where they will tell you like oh there's creptos on physical exam telling that the patient has like gaskin green or they may tell you that the person has like an elevated creatine kinase right like an elevated cp key because remember it causes like a myonicosis right so those are all things you should think about so what's the thing that causes toxic shock syndrome right for the most part TSS raises from a person like like the exotoxins that are elaborated by these bugs I mentioned right so for the mos

t part right it's like a toxic medial illness and there's actually a lot of stuff you need to do to manage these people and manage them properly right the first thing you need to do is you need to obtain source control already they have like an indwelling tampon or whatever you know get rid of it right you know pull it out weird gloves don't touch all your bare hands wear gloves pull it out and toss it away that's the first thing you want to do if you have like an abscess you know go ahead and drain the abscess but for the most part your first step in management your first step in management is to volume resources did them right you give them a crap ton of normal saline um if they are not responding to that normal saline augmentation go ahead and add on our visual pressers right you want to go ahead and add on something like norepinephrine because this this is essentially an septic shock right so you can add a norepinephrine under those circumstances and then for the most part these people you whenever you're treating them you you need to essentially have like a two pronged strategy you need to give them some antibiotic that either covers like merse or like group A strap and then you also need to give them an antibiotic that helps with toxin production right because the thing is this disease is mediated primarily by the toxin so if you give you you need to give something that will inhibit further synthesis of the toxin right like like a protein synthesis inhibitor like clindamycin clindamycin is like the safe go to answer on mbim exacts right so typically for these people if you're like it's probably merse that's causing this you can give them like a drug that covers merse like either like IV vancomycin or you can give them like IV uh limit solid memberly nasolique and costerotone syndrome because it has like a it's like a weak MEOI basically um but uh you you also ne

ed to add clindamycin to that a drug cocktail right if you're thinking okay maybe more so like MSSA um which will be a real situation on your exam you know you can give them like naphthalene or acacelene and then in addition to that you give them clindamycin okay so that's how you do that on uh on mbimics now the thing is if for example you've given those person this will be an unusual question that most people get wrong on the test when you won't get it wrong thankfully because you listen to this podcast but if for example they tell you that you know this person has got in vain and clinda and they're not improving improving from a clinical perspective actually your next step in my research is to go ahead and give those people IVIG okay IVIG actually helps although the literature on it is kind of mixed but it actually helps a few people that have uh that have a toxic shocker syndrome and the thing is sharp toxic shock syndrome is kind of like the symphony as staff toxic shock syndrome for the most part you know it's the presentation is very similar it's just a causative organism that is different so for the most part the treatment is pretty similar so i'm not going to repeat myself just again a ton of fluid resuscitation presses if they're not responding like nori penneferin um and typically right you want to also like culture these people operate you know we'll get like a blood culture get like a wound culture if you see that um there's all although there's somewhat slight difference here so if you're thinking about like group A-strip like strep hygienes that's the cause of their toxic shock syndrome um instead of giving you know like van colonizolid or naphthaline or xacillin kind of deal you want to give them something more like pip tizo right so like pip rastlin and tizo back them right um alternatively you can also give them like merrupenant you can also give mer

rupenant but again in addition to giving these things you need to give that clean the mice into sharp down a toxin production right if you suspect merse there's some people that actually get like pip tizo get vanic and then still get the clean the mice it right so again these are all big things you want to keep in mind and i mean obviously if the person has like signs of neck fascia on a test or they have like signs of like neck creases uh you need to take them consult surgery right you need to take them for like a deep treatment or they can do like a fascia to me if there's a lot of like muscle involvement um sometimes the unfortunately they may need to amputate the extremity so what do they give you a question about a patient or you know what let me make this a logical discussion instead of making it about a patient let's let's real quick talk about sepsis right let's real quick talk about sepsis so sepsis right the thing is um there's this new fungled stuff which is probably a lot more useful that people use known as q sofa but the thing is the mvm is for the most part still go with like sers and all that stuff so i'm gonna spend time on sers in this podcast i'll probably sometime in the future i'll make like some podcast about like shock just in general like shock shock shock like shock from like resident medicine everything perspective uh but that's not the place for this podcast but this mvm pod e-met podcast let me just focus mostly on shock as you'd likely see it on your shop so the thing is basically you want to be able to build your argument from sers you want to understand what sers means and then you want to understand what sepsis means and then you want to understand what severe sepsis means and then you want to understand what septic shock means right so build your knowledge that way so sers sepsis severe sepsis and then septic shock so the thing is basi

cally what a sers criteria right so sers criteria if i'm remembering correctly um they either have like a temperature so there's a there's there's four things and if you check two two or more so two or more of those four boxes the person has a sers positive right so there's a temperature requirement so it's either like temperature list at 96.8 so they're like essentially they're hypothermic or greater than 100.9 so they're like febrile uh there is a pulse criteria right so if your pulse is greater than 90 bits per minute so if your heart is slugging away at more than 90 bits per minute and then there is a respiratory rate thingy as well if the respiratory is more than 20 that's the third criteria and then the fourth one is if they have like a white blood cell count that is greater than 12,000 i believe so greater than 12,000 or less than 4,000 right so like luke opinion um those are the four criteria that make you think about sers if you meet again two or more out of those those four criteria the sers positive if a president sers positive and they have like a source of uh you have like an identifiable source of infection so let's say like they have like pneumonia or they have a uti or whatever that's sepsis okay so sers plus a source of infection equals sepsis now if a person has been a judge to have sepsis and then they have like some sinus symptom of like end organ dysfunction so let's say like the acryctin is going up or they have like altered mental status telling that their brain is not working right or they have like elevated LF Ts telling their liver is not working right if you just see or like a lactic acidosis right because that tells you that these people are having like organ hypoprofusion and those organs are like defaulting to anaerobic metabolism if you see that then that's what's known as severe sepsis right and then the thing that throws you into septic

shock is if for example they give you the question and they tell you that oh this person has received a lot of like volumal replicion but they are still persistently hypotensive if you see that that septic shock right that's essentially like sepsis that's not responsive to fluid uh a replicion if you see that uh think about sepsis I mean think about septic shock right essentially if you essentially for pressing needs to be on pressers to maintain their blood pressures then that person is in septic shock now so key things you want to keep in mind with sepsis right sepsis is actually has a very strong like they may ask you a question about like oh what's the most likely pulmonary complication of a person in like sepsis or septic shock uh think about ARDS right ARDS is a very common complication unfortunately of sepsis so um so those are kind of like the big definitions I think I would want you to recognize so how do you treat sepsis right so the thing is again like I said you want to recognize it basically there are three big things you want to keep in mind where you want to recognize it early that's why you want to understand and actually commit these definitions to memory that's one second thing is you want to um give fluids right you want to maintain them like him with an amically stable and they want to start in antibiotics blood spectrum antibiotics as early as possible right but what I guess some like not some bolts you can keep in mind right so not some bolts right you want to if these people are hypoxic give them supplemental oxygen if they need to be into bed it into bed that doesn't matter okay and then you you need to volume repeats these people right normal saline is just fine right and you can give them like a one or two liter bolus initially basically like if you're like okay define I want more exact numbers you can start them at like 20 to 30 mil per kil

ogram right for like at least for your first bolus right so my presence like a 70 kilogram person right 70 times 20 that's like 1.5 liters or you can say 70 times 30 that's like essentially 2.1 liters right so just give them like a 2.2 liter bolus is probably like a safe answer on exams right if the person is not responding to the fluid supplementation go ahead and start pressurize okay and the pressurize of choice on mbim exams for for septic shock okay it's norepinephrine they will try to trick you into picking a pinephrine don't pick a pinephrine you'll get it wrong a pinephrine is for an affelactic shock okay uh norepinephrine is for septic shock right so you go ahead and start those people on norepinephrine and the thing is your friends at the mbim you would like you to know some because they put a lot of lines in the emergency room right so one thing you actually want to keep in mind is you may actually want to consider putting like a central line right instead of putting central line if you say central vino scather it means one at the same thing right but for the most part you put a cvc so if you see me say cvc i mean a central vino scather is that thing you insert in the internal jogger laveine and then it goes to the right each room right so you insert a cvc because these are pressurize are you know pretty caustic right so you don't want to like no compressions blood vessels you want to supply through like a big biffy blood vessel right so um you put a central line where you start this patient on like uh norepinephrine uh affectionately known as levofet in the hospital right so you start these people on norepinephrine if norepinephrine is not enough you can go ahead and add visopressin okay you can go ahead and add visopressin and you want to maybe like follow the alactic level just to see if they're responding to like your fluids and whatever and in general

um uh in addition to giving the pressurize you want to give some kind of antibiotic therapy right so the thing is your antibiotic you probably will not be wrong if you started these patients on like something super broad spectrum like vancomycin basically let me tell you this study them on something like vancomycin like the nomonic i remember is remember the term iv i for imi penem or some other carbapenem and vancomycin those are like super super super broad right super broad right so in general imi penem vancomycin those are safe answers like given that combination that's a safe answer on nbim exempts if you think that the person for the most part probably has like some kind of uh intra abdominal infection that's the cause of the aceptus then one thing you can consider doing is instead of doing like imi penem and vancomycin you can consider putting them on like peperacidine antiso bacter or you can put them on unicin unicin is just the combination of ampeicidine plus so bacter um if you think that you have like a chest so notice i'm breaking it down by region of the body if you think that you have a chest cause of the eraseptic shock right you can consider giving them like safe triaxone plus is ithromycin plus a microlette okay i mean sorry safe triaxone plus is ithromycin plus a fluoroquinole ok uh so calf just remember like calfene right so like safe triaxone is ithromycin plus a fluoroquinole and typically also add vancomycin to this as well so there are four things you do if you suspect again like intra pulmonary like a chest cause of the aceptic shock sept triaxone is ithromycin fluoroquinole like either like livo or moxifloxacin right and then you give a vancomycin another one if you can you should remember that is like calves right like a person like if you're a friend you're like multiple like like C-A-L-V-E-S right the C is for sept triaxone the A is for is

ithromycin the L is for like livo floxacin or moxifloxacin and then the V is for vancomycin okay because remember merse can cause pneumonia so those are kind of like the big things you want to keep in mind again there are many other different combinations for permutations you can use but I'll say just sort of keep those two big things in mind now one big thing I will go ahead and mention is that if a person is neutropinic and they have septic shock you absolutely positively want to like they'll give you multiple antibiotic choices on your test the one you want to pick is one that covers pseudomonas pick a drug that covers pseudomonas and again there are many drugs that covers pseudomonas you can give the third generation cephalosporin, septazidine, septazidine covers pseudomonas you can give the fourth generation cephalosporin, septicine, septicine covers pseudomonas you can give a per a carbapenem like imipenem or meropenem right those covers pseudomonas or you can give like piptezo, piperezidentisobactem that covers pseudomonas you can give a powerful fluoroquinolone right so like livo floxacin, livo floxacin, moxifloxacin although I'll say that those are less commonly used on exams right so I'll say in general think in terms of the four things I mentioned earlier septazidine or septepine or imipenem or meropenem okay those are like the big things you'll consider using when a person is a neutropinic and then typically you almost always add like vancomycin okay because again right neutropinic when people have neutropinic fever it's usually merso or pseudomonas that causes their problems right so you typically give something that covers pseudomonas and then give something that covers merso but if we're conferring we both less it puts septazidimas an answer and vancomycin as an answer the thing you want to pick is something that covers pseudomonas and one classic scen

ario you may see on your image shelf is they may tell you that oh this person has been on like septazidimplos vancomycin or whatever and they're not improving from a clinical perspective let's say like these later you're like man this person is not getting better one thing you should consider adding on your test is an antifongal agent or you can add something that covers like candida so something like flokonazo or like a cusp of phongin or micapongin or anidula phongin right notice they all end in phongin those drugs are like they belong to the drug class known as the echinocandense they cover they cover a candida very well so again these are all high old things to keep at the back of your mind and I mean obviously already for a person has like something in dwelling inside of them you want to obtain source control in septic shock right like if they have like a iv line that's infected or like a prosthetic valve that's infected or something you know go ahead and get rid of it or if you have like an abscess in size and drink that abscess okay now what if you get a question about a patient and um let's see um you know this patient comes in with like like cellulitis let me maybe put it this way so if a person comes in with like you know like cellulitis what do you typically do what do you typically do for cellulitis or I guess what are the bugs that classically cause cellulitis on mbm exams well I hope you think about merse that's one right especially if the person has like a pureland discharge probably merse right and then another thing that causes cellulitis right is is a group A strap strap pyrogenis although the thing is physicians are beginning to shy away from terms like oh like cellulitis blah blah blah blah blah because for the most part they tend to have like fairly similar treatment these days they are known as S S T I's right so skin and soft tissue infections s

