DIP Episode 547 - HY Basic Sciences for Step 2 and 3

Welcome to episode 547 of the Divine Intervention Podcasts. Into this podcast we're going to be addressing a topic that's pretty high-yield. I'm going to title this podcast, Basic Science for the USMELIS Step 2, Seek & Step 3 exams. Basic Science for the USMELIS Step 2, Seek & Step 3 exams. Here's the thing. Our friends are the MBM Es, you know, especially after Step 1 became pass-field, they started putting on a ton of basic science on Step 2 and Step 3. So, I feel like these days, the basic science really throws a lot of people off. So, with this podcast, I want to try to address a lot of those high-yield basic science things that, in order to help you brush up some stuff from Step 1 you may have forgotten, but not just that to just help you know this material well, and know it in the level of detail that you want you to know it for the USMELIS Step 2, Seek & Step 3 exams. Alright, so we're going to jump right into it. So, what if they give you a question about a patient? They tell you that this patient has a history of microsity, canemia, and the patient's reticuloside count is extremely high, and that this person has required multiple transfusions, multiple transfusions. And then, they tell you that this person, do you ask you a question like which of the following should be done to reduce this person's risk of negative long-term outcomes? Well, I hope you're saying that, oh, divine, this person should get some kind of iron kill later.

So, what's going on with this person? Well, this person clearly has thalasemia. Remember thalasemia is a microsity canemia. It's one of those high-yield microsity canemias that will be associated with a higher retic count on the exams. Because in thalasemia, doesn't matter which one it is, especially if you have a severe enough kind, you're going to keep burning up your ret cells, using them or destroying them, so your body is going to, your bone marrow is going to really try to keep up. And because you have a lot of reticent destruction, your bone marrow to keep up, what it's going to do is it's going to try to pump out a bunch of immaturity blood cells, a bunch of reticulosite. So, if you see a person that has a microsity canemia with a higher retic count on your test, you really should be thinking about thalasemia. And if people have thalasemia that is severe enough, they're going to require repeat transfusions. The thing is, when you have repeat transfusions, that can cause iron overload. And that iron overload can cause a bunch of problems for you. Because remember, iron can trigger this free radical reaction known as the fentin reaction. That fentin reaction can give you issues. So, these people can generate free radicals that can damage many things, right? Damage the hearts, damage the lungs, damage your pancreas, damage many parts of a person.

So, this is part of why a person that is getting repeat transfusions to prevent volume of, I mean, an iron overload, they should get an iron killiter, like deferroxamine, deferroxamine, or you can use deferaserox, deferaserox, deferaserox. And obviously, this same principle applies to people that have hemocromatosis, because remember, hemocromatosis, we know that that's an autosonic recessive disease. You were absorbed a ton of iron from your gut. Again, that iron can cause ferritic odamage. So, those people should consider phlebotomy, that's the primary treatment. But don't be surprised on your exams. If they make you get a lot of work, they're going to get a lot of work to do with it. So, if you're a primary treatment, but don't be surprised on your exams, if they make you give those people iron killiters, again, like deferroxamine or deferaserox. And since we're discussing this topic of iron killation, let's not forget the anthracyclins, the drugs like doxorubicin and donorubicin. Those are anti-cancer drugs. Those drugs, they have a bunch of mechanisms, right? They inhibit topoisomerase, they intercalib between DNA, they do a bunch of things. But one big thing to know about, and they also do some things against DNA synthesis. But one big thing to know about those drugs is that they can cause an irreversible dilathecardiomyopathy. An irreversible dilathecardiomyopathy. And that has an association with this iron, ferritic odamage and all these problems.

So, one of the ways you can fix that problem or prevent that problem is to give the drug dexorosoxin. Dexorosoxin is spelled, D-E-X-R-A-Z-O-X-A-N-E. Dexorosoxin. It's a very amazing drug, very phenomenal drug. It's an iron killator, but you can use it to prevent the irreversible dilathecardiomyopathy. That's associated with a person having a, you know, taking a doxorubicin. And then, what if they give you a question about a patient and they tell you that this patient has, you know, is a sex worker. And this person has had, you know, let's say it's a sex worker, it's a female, and he showed you a picture of like an ulcer, a closer revolva, and he tell you that the ulcer is painless. And then, they tell you that the patient is started on pharmacotherapy. And then, three hours after pharmacotherapy started, the person has this, like, a rash that develops on their skin, they're hypotensive, they're diiferritic. What should you be thinking about here? Well, I hope you're seeing divine. This sounds a lot like the Jarish Hexheimer reaction. Okay, so let's talk about the Jarish Hexheimer reaction. Remember, the Jarish Hexheimer reaction. It's pretty much a reaction that happens when you take a cell wall inhibitor, especially penicillin. Many times on the USML is they love to test it in the context of a person getting penicillin for something. So, because remember penicillin is a cell wall inhibitor. This is actually something you want to lock down in your mind for your test.

Penicillin is a cell wall inhibitor. It inhibits transpeptidase. Because remember, transpeptidase is an enzyme that helps us make the bacterial cell wall. So, if you inhibit a transpeptidase, then you will not form the bacterial cell wall. And if you don't form the bacterial cell wall, that's going to be amazing, because you're going to pretty much prevent the bacteria from having any kind of outside structure. So, the thing is, if a person takes penicillin and you inhibit the cell wall, then the cell soup, the stuff that's inside the cell, is going to be released into the bloodstream. That stuff that's released into the bloodstream can trigger a very powerful inflammatory response. That's what we call the Jarish, J-E-R-I-S-C-H, hexheimer, H-E-R-X, H-I-H-E-I. So, H-E-R-X, H-E-I-M-E-R, Jarish-H-Xheimer reaction. Again, we tend to see that with cell wall inhibitors. We tell you to see that with cell wall inhibitors. And so, if you may be wondering, what disease did this sex worker hurt? I would really hope you're saying, oh, divine, this sex worker hurt syphilis. This sex worker obviously obviously had syphilis. Remember, syphilis is trapolymapalida, that's a spirochet. One of the awesome ways we handle syphilis on the exams is with penicillin. And don't forget your older, high-yield spirochet. The thing is, I don't know for whatever bizarre reason. A friend at the NBM Es for step two and step three, especially, they really love their spirochet.

In fact, they love them so much that sometimes on your test, instead of putting the actual bug name as an answer, they'll put spirochet as an answer. So don't forget syphilis trapolymapalida is a high-yield spirochet. Another high-yield spirochet to know for you exams is Borrelia Bokdufri. The bug that causes Lyme disease. Borrelia Bokdufri is a spirochet. Another one you may see this with like a Hawaiian association, think about leptospirin tyrogens. Leptospirosis, leptospirin tyrogens is also a spirochet. And I guess this is, again, just high-yield. There's all the spirochet, obviously. But those are three very big ones you want to make sure you know for your exams. And then I guess since we're kind of talking about penicillins because anti-phatic mechanism of actions are very, very high-yield to know for your exams. What are some other penicillins you probably want to know for your exam? Well, don't forget certain things like the differences between penicillin G and penicillin V