kin and soft tissue infections so whenever so I guess but let me again talk about it in the context of cellulitis my person has cellulitis right it's a clinical diagnosis uh especially if the patient you know it is not like super sick like they're not like hypotensive or like super febrile or anything like that and the ask for your next step in management you can actually discharge these people from the emergency room on like cleaned the mice in or like a back trip right like uh tremethoprimal assault from the thoxes all and the thing you can also do is if you suspect if you're like okay this person may have like group A strap that's causing the cellulitis if you're like okay I want to cover my b-sys you can actually go ahead and put them on like uh you can actually go ahead and put them on like sephalectsin in addition to like the cleaned the mice in or TMP smx remember cleaned the mice in or TMP smx will cover merse uh right they'll cover merse uh and then the sephalectsin right remember sephalectsin is a I think it's a first genersion sephalospory um it will cover um you'll cover um group A strap the strap pyro geners right but the thing is if the patient is like super sick they're like hypotensive or they have like systemic signs and symptoms uh then you know you need to admit those patients to the hospital uh usually those patients spend like a night or two in the hospital and you put them on vancomycin okay put them on vancomycin now so that's how you handle most of these like you know like regular good old skin and soft tissue infections um um I guess maybe let me talk about uh air syphilis right so air syphilis um if they ask you about the bug that causes an air sypula on an mbm example I want you to think about group A strap yeah it can be caused by merse but don't pick merse on your exact pig group A strap pyro genies and the classic wear syphilis present ri

ght for the most part the person will have like this uh like it'll be like sodium like abrupt onset very high fever patient will like be super super febrile right and then you'll have like us like like a well demarcated like area of erythema and you'll have like almost like a burning sensation and the skin is usually like super tense super painful if you see that think about air syphilis and air syphilis for the most part caused by a group A strap um and again really it's a clinical diagnosis you typically don't need to do any kind of like diagnostic testing and really your treatment is kind of like what I already mentioned for cellulitis right you can put these patients on like syphilis or you can put them on uh clean the mice in you can put them on like dicloxacillin that's fine um what if again the patient has like systemic signs and symptoms you're like super super sick you know you can bring them into the hospital you can put them on like IV syphazolen or like IV naphthalene or like IV clean the mice in those things all the thing is these antibiotics should not be very difficult for you to recognize on exams now if for example though they give you a question about a patient that you know the Hats cellulitis for a few days or they tell you that oh this patient you know they have like something that looks like cellulitis but they tell you that oh that this uh extremity like the red areas like it's physically tender to palpation and that area like feels like heavy or they tell you that oh like this thing has like a blue gray like that area of skin like you know you see the red telling you that oh okay this is probably like an SSTI but you also notice like a weird like discoloration or they tell you that you see like bull os changes or you see like this like false smelling like uh serosanguino's discharge or they tell you that oh the patient has like creptus on exam

right what do you mean see oh this person you know their heart rate is like 150 per mini-bother um both their body temperature is just like 100.9 so it's like they have to you're like man you're super tacky cardic but you're not super febrile if you see that you do need to begin to worry about like neck fascia right again they don't really call these things neck fascia anymore they now call them NST Is right like necrotizing soft tissue infections if you see that um you know think about like something bad right like but again I'll refer to it as neck fascia it's much easier to see that than uh necrotizing soft tissue infection so if you suspect neck fascia right I mean like some other things they could give you an acute stem to kind of leave you down that path is they may tell you that oh you're seeing like gas within like like uh soft tissue bellies on on like imaging like either like an extra like a CT scan uh the patient will have like a severe lactic acidosis they may have like kaipone trimia they may have like these are CBC abnormalities right so they may have them may be like anemic they may have like low platelets they may have like an elevated creatine kinase right that should probably lead you more towards like um like a chloserion perforingiens right or they may have like elevated creatine they will just have like just these like weird things they were like man this is a little more than NST this is a little more than ordinary for like uh guiding varieties and the lightest if you see these things right um firstly need to do is you need to start antibiotics early right and again because neck fascia typically caused by toxin producing organisms you need to give clindamysin right you need to give clindamysin because they will help with inhibiting the synthesis of toxin but typically for these people uh you want to go ahead and start them on like uh something tha

t covers MRSA and something that potentially covers like pseudomonas you want to go broad when you suspect neck fascia so you can give like vanc plus a carbapenem right or you can give a pip tizzo okay you can actually give pip tizzo pip tizzo is fine or you can give like vanc plus a meropenem but again for the most part you need to go ahead and add clindamysin to the presence of drug regimen and then you need to consult surgery right they're gonna have to debrief they're gonna have to do like fasciotomies right or they even have to like get rid of that extremely meaning to unfortunately and put it that extremity especially in a vision that's like a diabetic right and then these people one unusual thing that I don't know for whatever is in a lot of people tend to get run on on exams is when a person comes in with neck fascia or like a skin and soft tissue infection if they're due for like a tetanus vaccine go ahead and give them the tetanus vaccine during their during their hospitalization so again these are all key high-yield things to keep in mind for example um and then I mean and I guess maybe like probably like the last SSTI I'll talk about is like like an abscess right for prison has an abscess um classically if you just incise and drain the abscess the patient gets better and you almost always don't need to give them extra antibiotics right you you know you can use like a bedside ultrasound look at the look at something like the floccant mass you see that it's an abscess you know you just inside and drain it pack the wound and the patient will be fine you almost always never don't you almost never have to give a antibiotics on an on MBM Eexabs for abscesses you because by draining the abscess you've already obtained source control and remember already they give you a question about a patient you know you're classically like a female and she tell you that oh she

has like this floccant mass on like a labia right and it's like floccant um you want to think about like a batholinkland abscess right for the most part again you just drain the abscess and then after you drain the abscess you can actually do something called like a word WORD insert like a word catheter it kind of stays in there for a few weeks it helps the abscess drain so that it doesn't recur right a word catheter um decreases the incidence of like recurrence of of a of a batholina doctor or guess a batholinkland abscess and other abscess like condition you see on your exam right maybe like a person that you know like they tell you that they have like these very painful abscesses under like they're growing under like they're axilla if you see that you want to think about hydrodynamicis operativa okay hydrodynamicis operativa remember it's an inflammation of apocrym not a sebaceous glans that's acne apocrym sweat glands that's hydrodynamicis operativa those people um it kind of really doesn't go away unfortunately so I mean you can incise and drain all you want but in general if a person have like recurring disease you probably want to go ahead and refer them to like uh to like a surgeon um that's probably what will help them the best in the long term and then if they give you a question about a person that has like a fluctant mass like in the interglutial fold right so just above the buttocks I want to think about a pylonidocyst or pylonidyl abscess okay that shows up quite a bit on exams and then you may also see a person that has a and really pylonidocyst you need surgery for that like that an hydrodynamicis operativa for the most part surgery is what's going to be like the definitive therapy so that you don't have recurrence and then foliculitis right can also sort of kind of present like an abscess usually you'll find it you know like around like hair follicles

really for the most part you don't need to do anything about it but if they want you to treat on an mbm exam you can consider like topical like basi tracing that works pretty well for foliculitis or you can give like a first gen resion of low spory and like sephalectic that also works pretty well and then what if they give you a question about a patient that is like you know like a gardener like like owns like a garden shop or like a plant store something like that and then they tell you that they have like this painless module that's kind of like on one of the extremities and then you also see in like other like subcutaneous modules that are almost like it's almost like in a single file on the person's extremity like going towards like a lymph node chain if you see that what are you thinking about well I hope you're thinking about a sport trick courses right I remember sport trick courses is caused by sport tricks as shanky eye really that's probably all you need to know about it many if you want to treat you give it your connozzol and unfortunately you give it your connozzol for weeks and weeks and weeks these people are treated for like 12 to like 24 weeks on mbms for the most part and I mean if a person that's what you typically do it's like a fungal infection but if for example the person has like super severe systemic symptoms and they have like disseminated a sport trick courses right I'll tell you this as a general if a person has like a disseminated fungal infection and for teresimbi is almost always the right thing to do it's almost always the right answer okay now what did they give you a question about a patient you know in December they come into the ED um they say that you know like for the past like 12 hours they've been having like really high fevers uh they've been having like chills they've been having like my algeas really bad headache running nose

in December what are you thinking about well I hope you're thinking about the flu right the influenza vaccine please get vaccinated vaccines though cause autism I guess I'll use that as my public service announcement there but you're thinking about the flu under those circumstances the thing is the flu one unique thing that your friends at the mbm um try to throw an example quite a lot of the time actually is kids that have the flu they tend to have diarrhea for whatever bizarre reason they don't have like some kind of abdominal thing going on like clearly like more than half of the kids with the flu tend to have like weird GI complaints um but adults that's uh more that's a rare like rare presentation adults tend to have like you know the classics like abrupt onset fever headache my algeas chills feel like crap kind of deal right now what are some high-old associations or things you want to know about the flu right you want to know that if they give you a question about a person that you know have the flu the symptoms seem to like get better um and then they then start becoming like superfabral again and they have like a consoleditian synon chest x-ray and like a productive cough you want to think about like a like a super imposed bacterial infection uh something along the lines of like MRSA right especially staff warriors staff warriors love to cause super infections in people that recently had the flu because when you have the flu right your mucus ciliary clearance system is gone right like the like the cilia you have on like your pseudo stratified a colombin apathy of your ear it doesn't work as well so those no lapid is supposed to get in like soup like a bacterial infection on top of the flu that they just had and they remember if a person has the flu right don't give them aspirin especially like a kid right don't give them aspirin because remember the associat

ion like uh what like a rice syndrome and many people they think that oh on NVME exams it's only like Campino Battege Junai that's associated with a Guillain-Barré syndrome Guillain-Barré syndrome can also be caused by the flu so that's like a weird association when you keep at the back of your mind so for prison comes in with a flu right and they come in with like classic symptoms you generally don't need to do any kind of diagnostic testing right especially like classic symptoms classic time of the year you may not need to do any diagnostic testing but one thing you can do is you can do like the rapid flu antigen detection test right you can use that on tests uh again for the most part you don't need to do any diagnostic testing but you have to choose a diagnostic test on your exam pick the rapid antigen detection test it's not very sensitive the sensitivity is awful but it's very specific right it's like 90 to 95% specific for the diagnosis of the flu and really um one caveat I may say there though I just remember I said that for the most part you don't need to do diagnostic testing but the thing is if a patient is kind of like high risk so let's say um um you know like the patient is like an older person right because remember all people their pulmonary system doesn't work as well right so you know person is like you know like older person or person is like immunocompromised let's see they have like HIV or they have like some kind of immunodeficiency disease and it's probably smart to go ahead and subject those people to the rapid antigen detection test um and again if the patient is like not very sick you can you know discharge them from the ED what if they are very sick or they are high risk again all person immunocompromised admit them to the hospital okay go ahead and admit them to the hospital and really for the most part in terms of treatment uh you can trea

t them with like a new your um your amenities inhibitor right so um if for example the patient is like uh you know can tolerate PEO intake you can prescribe like Oceltami ver right for these people that's a new amenities inhibitor another thing you can do is you can prescribe a mammivere as a mammivere is actually an inhaled formulation that you can use for the flu but here is one sneaky thing your friends at the end game you love to do the thing is if a person has a reactive airway disease right so let's see they have like COPD or they have like cystic fibrosis or they have like asthma the mammivere the inhaled medication is not a good idea because it can cause bronchospasin is it's a bronchospastic agent right so if a person has like you know like airway like really bad airway disease or pulmonary disease the mammivere is probably not a great answer you want to go ahead and give those people Oceltami ver now if for example you want to give them like an IV medication let's say you're admitting them to the hospital and they can tolerate PEO intake you can consider this drug known as Pyramivere okay Pyramivere Pyramivere is the is an i is the only IV formulation actually believe it or not that can be used for the treatment of the flu and again if you see a super infection on top of a flu like a super like a long super infection think about MRSA so you want to give some kind of drug that covers MRSA again like like linesolid or like vancomycin things along those lines and then another classic infection you may see on on mbing exams like the especially again on the e-match shelf is you may see a person coming you know like I've kind of talked about like general herpes people may have like oral herpes right typically it's like on the lower lip usually it's caused by HSV1 or Dore remember it can also be caused by HSV2 other things you may see regarding herpes on mbing exam

s you may see like a person coming like like herpes like weak low right so like herpes involving the finger or you may see like a person that has like contact with like all the people like it can be like a wrestler or bodybuilder or like a gym person like a person that works out in the gym aton and then they have like herpes lesion on their like on their skin or something like people are involved in like close contact sports those people also tend to get like herpes you may also see like herpes are characterized on mbing exams so like they may tell you like oh what's your next step in diagnosis for those people you want to go ahead and do like a slit lump exam like a fluorescent slit lump exam you'll see like the dendritic lesion so that's like a classic presentation on your exams you may also see like a HSV and Sephalitis right so it will involve like the temporal loop so you see like a lot of white around the temporal loads on loops on imaging or you may do like a lumber puncture and see like a ton of rib blood cells and if you see that again think about herpes and again like I said you can do like a viral culture you can do PCR those are kind of like the things you should do don't pick the zinc smell you get it wrong when you're test so again those are all big things you want to keep in mind and remember when a person has herpes meningitis right if you do like a lumber puncture right they'll have like an elevated white cell count it'll be predominantly lymphocytes right because it's a viral cause of infection or it's so you'll be predominantly lymphocytes and for the most part you know again herpes you treat it with acyclovere if it's resistant um acyclovere is something you give multiple times of these it kind of sucks for people if people want to take like one drug every you can give them like valley acyclovere just a little more expensive right and again remembe

r if a person has like herpes that is resistant to treatment with acyclovere consider false carnage okay consider false carnage remember false carnage is a viral phosphate analogue that can be used and then I guess a closely related herpes uh I guess brother or cousin or sister whatever you want to call it is a varicella right so vzv remember vzv can cause a chickenpox right or he can cause like shingles right and uh you know like primary varicella for the most part it doesn't show primary varicella usually like aka chickenpox those are usually shopping at the matrimo distribution right unlike shingles shingles is like reactivation of like vzv from like a doze or ganglion uh that reactivation tends to show up when a dermatomo distribution right so um primary varicella infection like chickenpox for the most part again the patient will you know be febrile they'll have like these vesicular rashes uh you know different stages of healing like they crop over a different times um and you see like cross-stead lesions papules vesicles piosciules everything um and really for the most part actually one high-yield thing I guess I don't know for whatever is in his mind precisely many resources is that your person has varicella right um they actually are contagious until all the lesions have crossed it over that's a very high-yield factor you want to keep at the back of your mind right now when a person has like shingles right when they have like reactivation of the varicella typically um they will have their symptoms like on a unit one side of the body right like in a dermatomo distribution and typically the patient will see that you know they have like pain each end like parasteges like a tingling sensation on the area before the rush then shows up right um again these are all big things you want to keep at the back of your mind with uh with a with a zoster right like uh shingles

and really for the most parts the way you treat uh uh varicella is the same way you treat like hsv you give those people least psychover um and again you typically want to start like within like 72 hours of when the rush starts um because that's when you'll probably be more effective uh a cyclovatripe will be will be a lot more effective um i mean if it's more than 72 hours fine you can treat bodies no probably not going to be as effective under those circumstances and then there are two things i forgot to mention one thing is in general when a person has the flu um typically you want to treat them within like 48 hours of their symptoms beginning um after like 40 to 72 hours then given the amenities inhibitor really doesn't do squat and really doesn't have any inhibitors right they really don't cure the flu they just decrease the length of your symptoms by like a day right so they're not you know they're okay and typically you would give them to people that you know like have again high risk for complications of the flu like you know the efficient people or or high risk people like all people or people that have like a lot of comorbidities like end-stage funeral disease or like chronic liver disease or diabetes or HIV stuff like that and then the second thing i forgot to mention is you want to be able to differentiate between chicken pox and smallpox okay the thing is chickenpox you tend to see lesions like these vesicles at different stages of development when people have smallpox smallpox um okay let me put it this way chicken pox tends to be like on like your frog like in the middle of your body smallpox tends to be on the extremities that's a very key difference and then chickenpox tends to have lesions in different stages of healing smallpox tends to have lesions all at the same stage of development right and then the lesions in smallpox tend to be a lot bigger

it's kind of kind of like uh kind of weird right judging by the fact that i said oh that oh it's uh um what did i say it's like smallpox but you tend to have large lesions right versus varicella that tends to have more like smaller lesions okay so that's kind of like a nice way to keep keep those things at the back of your mind um and then right what did they give you a question about like a 24-year-old female you know let's say she made a new boyfriend recently and then um they tell you that oh she has like she says oh she's been having fever like at temperatures 102 she has like um phatonopathy it could be anterior posterior classically posterior but the mb also writes questions with these give you like a mono question and it's like anterior cervical lymphatonopathy and then the patient will have like you know like sore throat with like exudates and all that stuff like an exudity firing gyrus and then they may have like spleen omega-le if you see those things right think about ebv right think about the epstein bar virus remember ebv right typically you make the diagnosis with uh with a mono spot test if you see a present that has like an ebv like presentation and the mono spot test is negative they want to think more along the lines of uh cmv right remember if you see like uh mono spot negative mono nucleosis like saying from want to think about cyto megalovirus right and really ebv remember ebv actually has a lot of like terrible associations right it can cause like it can cause many b cell lymphomas it can cause Hodgkin's lymphoma it can cause Brickett's lymphoma remember like the star sky pattern on on histology with a 814 translocation uh and then you can also cause like Nizofar and Joe Carcinoma right so those are all things you want to keep in mind with ebv and again like I said you want to go ahead and do the mono spot test uh sometimes you may do a blood sme

ar and you may see like a preponderance of a lymphocytes right which makes sense right because it's it's a virus right but one kind of lymphocytes you want to keep at the back of your mind is uh they're called atypical lymphocytes on mbm exams sometimes you may see them refer to as Downy cells right so d o w and e y Downy cells if you see that um if you see that again think about uh think about uh think about uh ebv and really for the most part you know supportive care you know give them pain control tell them to rest tell them to avoid contact spots for like at least three weeks to a month right so that they don't rupture their splints if you rupture your splints you have a whole new set of problems you're going to be dealing with for sure right and the thing is if for example they give you like a weird bizarre question okay this person has got mono and they're beginning to have like signs and symptoms of like early compromises or they're beginning to have like uh like they tell you that oh you see like she's two sites on a blood smear telling you that they have like a hemolytic anemia or they're beginning to have like altered mental status like some kind of symptom of like like brain dysfunction you actually want to go ahead and consider those people uh uh uh uh what actually want to go ahead and maybe give those people steroids okay steroids generally help for these kinds of people but in general for ebv like mono steroids are actually not a good idea they tend to be actually not like just more complications right so the only time you give people steroids for like mono is if they have like early compromise bring compromise or a cbc problem so remember your abc's a for early before brain c for cbc like a hemolytic anemia kind of deal now what if they give you a question about a patient you know let's say it's like an eating california right because that's where peop

le tend you you'll get what I mean by the end of this well you know like some eating california someone comes in and then they bring in their child and they say that oh their child has been having like you know like temperatures to like 103 having like a lot of cough like runny nose has like a conjunctival injection and then they tell you that on physical exam you see like some white spots on the bocomicosa aka couplic spots and then they tell you that oh you know this child had a rash that started on the head and then he spread downwards spread throughout the body from there if you see that want to think about measles okay want to think about measles remember measles right the very likely one test on this but if you want to make the diagnosis you can actually do like you can do some testing to detect like some antibodies against measles like the like age immunoglobulin against the measles that's really what you used to make the diagnosis and really for the most part there's no real treatment but the two things you want to do on your NV Me exam for measles is you need to contact the health department I need to give those people vitamin A the administration of vitamin A actually decreases morbidity and mortality in a person with measles and then if they give you a question about a patient that you know has like very high fever and then they tell you that maybe they travel to like some African country right recently and then they tell you that oh this person has been bleeding from their ears their nose and all that badness and they want to think about some kind of hemorrhagic fever right classically Ebola on exams although there are some other things besides Ebola that then cause a similar presentation say for example you've been in contact with like rodent urine for whatever reason I won't think about like chlasafiva or like the hunter virus although hunter virus tends

to cause like more like a bloody hemoptysis because it's like a like a hemorrhagic fever with like pulmonary symptoms for the most part you want to think about hunter virus and again exposure to like rodent urine right like rat urine rabbit urine I think about hunter virus and you may say okay why did these people get these hemorrhagic fevers well the thing is typically when they're ill right they tend to have like an increase in like vascular permeability so blood begins to leak out they become like super hypotensive it's just bad I mean like many of these people don't survive unfortunately and usually for the most part you typically want to send this people to like a center that handles this kind of like emery in emery hospital kind of deal for the most part you want to make sure you isolate these people right and you want to use like contact like every precaution known to man right full contact precautions droplet precautions right so you gown glove face mask eye protection everything right because anybody fluid you in contact with can actually cause you to get these things right so again you probably want to refer these people to like the CDC or some kind of thing there's really no treatment unfortunately for Ebola I mean what you can do for the most part you know you can into be them to like support the respiratory system you can put them on dialysis if your kidneys are feeling you can give them like a ton of ivy fluids I mean there's like some experimental stuff so for the most part again go ahead and send these people to centers that are best able to deal with those kinds of things now what if they give you a question about like like a man that like a 24-year-old guy you know he has sex with other men or you know a person that just has you know a lot of risky sexual behaviors and you know they come into the hospital and they say that you know for the past three

weeks they've been having like low grade fevers like okay let's say maybe the temperature of them like 101 they've been like wiped out super tired if had like soft throat like a generalized rash and they have like like an apathy like generalized lymphatic apathy if you see that what are you thinking about well I hope you're thinking about HIV right I hope you're thinking about HIV HIV for the most part you know it's an immunodeficiency disease arises you know it's a sexually transmitted infection right so people get it for the most part through a sexual contact and really in terms of diagnosis right like you you do like the antibody detection although you can do like PCR to like get like a relatively immediate diagnosis but for the most parts the recommended testing method is you know you detect antibodies to like the P24 and DGIN on NV Me exams and HIV right I mean there are many as residual HIV right like remember like your CD4 counts thing in fact let me just walk through all these things right so people that have HIV right they can have like they can have like they can have like a so far jie this from like HSV CMV or Candida right they can have throsh right from Candida remember throsh is a thing that scrapes um scrapes easily from the tongue um they can have like uh when you treat them for example they can have this thing called like iris like immune reconstitution inflammatory syndrome right where uh you know you are treating them because let's say these are people that have like super low viral loads and then you start treating them and then you notice that oh they start having like very high fevers they have like you know like just it's almost like a flu like illness they have like this you know relatively severe systemic uh symptoms um if you see that uh think about iris you just it's just something you want to be able to recognize for the most part or you se

e a person with HIV and they tell you that oh this person has like retinitis right you want to think about CMV as the potential cause right or if for example they have like pneumonia the thing is pneumonia is one way that the embryo may kind of please people dirty on uh on exams but there are some key things you want to keep at the back of your mind with uh pneumonia and a patient that has a HIV believe it or not the most common cause of pneumonia again I believe it or not that means you should believe it the most common cause of pneumonia in HIV patients is actually strep pneumonia okay the most it's not pneumonia system you're right see it's strep pneumonia okay the most common cause of pneumonia in HIV patients is is strep pneumonia right so typically the thing you do for these people they will present it as like they have like a consolidation right on chest x-ray versus PCP pneumonia that tends to cause more of like intestine in filtrate right so PCP um if you see intestine in filtrate HIV patient uh think about um the most easy to do vaccine right and again these people you know they'll have like fevers non-productive cough they'll have like butt shortness of breath um again you obtain imaging like a chest x-ray you see the interstitial infiltrates uh these people tend to be like super hypoxic right and they also tend to have like elevated levels of like LDH okay elevated levels of LD they have like an increased AA gradient those things are pointed towards the most cystis gerovetis and again the most cystis gerovetis are you want to go ahead and treat them with uh IV uh try and let's open myself from a foxes all aka backtrane right and then if they give you a question about like a HIV patient you know that has like seizures and then they tell you that oh on imaging the person you see like multiple ring enhancing lesions right you want to think about toxoplasma on

DI right um tip of view make that diagnosis with like a contrast CT of the head or you can do an MRI of the brain uh that can help you under those circumstances um or if you see like meningitis in a HIV patient like all like high fevers no corrigidity and then they may tell you that oh you perform a lumbar bone trend the opening pressures are like crazy hot um think about crypto crypto caucus is one of those bugs that can cause a pretty impressive uh opening pressure when you do a lumbar puncture like literally like you just gain access to uh uh the air where you're very like the uh css from and it just comes out like like like uh almost like uh like a river right if you see that think about crypto caucus new ferments you know back in the dark ages these two diagnosed this with uh with uh india angstine but essentially no one does that anymore right these days on india makes them so you want to pick the latex particle at gluteinitian acid right um so uh i guess let me just say some more things about like infections in HIV patients right so if you see a patient on HIV and they have like you know like profuse watery diarrhea that has been chronic lasting for a long time i want to and they tell you that oh you do like an over one pill of your stool and you see like um acid fast osis right you want to think about crypto sporidium right crypto sporidium parvam please do not confuse crypto sporidium with crypto caucus new ferments crypto caucus new ferments causes meningitis in uh HIV patients crypto sporidium parvam causes diarrhea in HIV patients it's like a diffuse watery fast mening diarrhea in HIV patients um and one thing though i you should keep in mind is if you have a person that you know like has like very late stage eights or like their city for counties super super low like in the 30s 40s and they have diarrhea they actually want to think more along the lines o

f my co-bacterium avion complex and cmv being the cause of their of their diarrhea and again like i've said i've talked about like they give you a question about a HIV patient the patient's complaint of like trouble swallowing or like painful swallowing so like a dyno-fagia think about it so for gydays right from like candidate or like hsv or like cmv okay um again those are all big things you want to keep in mind and then they give you a question about like a HIV patient and this patient has like you know like a rash um that's you know like brown black or like purple on the skin and you have all these nodules uh think about um um think about uh kaposis or coma remember it's caused by hhv 8 right so kshv um and then remember i said that when a person has like a shingles when it reactive it it typically you know is limited to like a dermatomo distribution the thing is when people let me know compromise like hiv patients uh they may actually have like shingles and it will sharpen like a non-dermatomo distribution that is one thing that occasionally your friends at the end of the year used to mess with your head on exams so really what are the big things you used to treat uh some of these HIV infections right so if for example a person has like again like pneumosis is your vetsin ammonia um again for the most part right like uh you typically will consider like tmp smx and if for example there uh p little ale to right so like there are oxygen tension in the blood is less than 70 or there are 8 ingredients good than 35 i want to go ahead and aqua-culture right he reduces morbidity and mortality right if a person has like cmv like right now it is right you want to go ahead and give them gun cyclovere if uh remember you gungop on cmv with gun cyclovere right and if whatever is in uh the infection is like resistant to gun cyclovere you can give them foskinet or you can give th

em foskinet if the person has like micro bathroom evom complex like mac um remember you can give them like uh you can give them um um basically like the way i remember what you give is just remember like wreck like r-e-c you give them like uh uh like uh refampender evative it's called like refabuting and then give it thambutal so thambutal is only isn't remember is you use it for micro bacterium tuberculosis you can also use it for micro bacterium uh evom complex right so i and remember for tb um uh micro bacterium tuberculosis you also use refamping right so it's kind of easy to remember right so you use like refabuting you use um uh ethambutal and then you use clarithromycin clarithromycin is uh is a macro you remember it's one of those things that you also use uh for triple therapy in a person that has a hitch pylori right and then i've talked about how you treat pcp if you don't see trimethropramesophane toxisol as an answer choice uh consider putting those people on uh uh pentamidine like then actually put them on pentamidine uh work i mean tmpsmx is preferred but pentamidine works works just fine right and then if a person has toxi right for the most part you give them like pre-methamin and sulfidizing um maybe let me take a small sidebar here right like prophylactic strategies and patients with HIV right so if a person has HIV and the acidity for count is less than 250 uh for the most part you and they give you an associable area like Nevada Arizona California Texas um new Mexico all right and the acidity for count is less than 250 you give them prophylaxis against a coxidiumicosis right with uh etroconozol right if the cd 4 count is less than 200 you're trying to cover p p cp right the mosis is reveti you give um trimethropramesophane toxisol for that if the acidity for count drops you low 150 and you leave an associable area like Ohio Kentucky Missouri you wan

t to cover histoplasma right so histoplasmaosis histoplasma capsuleata with etroconozol as well if the acidity for count drops you low 100 you want to cover toxoplasma condi i with tmpsmx if they are cd 4 count drops you low 50 you want to cover micro bacterial area okay um with uh easy thromize okay now notice for toxois f for prophylaxis right you should you prefer large with tmpsmx not so for treatment if a person has toxo you treat them with a different kind of folate inhibitor it's known as pyramethamine and sulfur die as it okay pyramethamine and sulfur die as it right and in addition to this you also need to add local worry okay so the regimen is like pml right so like pyramethamine or i guess psl so pyramethamine, sulfur dies in a local worry remember if a person has boomer or suppression from taking like a folic agent you do need to give a full limit not folic for lemicacid analog like like local worry right and then if you have like cryptococcal meningitis for the most part right you can give those people like amphotericin B plus flu cytosine and then after they recover you need to put them on floconozol for like a year for the most part right and then again if they have CMV, GAN cyclover or like val GAN cyclover if it's resistant you can put them on false carnets if they have candidiasis you can put them on like floconozol we can do like the my studying a swish and spit or my studying swish and swallow if they have like the candidias of agiades again floconozol does just fine for that if we have the cryptosporidium I mean you can consider things like can mitosoxamide but cryptosporidium problem is extremely hard to treat it is extremely hard to treat but you can consider mitosoxamide as a treatment option on your exam and I think I mean one thing I guess you maybe want to maybe know about at least highly active antiretroviral therapy if you're studying a pat

ient on HAART right typically what you do is you study on two NRT Is right so like a two nucleoside reverse transcripties inhibitors and then you add like one other drug right like either a predis inhibitor or an integrase inhibitor or something right or like an NRTI it doesn't matter right so you put them on triple therapy right and if you're a healthcare worker on MDMA exam so you know you get stuck with HIV and you want to go ahead and start post exposure for philoxys as quickly as possible in general you want to study at least within two hours of being stuck right and for the most part you'll get treated for like four weeks pretty much right you get treated and it's pretty much like HGART like two NRT Is plus one other drug class like a predis inhibitor or an integrase inhibitor or an NNRTI right and occasionally the MDMA like sometimes they put like some bizarre questions where like you're like scratching your hair like what exactly are they trying to test you right occasionally you see questions where they ask about like risk factors for the person like like a healthcare worker like almost like oh like if you get stuck by a needle from a HIV patient what are some risk factors that increase your risk of actually like contracting HIV from there well some things you can do is some big risk factors is if the person has like a very large viral burden right that can trigger that that's like a risk factor if the person has like like if it's like a deep injury so you get stuck like big time that can increase your risk and if the patient like again like has like a big viral burden like they have like least HG HIV that's a big risk factor right or if for example when you get stuck you get inadvertently get stuck like and it goes straight to like a blood vessel like a vein or a artery those things all increase your risk of badness right so I think those are kind of like the

big things you want to keep in mind with HGART for purposes of the of the show now what if you get a question about a patient you know this patient comes in they have like I will say IV drug you know I don't know like I have a drug user right and then they have like fever like they say for the past two weeks talk my temperature has been like 102 and then they have like a new heart murmur and maybe they have like you know like some heart failure style symptoms like oh like an S3 heart sound what have like pulmonary demon and all that stuff if you see that what are you thinking about I hope you're thinking about endocraditis right endocraditis remember the most common cause of endocraditis is stuff for you that's like a big one you want to remember the person has a prosthetic valve and it's like 60 days out from them getting their surgery like within the first 60 days think about stuff every intermediate but once it's more than 60 days it's actually stuff for your stuff for us becomes the most common cause on that those circumstances and then if a person has had like some kind of GI or GI procedure I want to think about like interococcal species right when you think about interococcal species and when it's an IV drug user right it's going to be like a right side of heart valve classical like the tracospid valve that's affected right but otherwise endocraditis most commonly occurs in left side dead heart valves okay left side dead heart valves with the exception of IV drug users right so you may see okay divine why the right side of the heart and IV drug user well look at the name IV intravenous drug user well if you're an IV drug user you're ejecting two veins and where do veins ring to veins ring to the to the veins ring to the to the right side of the heart right so that's why the right side of the valve tend to be torched by endocraditis and an IV drug user and IV dr

ug user endocraditis almost always is stuff for us on test right so again fever, new murmur, heart failure, stile symptoms endocraditis, acute onset endocraditis right and there's some classic physical exam findings that your friends at the MDME kind of want you to know for endocraditis right so those people have like you know like osler nodes remember those are painful like osler out right and then they may have like the genuillisions right genuillate think of genuillas like a calm mild mannered person so it's pain less right they may have like splinter hemorrhages um again those are all big things you may see on exams with with endocraditis and the thing is when endocraditis affects a valve it typically affects it typically causes like a regurgitant lesion okay it typically causes regurgitation typically causes regurgitation that's a big picture thing you want to keep in mind on exams so you may say okay divine person comes in with endocraditis what do I do for diagnostic test right if they say oh what is your next best step in diagnosis on your exam you want to do a blood culture before you start antibiotics you need to get three sets of blood cultures and the time gap between your first blood culture and your last blood cultures be like an hour right so three sets of blood cultures right before you start antibiotic therapy and then you also typically get imaging on these people although you can do it after you've studied antibiotics you can get a TEE right I mean some people do TTE so if you don't CTE you can be TTE as an answer choice but the thing is TEE a trans-esophageal echocardiogram is a lot better right so blood cultures before you start antibiotics when you start antibiotics or whatever you can then go ahead and get the echo and I mean there's all this major minor criteria but I don't think there's a very high yield to know for purposes of the exam when a

person has endocraditis you know that he having endocraditis on a test but those major minor criteria that you need to know them for like actual clinical practice I remember this podcast that targeted towards a test prep for the most part right so again three sets of blood cultures from three separate sites so you don't obtain the blood cultures from the same site three I know these people I mean I've treated tons of people in look at it is these people is just a terrible situation right like you're literally like almost like blood letting these patients right you take tons and tons of blood from three different vascular sites again to help you again kind of guide antibiotic therapy and really for the most part you know when you send off like cultures and sensitivities and all that fun stuff that's all well and good right but you want to empirically start them with like on like vancomycin right in fact I'll tell you this your typical regimen for endocraditis on MDM exams is a combination of empiric therapy without knowing what's going on is you please those patients on vancomycin and gentamysin okay sometimes on MDM exams in addition to placing them on vancomycin and gentamysin you also place them on rifampin so just remember vgr vancomycin gentamysin rifampin those are things that you can use to treat those are agents you can use to treat endocraditis on on MDM exams okay at least empiric treatment empiric treatment and then one last thing you may see tested on exams occasionally is who should get who should get antibiotic prophylaxis well the people that get antibiotic prophylaxis for the most part are people that you know they have like big-time dental procedures usually use amoxicillin like big-time dental procedures where you may like you know like mess around with the teeth and like the gums and all that stuff or if for example a person has like like you know l

ike a big like intra abdominal process like a big tiny infection you probably want to go ahead and give those people like antibody prophylaxis or if a person has like a prior he's treat this that one is actually very high for exams right so if a person has like a prior he's strong like infections and endocraditis or they have like a prosthetic heart valve or they have like a congenital heart defect that has not been fixed especially like a sanotic one or the patient is like a cardiac transplant patient or you have like you already have like a valve-illapathology right and those people do need endocraditis and prophylaxis okay so again these are all high-yield things to keep in mind and again like I said in period therapy you can give like vancomycin plus gentamysin or you can give like vancomycin gentamysin and rifampin okay so let's go ahead and jump to another topic okay so what if you get a question about a patient and this patient gets you know recently had like a puncture wound or had some kind of recent surgery maybe that was not done with the most sterile of techniques or you know was bitten by an animal or this person had like an on sterile abortion right um and then they tell you that this patient has been having like you know he first he studied had like pain stiffness in his jaw and then he also kind of noticed that he's like his face is almost like expressionless kind of looks like like uh what term what term can I use let me see anarchy person basically like you kind of know what I'm already talking about like the rice or sardonecus and these patients having like weird spasimos of like multiple muscles and they can swallow and every way is like rigid their fists are like clenched and the abdomen is like super super tense because all the rectus muscles have all like tense stuff um and then you're all like in an extended position um what are you thinking ab

out with the hope you're thinking about tetanus right tetanus um this person has a most trivium of tetanite and I've essentially like in the custer might give you describe like the classic risk factors for tetanus right so the thing is why does tetanus cause all these problems well the thing that tetanus causes is that um you know the tetanus toxin includes these snare proteins right so you don't release um inhibitory in your transmitters like glycin and GABA right so you're in and always on excitatory state right so you get a spastic very high-eat-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at-at that like seven days after the baby has been born, think about a new needle or tetanus tetanus can actually happen in a new needle, try it on again, it's a toxic, toxic needed illness for the most part.

And really, how do you treat tetanus, right? There's many things you have to do, right? Basically, you need to essentially like, you need to admit these patients for sure, because they're going to be in the hospital for a while, right? And you try to put them in like quiet rooms, because if you put them in a room that you know, is not quiet or whatever, they can actually, whenever they have like, like stimuli from the environment, they can actually worse, worse in their muscles, passins. And then you typically give them like the tetanus immune globulite, right? You give them tetanus immune globulite. And tetanus immune globulite, you give it like in a different arm to the arm where you're going to do the next thing, which is to give the tetanus toxic vaccine, okay? You give them a different arm. And the thing is, typically you want to make sure you give this tetanus immune globulite before, because sometimes if you want to like do the breedment, to get rid, at least try to like, obtain like source control, you want to give this tetanus immune globulite before you do the breedment, because the thing is, as you manipulate the tissue in the process of the breedment, that can actually like, release more toxin and worsen the patient symptoms. And then again, if there's tissue that's dead, you need to go ahead and debris that tissue. For the most part, you can also please these patients on benzoes to help with the muscle spasins.

And then, if for example, they have like sympathetic hyperactivity, so let's say like they're tachycardic, they're tachypnic, they're like superhypertensive, you can go ahead and put them on like a bit of blocker, like labidolol, labidolol is a great drug for this purpose. And you also tend to like, into baby spasins and put them on your muscular blocky, because again, you essentially want to quiet down their muscles, right? So you can put them on like, the coronium or a coronium or something like that, just to again quiet down their muscles. And other things you can use to again, sort of control their autonomic hyperactivity, you can use things like magnesium, you can use morphine, you can use clonidine, but labidolol is probably like the big one, you'll see for the most part when an ambient. And here's the thing, after they recover from the infection, right? You do need to still immunize them, because the thing is, the passive immunization that they get, or you may say, oh, okay, they've got in tetanus immune global insulin, so they should be fine. No, the thing is typically right, you think about it like, oh, you know, when a person recovers from infection, they've established immunity the hard way. No, the thing is when a person recovers from tetanus, they actually don't establish immunity, so you still need to vaccinate these people. And then, what if they give you a question about a patient, you know, that is like, beating by like a dog?

So you get a question about a person, you know, who's beat by a dog. And then, you know, this person starts like days, later, weeks, later, starts behaving weird, like, the kind of like, get hyperactive, episodically, and they're seeing like weird things, they're like having hallucinations, they're making a ton of saliva, they have like temperature, dysregulation, they're having like all these arrhythmias, and they have like these, they don't want to drink water, right? They're like afraid of water. If you see this, what are you thinking about? I hope you're thinking about ribies, right? So ribies, the thing is, your friends at the MBM, there are many things they put on exams that can cause ribies, right? They can be beaten by a dog, by a raccoon, by a bat, by a skank, by cattle, right? Cattle believe it or not, they can actually carry ribies as well, right? So if you see that history, right? And then you see all these things that I'm talking about, like again, like hydrophobia is a very classic thing, they put on exams. Like, the person is afraid of water, they don't want to take showers, they don't want to drink water. And then the person, you know, ultimately becomes comatose and dies, think about ribies, under those circumstances. Usually people, those people go comatose and then they die. And the thing is once ribies has got into the central nervous system, that's it. The person is essentially dead.

There's only people that survive, but it's very, very, very, very, very, right? So basically, if you see a person, again, that was beaten by like an animal, right? Or like leaves amongst animals? And then they tell you that this person is just having like this weird like encephalopathy, and has like all these autonomic troubles, and they are not able to swallow. They avoid in water, right? So like hydrophobia, under those circumstances, think about, think about ribies. And really, how do you diagnose ribies? Right? You know, you check the serum, check the CSF, you can do like some antibody testing. Really, for the way you make the definitive diagnosis after like the patient is dead, and then you take their brain and then analyze it at pathology. And then you see like the, you see like the, the box. But really, ribies is just a bat. Once it has read the central nervous system, it's kind of like a bat situation at that point. And really, for the most part, there's really no great treatment for ribies, right? You know, you get those people to an ICU, you go to bed, then. So what if care, try your best, but most of these, most of these people, like a very large percent, like almost like 100% of them die pretty much, right? Now, so where is the meat in terms of, I mean, other than recognizing the disease, what would your friends at the end of the month to test on the exam?

So the thing is, if a person has been bitten by like an animal and they're like, oh, worried about ribies and they come into the emergency room. Well, you can certainly do something about that because that would decrease the risk of them going to like ribies that has got into the CNS and then they have a lot of trouble. So the thing is, if a person has had like direct contact with like a bat and they have like a bite wound or a scratch wound or whatever, you know, you, you go ahead and provide a post exposure for relaxes. And really what post exposure for relaxes, you give like the ribies immunoglobulin and then you give the ribies vaccine. But again, you give it in two different arms. You don't give it the same arm because you don't want the immune globulin to bind up the vaccine that you're giving the patient, right? And the thing is, if for example, right, the person like they tell you specifically in the question that, oh, you know, this person has been bitten by like a healthy animal that is, you know, pretty healthy, like a domestic animal that doesn't have any significant problems. Then, and they have the animal on hand, right, then you can observe that animal for 10 days before having to give them any like ribies immunoglobulin, like post exposure for relaxes basically.

But if for example, right, like a person was bitten by like a wild animal or a stray animal or an animal that cannot be captured, right, just go ahead and give the post exposure for relaxes, like I already mentioned earlier. And then remember that if the person also like cannot remain like they can like their stories in congruent right there, like I'm not sure maybe I was beating, maybe I was not beating or like they were in a room with a bat and they just don't know or you can't find the animal, just go ahead and give those people the post exposure for relaxes. That's the right thing you want to do on an exam. And then again, if a person has, if a person was beating by an animal, make sure you give them tetanus as indicated. Remember I already mentioned that for, for like a different infection or so again, just kind of keep those things at the back of your mind. And again, when you're given the vaccine and the immunoglobulin, give them at two different sites. Those are all very high of things to keep in mind for your test. Now, what if they give you a question about a patient and this patient you know is like a missionary just recently came back from some African country. And then this person has been having like fever like every three days or like every four days and they have like myalges and they give you like some laps. And you notice that the patient has like an anemia, the immunoglobulin is low, they have like a thrombocytopenia.

If you see that what are you thinking about? Well, I would hope you're thinking about malaria. I would hope you're thinking about malaria, right? And malaria, there are four species you want to know. So let's break those species down one by one. So if you see this, you want to think about malaria, right? And again, there are four different kinds of malaria, right? So there is a plasmodium falsiparam, there's plasmodium viwax, there's plasmodium ovali, there's plasmodium malerie. Really, the big things you want to keep in mind with these ones is the one that's the worst is p-falsiparam. Has the longest thing gives you bad, bad, bad, bad, bad, bad, bad, that's right. And then p-vivax p-o-vali, they tend to hang out in the liver, right? So they can cause like a dominant infection. So those people you generally need, you know, primary queen to get these people fully well. So what's the big deal with malaria, right? So the thing is usually, like when you get infected, usually get problems with the anophilis and mosquito. And so again, it will be a present that has traveled to like sub-Saharan Africa or something like that, right? And then this present comes back and then typically the thing that happens is first the bugs, right? The sporesoids, the, you know, the kind of tick shelter in the liver. And then, you know, they grow, grow, grow, grow, grow for a while. After that, they leave the liver, right? And they leave the liver, the merosoids infect their ribloids cells.

When those more revoid, merosoids infect their ribloids cells. And those ribloids cells begin to humanize, right? That's why this person has an anemia. The person I give in the Q-stem, as the ribloids cells burst and release the bugs. The merosoids, as they release those are merosoids. And that causes like an amolecanemia. And usually those, those burstings occur at like fairly like regular, tiny intervals. That's why these people tend to have like, 4-10 fevers, right? They have fevers like every 3-4 days kind of deal. And the thing is though, p-falsyperum, right? It leaves the liver, it leaves the liver. But the thing is p-vax, p-o-vally. Some of them actually stay within hepatocytes, right? That's why dominant infection can happen with p-vax and p-o-vally, right? So again, classic presentation, cyclical fevers, chills. And when the person has these fevers and chills, they're like completely wiped. They're like sweating a ton, right? And then again, they have like anemia, they have thrombocytopenia. And the thing is remember your spleen is the organ that sequesters a lot of ribloids cells, right? So the thing is all this, hemolysis of ribloids cells. Some of it can happen in the spleen. So these people tend to have like abdominal tenderness, really bad spleen omega-lead. And again, p-falsyperum is the worst. P-falsyperum can cause a lot of bad, bad, bad, bad, bad problems, right?

Like especially like if you're saying like the hemolytic anemias, the splinic rupture, or like cerebrum alleria with the person's like comatose, or like altered, like delirious, having seizures. Think more about p-falsyperum causing those kinds of problems. Or like there are some people where they can have p-falsyperum. And then they have like jaundice, they're putting a ton of blood in their urine. Like they have like renal failure. P-falsyperum can cause like a special kind of fever that's just really bad, like a really bad complication. And really all you want to know for the most part with malaria is that in general in terms of diagnosis, you want to do a thick and thin blood smear. That's really all you need to know in terms of a diagnostic testing. And for the most part, again, if a person has like p-falsyperum, you want to go ahead and admit these patients to the hospital, right? And there are many different, you know, regimens you can use. I will say for the most part, you probably want to avoid prurquino, you examine, because there's a lot of resistance to prurquino. And then don't forget that if a person has a p-falsyperum, they also do need to get, especially after they recover from like the malarial syndrome, they do need to be placed on primacuin, right? Although primacuin you want to think twice, especially in a patient that has a history of a G6 PD deficiency, right? So like a glucosix-phosphid dehydrogenase deficiency. So some regimens you can use, right?

You can pick things like athermeta and lomyphanthrin, right? That's something you can use. You can use atovacone and progonia, right? You can use quinidine, right? You can use quinidine, although typically you add that, you do either quinidine plus doxycycline or quinidine plus a clindomyces, right? Those are things you can all use. And really for some people, believe it or not, you can just give them clindomyces, particularly if it's like a kid that's less than 8 years old, that's absolutely fine actually. You can go ahead and consider just using a clindomycin in those kids, but again, at the methamphetamine, my fine-train, atovacone progonia, quinidine plus doxycycline or quinidine plus clindomyces, right? But again, you don't want to give doxy to kids, right? So if a kid is less than 8, you can probably just give them a clindomycin for their malarial. And then, the thing is, when you want to pay attention to some side effects here, right? So like I said, primary queen, you want to check for g6pg deficiency, you want to monitor g6pg deficiency before you put a patient on primary queen. And the thing is, if a patient is being placed on quinidine, you want to make sure that they don't have, you know, like some cardiac arrhythmia thing going on. Because quinidine, right? So quinidine is a class 1a antirithmic as well, right? So you can cause arrhythmias, it can actually cause like a pretty severe hypoglycemia, right?

So those are all things you want to watch out for in your exam in terms of side effects of the malarial treatment. And really, I think those are all you need to know about malarial for purposes of the test. Okay, so let's jump to another concept. I promise this podcast will hopefully soon be over. And really, I think for the last few questions so that we can get, I can get them with this podcast. I'm also getting tired myself. I'll just give you some quick associations like how you'll things you want to keep in mind. So what did they give you a question about a patient? You know, this patient is a long-term alcoholic. And let's say this person was, you know, maybe swam in a river or pool or something recently or maybe a shellfish or something like that. And this person has like really bad left-low extremities and lightness. And you see like bullshin changes and the patient is like super, super sick. What bug are you thinking about? Well, I hope you're thinking about a vibriolvanificus, right? Remember, vibriolvanificus and vibriol parachemolylicus. But most of vibriolvanificus has an association consuming like shellfish or like water exposure. And then this person will have like salelitis and they can have like almost like an acryptizing infection of the skin. Really, the way you treat this for the most part. And it typically has like a very bad... Like people that have like some liver problem or they're pretty supposed to like bad liver problems.

They tend to have like, you know, like a pretty like terrible prognosis, right? So for example, like a person that is like a long-term alcoholic or has here a tissue hemocurmitosis or has aphorone antitripsine deficiency or otozomodominum policistic kidney disease. They can have a lot of issues with this, right? And really the way you treat this for the most part is you treat it with doxycycline plus cephepine, okay? Doxycycline plus cephepine. And again, if you have like necropsis of an extrubility you need to consider like, you know, pretty aggressive abdibrightment. And then if you see a person that you know was exposed to like fresh water and again they have like salelitis, you don't see vibriolvanificus as an answer choice, you know? Maybe think about aromones. They're not gonna test how you treat aromones and an immune exam. So I'm gonna skip that. And then if they describe a person that you know has been working out like, he's been using like a hot top and then they tell you that, oh, they have like, it's almost like you can see like, they'll have like almost like a salelitis or like a folliculitis, but it will be like in the shape of like whatever swing here they wear. If you see that, think about hot top folliculitis, think about pseudomonas, originosa and other circumstances, and really pseudomonas, right?

And then if you see a person that you know uses hot tops a lot and then they've been having like this like respiratory issues, like fine crackles on your scotibular chest and all that badness. And then if you wanna think about hypersensitivity in the 90s, remember that thing has a strong association with thermophilic at nomisites. And I talk about that in one of my medicine videos from like way back in the day. And then if a person has like a lot of like, you know, like skin infections and they tell you that, oh, they biopsied one of those skin lesions, and less of this person works with water and all that stuff. And then this person has like, you know, like the cello granulomas in those lesions, then on those circumstances you wanna think about a micro-bacterium marina. And then you just wanna know like your causes of like water versus bloody diarrhea, right, on the exam. So if you see like a cruise ship, right, or a person like was like in subcrate of like recreational environment, and then they have like, you know, like a not watery diarrhea, think about neurovirus and little circumstances. If you see a kid with diarrhea, think about rotavirus, right, think about rotavirus. If you see a person that just recently ate like potato salad or like we're at a picnic and the eat like food that was left out, think about stuff for your stuff for your, you know, it has like an early onset early offset within like 30 to 6 hours after the person gets exposed.

They get nasty, nasty diarrhea, nasty, nasty vomiting. And then it goes away within a few hours. And then remember, we're gonna color it like developing country, dirty water, right. Like a profound diarrhea, right. And then they're like, you know, pooping, pooping, pooping, pooping, pooping, pooping, a ton. Like really nasty already diarrhea, they can be up to like 20 liters volume down, right. Those people think about a vibriolcular and little circumstances. And really if a person has vibriolcular, they need a lot of, they need a lot of fluids of the mentition. I wanna give like something called oral rehydration therapy, right, where it's like a salt sugar solution. I've talked about the mechanism behind that in for the podcast. I'm gonna go ahead and move on from that. And then remember HIV patient with diarrhea think about cryptosporium parfum. I mean, if you see a person that has like bloody diarrhea, you wanna think about like shegella, I wanna think about Campilo bacteria, Junai, you wanna think about salmonella, I wanna think about like ehec, right. So equal like 0157 each seven. I wanna think about a year senior enterical and that one tends to cause more like a pseudo appendicitis, so like regular cordron pain. And then enter me by histolyrica, right, that also tends to cause a bloody diarrhea as well, right. That one usually causes like bloody diarrhea plus a liver abscess, right.

If you see that think about a ehec, and because it's a parasitic infection, those people have a utenophilia on an embigme exam. And then remember that if a person has like equal like 0157 each seven or like shegella, that can cause the hemolytic uremic syndrome, right. And he, she was remember that remember that it has an association with a person having like like a maha, like so like a micro and apotic hemolytic anemia, right. So you'll see shegell sites on a blood smear and then they'll have thrombocytopenia, so they'll have low pleclets and then they'll have acute renal failure. So they'll have like an elevated creatinine, they may have like an ephretic syndrome style presentation, even if it's really not an ephretic syndrome. And then if you see a person right that has what is it called if you see a person that has you know like either what you're a bloody diarrhea and they recently took her like antibiotics, then on your exam, the thing I absolutely want you to think about is cdif, okay. You want to think about cdif as the cause. I remember cdif the first line agent for treating cdif these days is is what is it called first line agent for treating cdif is a vancomycin right it's not longer metronide is all the first line agent for treating cdif these days is vancomycin, okay. So those are all big things you want to keep at the back of your mind and again don't forget the history of you know like recent antibiotic exposure.

And the thing is again if a person has nasty nasty diarrhea you want to rehydrate them that's probably like the corner sort of treatment. You usually don't need to do any kind of you usually don't need to do any kind of like testing or anything like that right you just you know rehydrate them as much as possible you give them an anti medic right so you can give like metaclopromide remember metaclopromide is a defect to anti psychotic right so remember metaclopromide can actually cause what is it come on divine think metaclopromide can cause a strapper or a metal side effects right and then you can also give on dancer trauma remember that's a serotonin receptor antagonist. And then the thing is I'll talk about some out in fact let me maybe hold off on that for now I'll talk about that in a second but yes you can again rehydrate these patients give them an anti medic like metaclopromide or on dancer trauma remember on dancer trauma can prolong the cutie interval.

You can also give lopera mind remember it's an opioid analog right so you can use the constipation side effect to treat diarrhea right and the thing is if for example the person has diarrhea and they're trying to get you to pick an anti biotic you can consider giving like a fluoroquinolone like siper floxasin or like livo floxasin right in general fluoroquinolones are very good agents for the empiric treatment of diarrhea right but if a person has E coli O157 he 7 it is an awful idea to give them anti biotics because as you kill more of the bug you release more toxin and then the patient will have an even worse even worse prognosis so those are actually high things to keep at the back of your mind for example now if they give you a question about a patient you know let's say they like the consumed some kind of fish maybe like I don't like puffer fish at a restaurant and then they have like flour shame they have like headache they have like auto monodonomic instability think about a scumbraid poisoning right think about scumbraid poisoning remember scumbraid expresses this enzyme known as a histid indicarboxylase which converts histid into histamine right so he can cause a lot of it can cause a lot of symptoms right so that's actually something high to keep in mind so they have like flushing they have headache they have like auto non-mic symptoms think about scumbraid poisoning really scumbraid poisoning can actually consider giving those people a bifin hydramine right in anti histamine it actually generally it actually generally helps helps quite well under those circumstances and then don't forget to your chigua terapoisonin like si g u a t e r e right so like chigua terapoisonin those people have like headaches they'll have like muscle aches hot things will feel cold to them cold things will feel hot to them that's what's known as the reversal of the hot cold sensat

ion and then they may have like basically they just have a lot of like temperature dysregulation problems think about chigua terapoisonin with that I remember those this toxin tends to like mess up like a person's sodium channels right so it causes all these like weird symptoms right weird symptoms like these like temperature like issues with temperature regulation or recognizing the right temperatures right so just gonna keep all those things at the back of your mind with that chigua terapoxin uh that's like the classic presentation on mbim exams um and yeah I think those are the associations I want to talk about with diarrhea again know your water reversal bloody diarrhea and again remember cd if can cause it or a watery diarrhea or a bloody diarrhea right so watery diarrhea does not always mean cd if on a name being an exam that's very high you to know and on the sample purpose of exams now if they give you a question about a patient you know that um you know like maybe breeds dogs or something right and the inspiration has like a weird fever um like fever that seems to go up and down up and down up and down like they have fever and then they become a fever have fever they become a fever right so on-to-learn fever's on the those circumstances you want to think about brosela and really I'll say like the next couple of bugs I'm gonna talk about right then basically gonna be talking about like the zoonotic infections for the most part these bugs you treat them with doxycycler right if you kind of like spaz out on the exam you have no clue what to pick for zoonotic infection doxycyclerin is almost always a good idea well if a person is less than eight years old they may be doxycyclerin is not a great idea right but the thing is their exceptions to that role if a person has rocky mountain spotted fever or a person has early cuses like the way I remember that is with the

nomonic ER right so like emergency room right so ER for early cuses are for a cat's ear a cat's side the bug that causes rocky mountain spotted fever then if those kids are less than eight you still give them doxycyclerin okay you still give them doxycyclerin that's very high you to know so person has like you know like they have dogs um and then they you know they mean having like these on-dolan think about brusselosis and again can treat that with like a doxy um and then if a person has like osteomyelitis and we're recently bidding by like a dog or a cat then you want to think about this bug known as a capnocytophagia so I'll spell it it's C-A-P-N also capnocytocytyl and then phagia pH-A-G-A and then kinemorsus like capnocytophagia kinemorsus right it causes like osteomyelitis can even cause like meningitis believe it or not again it will be a person that has like a dog or cat bite again for the most part um for this one though it's kind of different you can treat them with like augmenting or it's so like a moxissin clavlanit or you can think of um you can give them like cleaned amycin that's pretty much all you need to do and then if they give you a question about a person that you know like has like pneumonia or like a flu-like illness or they may even have like endocratitis and they tell you that you know they have like a bird shop or something like the breed birds and they want to think about clavidophilicidickey okay clavidophilicidickey and again doxycyclerin works well you can also use uh uh something that those remember i.e.

typical organisms like chlamydia you can use uh microlytes for those right so is it through my sing works just well for those people and then if they give you a question about a person that you know like rare scatle or rare sheep or rare goats and then they tell you that against person they're having like fever for a while has like pneumonia has like maybe endocratitis or meningitis again the thing is for these things you just want to be able to recognize the associations right this is q fever from coxular bone adi okay and for the most part um you need to go ahead and uh you know consider like doxycyclerin or again you can give a marker in it right and then if a person has early ciosis for person has early ciosis um again it will be a person that you know probably had like a recent like tick bite right and again fever meningitis they need be septic um really for the most part to you know you go ahead and again give doxycyclerin for lecyosis and again remember if a person is less than eight years old he doesn't matter they still get doxycyclerin for lecyosis um any you can use right fan pin but um go with doxycyclerin when you're test that's essentially what i'm saying here and here's the thing if a woman is pregnant and she has early ciosis you still give doxycyclerin okay doxycyclerin is the drug of choice for treating every kind of early ciosis you want to be able to compare and contrast this with um with um uh we're also thinking about rocky mountain spotted fever rocky mountain spotted fever everyone gets doxycyclerin doxycyclerin is the drug of choice for treating all kinds of rocky mountain spotted fever with the exception of a pregnant woman if a woman is pregnant the way she'll work in mountain spotted fever on dodo circumstances is with um chronic clinical that's literally like the only indication for chronic clinical that you'll see on your shelf exam right

and then if they give you a question about a patient that goes to Hawaii right um and then maybe they swam in some waters in Hawaii and then they have like conjunctival injection they have like generalized lymphodermapathy they have like fevers you want to think about leptospirosis right from like leptospiror and terrogens right and again because it's a spirochet you can actually see pretty well on the dark field microseopy and again for the most part because it's a spirochet response extremely well to penicillin okay extremely well to penicillin but you can also give doxycyclerin and then if they give you a question about a patient that you know like maybe works around rabbits or was bidding or was bidding by a rabbit and the person has like liver function test abnormalities has like fever has like a rash i want to think about a francicella tolarensis okay this thing can actually be used for bioterrorism right exactly one of those weird bizarre things you want to keep at the back of your mind for your exam um and really for the most part um you can again try with doxycyclerin although you can also use an amino glycosyl legendomycin or nyomysin or streptomycin for for uh tolaremia and again remember the association with rabbits and then rechetsy rechetsy are already talked about this for the most part again everyone gets doxy including if you're less than eight years old well if you're pregnant you get chloramphetico okay and it will be a person from like North Carolina that's like the classic geographic association on mbim exams and you have like very high fevers you have like diarrhea they may even have like some cbc abnormalities like thrombocytopenia and anemia you need to treat Rocky Mountains body fever like quickly because the mortality if a mom is taking it is like a hundred percent if it goes untreated right they go on treated so the person comes in in july

and they have like a non specific fever and you leave like in North Carolina or anywhere around North Carolina like like Georgia and things like that go ahead and give those people a doxycyclerin and then ask questions a leader and the thing is rechetsy are species there's this test known as the will philic test I don't know for whatever reason the mbim loves this stuff they eat this stuff up right so the will philic test is like you detect like I think like proteus ox 19 antigens or something like that uh that's actually something you can use in the potential diagnosis of like rechetsy are species right so that's something high you do actually want to keep at the back of your mind for exams so I think I'm going to go ahead and um um move on but actually you know okay let me say something because I don't know for whatever reason Rocky Mountains body fever they love to test this stuff on exams right so the thing is people that have Rocky Mountains body fever they will have a rash and the rash here is a very high ill thing to know the rash starts on the pumps and soles and then he spreads towards the trunk right that's kind of unusual right most other rashes these starts on the trunk and then can express to the pumps and soles not so with Rocky Mountains body fever they'll start on the pumps and soles and they'll express centrality right towards the center of the presence uh but right so you'll have the rash you'll have fever and you'll have like a again a recenting bite and again it'll be a person that's like Georgia North Carolina Tennessee uh Missouri Arkansas if you see those things think about Rocky Mountain spotted fever okay and again on labs these people may have like anemia they may have like low pleaklets they may have like hypoinitremia right and again like I said doxycycline for all ages and then if they give you a question about a person like Boston or New

York or Maryland or New Hampshire or something like that right and then the um you know you kind of see like a bullseye rash on an extremity think about Lyme disease right remember Lyme disease is carried by the spirocheta borerella bodeur free right and the vector is like the exodistick and Lyme disease right he has like many different stages there's like three stages but the only stage you probably really care about on endemic exams is stage one and stage two stage one is the bullseye rash right uh the arithema chronic on migrants um arithema chronic on migrants you feel it with doxycycline right and vision is fun if the vision is less than eight years will you give a moxicillin okay eight years or less a moxicillin on exams and again don't forget the astro the northeast right like Maryland Baltimore Boston New York stuff like that right New Jersey kind of deal and then second stage of Lyme disease right they can have many weird things happen they can have like heart block right they can have bilateral bells policy they can have um a rash on the um they can have like uh like kind of like a disseminated rash on the skin they can have like a throgeus and all that stuff right um so if you see that again think about a secondary Lyme disease the thing is the only second like let me just maybe make it simple for your next exam if a person has secondary Lyme disease and they have like the a throgeus give doxycycline right but if the person is beginning to have any cardiac manifestation of Lyme disease like like endocraditis or myocarditis or heart block or they have like neurological Lyme disease like the bilateral bells policy or they have many anxiety so anything like that the drug of choice is septriaxal okay the drug of choice is septriaxal if you don't see septriaxal as an answer choice on your exam you can consider uh picking um acetal taxis septal taxis is another l

ike notable third generation septal aspirin you can use for that on mbim exams right and really the way you make the diagnosis of Lyme disease where you do an elisor first that's the screening test and then after that you do the western blood as a confirmatory test you can also do PCR but that's not available in many in many hospitals and again like I said Lyme disease doxy for everybody if you're less than eight years old I'm oxycyling if you have like neurological Lyme disease or cardiac Lyme disease you get septriaxal okay and then early killcis right again like I said um um it's kind of like a non-specific presentation but I think maybe like the one thing I've not mentioned is remember the association like the lone start tick okay the lone start tick and usually for whatever reason both I have a Lyciosis they tend to have again like fever fever is very non-specific right but you see a person like fever diarrhea and like severe abdominal pain um go ahead and think about early cure uh chaffyenses um early killcis and again it's carried by the lone star tick right and again these people tend to have like again CBC abnormalities like anemia thrombocylopenia kind of deal on exams and again you treat with doxycycline okay you treat with doxycycline um for the most part pretty much everyone that has a Lyciosis gets doxycycline even if you're pregnant the only exception to that rule is if for example the person has like some weird bizarre ridiculous reason why they cannot tick doxycycline then you can consider right fanping in those people on mbim exams and then I've kind of talked about uh uh frenzy cellulatoral arensis right remember the association with uh with rabbits right and remember it can cause like how do I put it like the way we present is it can cause like ocular infections right so the person will have like sometimes they call it like a oculo glandula or what

ever blah blah blah or you can see like the person having like painful osters on the skin right um where like you have like a bite from the uh uh you have like a back from a bite from the rabbit right so if you see if you just see rabbits think about frenzy cellulatoral arensis and the thing is again because it can be useful by your terrorism if you're doing like diagnostic testing for frenzy cell uh you actually want to be careful as the person in the lab that's actually one of those bizarre again like behavioral science styl things in the test on you exam and really the way you treat uh uh uh to larimia is you actually use uh an aminuk like osyke where you can use like gentamysin or you can use streptomysin what again if you don't see that as an answer choice doxy doxy doxy so it's a safe answer now what if you get a question about a patient that you know maybe works for the FBI or works for like a natural security agency or let's see this person uh you know works with like cow hide or works in like a wool sorting facility if you see that right and then they tell you that oh this person has been having him up to sis and then they tell you that on imaging like on a chest texture you see a widened beauty spider if you see that what are you thinking about right i hope you're thinking about like um anthrax right bacillus and threesis um remember bacillus and threesis is a spore it's like a spore based uh disease right and again people get it like okay from my bioterrorism you can get it from um you can get it from um what is it called from in healing like animal hide or working with um what is it called uh working with like wool right so like that's why it's called like wool sorting disease if you see that think about anthrax and anthrax right the two primary things you want to know is they can have like cutaneous anthrax where you know they'll have like this macula tha

t sort of develops on their skin and then it then becomes an ulcer and then it kind of becomes like a black eschar and then it kind of like falls off after a couple of days and if you see that that's like cutaneous anthrax most people tend to recover from that so that's good right what pulmonary anthrax is awful it's terrible right uh it causes like a hemorrhagic medias the night is right so your indisection is not the only thing that can cause widened medias thino or uexam you can also see a widened medias thinam in a patient that has anthrax okay because again anthrax bacillus and threesis causes a hemorrhagic medias the night is right and the way you treat this is you give the patient c pro and meropenem okay c pro meropenem in fact here's the treatment regimen remember the term cml okay cml c pro meropenem and lenezolid on your test okay but the thing is if for example they don't give you that combination on your exam just give the person some kind of fluoroquinolone okay some kind of fluoroquinolone or they affectionately loved doxycycline okay but i'll see that the most common answer choice for the treatment of anthrax on mbme exams is c pro floxycy okay the fluoroquinolone is actually very good drugs for the treatment of for the treatment of anthrax okay for the treatment of anthrax and then i think the last in our mention here especially with Lisa Zwanodica diseases what did i want to say just if a person has like neck like almost like necrotic draining like lymph nodes like in your groin or in many parts of the body think about the bubonic plague the bubonic plague just remember that it's caused by your cemia pestis i think that's what i'm going to see with that and really this infection you treat it with with an amino glycoside right remember you have an amino glycosides and drugs like gentamysin neomysin amicasein to bramycin and streptomysin where remember

that those drugs they cause like a combination of auto toxicity and nephrotoxicity and the thing is your friends at the mbme they actually kind of like you to know drugs that have that unique combination of causing auto toxicity and nephrotoxicity remember you amino glycosides can do those vancomycin is also nephron auto toxic in addition to also causing a red man syndrome cisplatin right remember cisplatin is a platinum analog it prevents a cross-linking you can know many causes cross-linking it also causes nephron auto toxicity although the nephrotoxicity you can prevent it with a drug known as amethostate right and they remember the look diuretic ethycrinica as you remember it's that look diuretic that does not have so far allergies associated with it they can also cause nephrotoxicity now what if they give you a question about a patient you know that has like severe bone pain like their burns everywhere just hurt like like crazy right and then this person has like massive hepatosplenomegaly and this person has like very high fever and let's say that okay maybe they traveled to like some southeast Asian country or some African country what are you thinking about well I hope you're thinking about dengue right dengue fever remember for the most part you get it from like the aides mosquito these people right like when they have this a dengue they can actually have a ton of himolysis of their red blood cells so actually one very high-yield thing you want to keep at the back of your mind for the USML exams with a person that has dengue is you need to check their blood counts regularly right you need to check their blood counts because the thing is they may occasionally because it's almost like a hemorrhagic fever kind of deal they may occasionally require like blood transfusions right they may require like blood transfusions or like platelet transfusions right and the

thing is you also don't want to give these people like aspirin on insets right because these people are pretty supposed to like thrombocytopenia right so if they already have like low blood counts I mean low platelet counts I think give them a spring so whatever little platelets they have you then render them like important pretty much those patients can get into a lot of trouble right so you don't want to do that on your exam and then if you see like a somewhat like I don't think there is maybe like personally I don't see like a big difference between these two diseases I feel like they almost present identically right so if you see like a dengue like presentation on your test and you don't see a dengue answer think about chikungunya okay chikungunya how does this spell the things like CHI shikun so CHI KUN, GU, N, Y, A, CHIKUN, right it presents almost identically to to to dengue fever right so that's really like all you can do is like so what if care many of these diseases I'm going to talk about now there's really no good treatment for them unfortunately so like all these like abo viral style infections right and then zika zika is something that is definitely at least over the last couple of months to like two years has been making its way quite commonly on the nbn exams right so the classic presentation of zika already is a person you know they'll have like like you know like fever they'll have like a rash they'll have like you know like conjunctivitis so they'll have like conjunctival injection they'll have like severe joint pain and here's the thing you're almost always being a pregnant patient on your exam okay you're being a pregnant patient on your exam and then they'll tell you that oh she delivers a new one with microcephaly right like very small hits or confronts if you see that think about zika virus there's really no treatment unfortunately it's just so

polyph care zika can also cause giomberry syndrome right so that's one of those like weird associations you want to keep at the back of your mind for exams and then if they give you a question about a patient that you know let's say you know they again come back from a foreign country and then they tell you that they have like like a very like so pay attention to this cluster of symptoms right this person has a very high fever let's say the temperature is like 103 kind of deal and then they have severe abdominal distension they have severe abdominal pain and then they are pretty cardiac and then they tell you that oh like after a few days of having these symptoms you see like a salmon so like S-A-L-M-O-N like a salmon colored lesion on their abdomen on their trunk sometimes they call it like row spots on the abdomen if you see this you want to think about typhoid fever okay typhoid fever is caused by salmonella typhi so sometimes you may see it referred to as salmonella typhi okay they have typhine in the name because they cause typhoid fever please do not confuse you with salmonella in terrier it is salmonella in terrier it is what causes bloody diarrhea when you consume like poetry or eggs and things like that so if you see a person that has like high fever but they have like pretty cardiac and then they have like row spots on the abdomen severe abdominal distension think about typhoid fever and the thing is typhoid fever actually responds pretty well to fluoroquineolones right so you can put these patients of fluoroquineolones like cyprophloxacin or you can put them on like septal axoncypteraxon also works pretty well for these people another thing you can also do is if for example you know the patients like super super sick let's say like their comatose or the delirious or they have like dic stals symptoms you can actually go ahead and add that dexamethosum to th

e to the atherapy right you want to go ahead and add that dexamethosum to the atherapy and then if for example you know they tell you about a person that for the last couple of days you know let's say they again maybe they didn't get vaccine uh vaccine they didn't get vaccination let's say it's like a missionary or you know so on that travel so foreign country and then they come back from that country right and then let's see maybe they were not vaccinated appropriately before they left and then they come back and they tell you that you know they've had like a flu like illness and then after a while they start having like hemoptosis and then they tell you that when the vomit like the vomited tone when the vomit is like black when you see like black MSS and you see like heavy proteinuria so they have like a lot of protein in the urine and then these people subsequently die you want to think about yellow fever okay you want to think about yellow fever remember yellow fever is a flavy virus there's really no treatment it's just a body of care and then you hope for the best and then if they give you a question about a patient that you know consumed pork right and then this patient is like having seizures um especially again tone from like a developing country think about neurosis or causes right like uh neurosis or causes for the most part um these people if they have seizures I want to go ahead and just give them like an anti-pileptic agent um like um like phenytoine for example but if you want to treat like uh cystic or causes and one thing you can do is you cannot free give a prezy quantel you can give prezy quantel um again if a person is having like seizures or like signs of meningitis and civilitis in addition to the prezy quantel you want to go ahead and um um um steroids to their drug regimen in fact some people just get steroids because by getting prezy quantel t

hey can have like very severe uh it can get very severe symptoms right and really the way you can make the diagnosis because like most of these things are calcified you can actually see them pretty easily on a non-contrast the CT scan of the head and then if they give you a question about a patient um um you know that comes let's say again comes to the US from like some African country and then they tell you that this person um you know has like like a painless ulcer like somewhere on their body right and you know like they'll write this question nicely like you'll be a person again coming from my African country they won't or it'll be an immigrant they won't say anything about the person having like you know like risky sexual behavior those who are like oh painless ulcer painless shanker painless shanker syphilis no syphilis is not the only cause of a painless shanker right so if you see a question about a person some immigrant you know they tell you that oh you know they've had like uh uh they were maybe like bidding by something right and then they tell you that oh they had like this like painless ulcer somewhere on their skin and then after that they start like you know like having like these fevers that common goal fevers that common goal right and then they tell you that maybe the person's family starts to think that okay this person starts behaving like weird right like the person is like very somnolent not very responsive and then this person like you know ultimately becomes like comatose and dies right if you see that um think about um sleeping sickness uh you get this when you get bit by the cc fly um this is like uh uh they call it like African tripe anus tripe anus somiasis right so like sleeping sickness and if you see this that's like a classic presentation in general treatment is very difficult i mean you can consider using like a drug like pentamidine

but that's like the classic presentation again immigrant painless shanker initially starts having fevers that common goal and then after that the person uh you know that's why it's called like sleeping sickness vision is kind of like sleepy sleepy right so they have like um they're like somnolent they become comatose and then they ultimately die and think about a tripe anus somiasis and then don't forgets like tripe anus somarkruzii right like this thing causes like big problems you know people tend to get it from when they get bit by the by the red of it bog some people call it like the kissing bog um and really for the most part the way um um t-cruzii i mean t-cruzii causes many problems but like if they are testing it from like an emergency medicine perspective it'll be a person that um it'll be a person that you know comes in and you see that oh that you know they have like a dima around one eye okay so they have like a unilateral pair uh period a bit of a dima and then they'll have like like the place where like the uh they were bit by the bog they'll have like a very painful like that place will be swollen i'll be like super painful if you see that think about shagas disease right so and really shagas disease you can treat it like your uh big uh you can treat it like your bend azoths right or you can use this drug known as a my 40 mox so n-i-f-u-r-t-i-m-o-x my 40 mox can be used to treat um can be used to treat uh shagas disease remember t-cruzii can also cause like a dilated cardiomyopathy right it can cause a ecalicia right and it also cause herch problems disease those are all high-oed associations you want to keep at the back of your mind uh in a person that has a t-cruziia infection right and then if they give you a question about a patient you know that's from like Egypt and this person has been having like a lot of hematuria i think about she's to some uh

she's to somai acids right like uh remember the vector is like the snail okay uh the larvae are kind of like released into like water by snails and then come in contact with that and then get into trouble right or these people may have like hematuria right basically the reasoning behind this is that she's to soma uh like hematobium it also like you know take residence in the presence bladder right so it can even actually increase the presence risk for like bladder cancer right but if you see like hemorrhagic cystitis in an immigrant's vitro zone from like Egypt think about she's to somai acids or an embankment exempt and then if they give you a question about a patient again that has bloody diarrhea elevated your xenophils and liver abscess think about entamibe histolyrica okay entamibe histolyrica and remember it's part of that get up on the metronomonic so you can treat it with metronidousol right and then if they give you a question about a patient that you know maybe travel to a foreign country and eat a lot of like roadside folds you know they really want that to integrate into the culture and in the detail that when the person comes back they have like weird symptoms like they have like this weird pneumonia they have like this dry cough they have like elevated your xenophils because guess what this is a parasitic infection what it may tell you that this person has like you know like constipation and um like you know like really bad constipation because they're not real like they almost have like small bowel obstructive style symptoms think about um infection like astary slombricoides okay think about infection as astary slombricoides the thing is the box sometimes they can go through your lungs right they can cause something called like a loveless syndrome where you have like a pneumonitis so that's why the person may have like a pneumonia you have like a dry c

ough you have like a use like use a philia because the parasite right and these things they can pretty free so much you can have like such a large one-boarding um if you look up pictures of this if you want to like really mess up your day look up a picture of like ascaris being put up from a child's ass it's just it's probably the most awful thing I've seen in all of medicine um I mean I've not seen it physically but I've seen it like in pictures and those pictures have left like an indelible mark on my mind you're just terrible terrible terrible I really the way you treat this is you treat because it's a worm you should it would like your bendazol so you can use like a bendazol me bendazol thia bendazol where you can use a drug known as ivermectin IVER MEC TIN and you can use ivermectin on nbm exempts and then if you give your question about a child and you think that this child comes to these mom brings him to the ED because he's like each and his ass like all the time right each and his ass all the time are you want to think about like the like a pin worm infection uh pin worm infection um it's caused by interrobial vimicularis right so interrobial interrobial have hemicularis and one nice thing your friends at the eminem love to test on the exam is how do you make the diagnosis the thing is to make the diagnosis you use this very technologically advanced test uh it's it's not really technologically advanced I'm just making a joke here but basically the thing that happens is you take like scotch tape it's called like the scotch tape test you take a scotch tape when the kid is eating at night you know you just go ahead put a scotch tape and then peel it off and then you look at it under the microscope and you see the you see the box right you see the box if you see that's that's pin worm infection and really you can treat it with like a bendazol or maybe bendazol um

you can use a drug known as a parentele pammal it but I'll say for the most part you see any of these worm infections think about your bendazol as treatment right and then if you give your question about a patient that you know has like abdominal pain has like iron deficiency anemia and they may tell you that oh maybe this person was like uh is like a house builder and maybe was like working on the ground for a long time and they may tell you that oh you see like like a weird bug burrowing under the person's skin if you see that you want to think about some kind of hookworm infection right hookworm infections typically on imbiim exams you have like a very nice association with uh with iron deficiency anemia right so if you see hookworm infection uh think about like nekator or ancelostoma as the causes right and again it's a worm so you give the person a bendazol right you can really for most of these one infections you can use like your bendazols or you can use the drug again known as pirantel pammal if I feel like uh back when I grew up a little pirantel pammal pammal if was used that quite a lot that's why I kind of like know how to pronounce it really well um I've seen tons of people use use this drug and then remember your tapeworms right tapeworms can cause a lot of problems right like remember like die filibutrium lardum it can cause like a megaloblastic anemia uh you can essentially cause like a bit of deficiency and then don't forget like your tina sodium from like on a cook pork or like tina saginatum from like on a cook like beef right these people have like diarrhea uh and this thing the thing is these are cis can like go to the brain they can go to the muscle they can go to many many areas of the body and for the most part like these tapeworm infections like these tina infections you can treat them with a priziquantel okay you can treat them with priziqua

ntel and then don't forget that trichinella trichinella spirales um trichinella spirales loves to hang out in muscle that's all I think you'll probably ever see tested on a one trichinella on your exam okay so um let's see let me try to finish this topic let me try to finish this this is going on for a long enough so really the last things I think I want to see here is um um what if they give you a question about a patient and this patient you know recently got like some kind of stem cell transplant and then this patient comes in and has like a rash like all over the your skin they have like a rash and then um they tell you that they have like diarrhea like a rash and diarrhea after like a stem cell transplant the big thing I want to think about is uh is uh gravestones host disease right this is something that can a patient can present to the idiot with and how do you treat it right for the most part um you know mostly supportive care and then you give them like steroids right like predisone um and then for the most part you continue whatever immunosuppressant arrangement they've been placed on and then if they give you a question about a patient that has like a liver transplant like a recent liver transplant and then this patient starts completing of like severe abdominal pain um and they even have like a botquiarri like syndrome presentation from like hepatic artery thrombosis uh hepatic vein thrombosis or something like that uh and then they tell you that oh they have like signs and symptoms of peritonitis think about a bowel leak okay a bowel leak is a very common complication of liver transplants and the mortality is actually pretty pretty high um for the most part those people need to go back to surgery uh they need to go back to surgery they need to go ahead and uh uh you know like do whatever your attachment you need to do but surgical consultation is your nex

t type of manipulation when you suspect the bowel leak and the thing is a bowel leak is actually one of those nice things that you can also diagnose with a high-disk scan that can be an unusual answer choice on in-beaming exams you can make the diagnosis of a bowel leak with a high-disk scan and then remember that bK virus like the bK polium of virus lots to cause infection in people that are recent like a renal transplanter patients so that's a big thing when you keep at the back of your mind and then if for example a person has like a recent heart transplant right um if you're having like you know like rejection of the transplant if they come into the eG you want to study them on like pretty high dose uh methyl predensalone right like IV corticosterotherapy um the thing is if for example the person is having like a brady arrhythmia right so you know they just recently had a heart transplant and um you notice on in-beaming exams that oh their heart rate is like profoundly low is like in the 40s or something and they ask for your next step in management they'll try to trick you into giving an atroping because usually atroping is what you give for brady arrhythmia on in-beaming exams but in this case for a person that is a post-heart transplant person you actually don't give atroping you give isoprotarynal remember isoprotarynal is a better one and beta two agonist okay it's a beta one and beta two agonist right so that's what you do on in-beaming exams and um I mean if a person is having like cardiogenic shock and again they have a heart transplant give them like a dubiotomynes like a beta one agonist that can help or you can give like dopamine um that can also help you can give me a re-known remember me re-renon is a post-photitis raising inhibitor that can help on that those circumstances um so I think for the most part um I think I've kind of talked about all I wan

t to talk about here so I think I'm gonna go ahead and post here as a long one that's more than two hours probably takes the kick as probably one of my longest podcasts not videos but podcasts right so um as I do at the end of every podcast I don't offer one or one to learn from any exams right so like step one step two C key step two C step three uh pre-tranical med school exams 30-ish off exams if you're a medicine resident I tutor for the internal medicine including an exam the ABIM internal medicine board exams um I also do this then I call on student tutoring if you're like a first second or 30-amid student out to do it for like your block or shelf exams and then I tutor for your upcoming USMLE exams again people have done this with you've been like wildly successful on the USML Es and then I do like this then I call a booster course right it's like 10 hours for step two C key and step three or 20 hours for step one um where um it's something you do like you know when you want to like put everything together like at the end of the day get a period um basically in a Q&E format like rapid fire um we essentially cover like the high heels like the most nose for the exam and again most people have done this with they have absolutely loved this they found this to be like super fruity they've been like oh divine many of these things went over in that short time frame like represented like a ton of the questions that I saw my exam right so again if that's something you're interested in feel free to reach out to me and then I'm also offering like a group USMLE course if you have like a group of five or seven people and you all are in and really if you're like really like you all are in amongst yourselves and you have like a location where I can come and meet you for like a two week period um for any of the USMLE exams I continue for that um that you're probably want to rea

ch out to me via email really for all these things if you're interested in any of them reach out to me via email and then I'll point you in the right direction in terms of exactly how you structure that course that's something I'm going to make available over the next couple of months at least the next six to eight months and then if you're a med student applying for like residency so like an ERAS app or a college student applying for med school so like an AMCA SAP I'd offer like one-on-one coaching like mock interviews personal statements reclators edging applications and kind of deal and then if you have like a college buddy that needs to learn for like Gen CAM, O-CAM, physics, biochem, histology, physiology of a student for all those things so thank you for listening to this podcast I know this was a long one but essentially if you master everything in this podcast I will be extremely surprised if there is an infectious disease question and I you see on your exam that you get rock I mean there's still some ideas to fall on to talk about but I think they're probably best discussed in another format but I feel like I've made so many errors into infectious disease with this podcast so have a wonderful rest of your day I'll see you in the next podcast God bless you thank you

Skin findings, such as tenosynovitis (TKI) or pustular rash, often involving the palms and soles.

Nucleic Acid Amplification Test (NAAT), not Gram stain.

Gummas, carditis (cardiac involvement), and neurosyphilis (meningitis/meningoencephalitis).

Norepinephrine.

C = Ceftriaxone, A = Azithromycin, L = Levofloxacin/Moxifloxacin, V = Vancomycin (plus Clindamycin).

Treponema pallidum.

Erythema migrans (EM), which can appear as a bullseye rash.

Cryptosporidium parvum or Cyclospora.

Urethritis, conjunctivitis, and arthritis.

Benzathine penicillin G administered intramuscularly.

Staphylococcus aureus (S. aureus).

Non-treponemal test (e.g., RPR) as a screening tool, and Treponemal test (e.g., FTA-ABS/MAT) as confirmatory.

Vancomycin (or Fidaxomicin).

Puncture wounds, contaminated wounds, or injuries from sources like animal bites.

Vancomycin (or Metronidazole/Fidaxomicin).

Varicella lesions appear in different stages of healing; Smallpox lesions tend to be uniform, large, and all at the same stage.

Penicillin or Doxycycline (or Ceftriaxone).

Meningitis/meningoencephalitis and peripheral neuropathy.

Streptococcus pneumoniae (Strep Pneumonia).

Urethritis, conjunctivitis, and arthritis.

Benzathine penicillin G administered intramuscularly.

Staphylococcus aureus (S. aureus).

Non-treponemal test (e.g., RPR) as a screening tool, and Treponemal test (e.g., FTA-ABS/MAT) as confirmatory.

Vancomycin (or Fidaxomicin).

Puncture wounds, contaminated wounds, or injuries from sources like animal bites.

Vancomycin (or Metronidazole/Fidaxomicin).

Varicella lesions appear in different stages of healing; Smallpox lesions tend to be uniform, large, and all at the same stage.

Penicillin or Doxycycline (or Ceftriaxone).

Meningitis/meningoencephalitis and peripheral neuropathy.

Streptococcus pneumoniae (Strep Pneumonia).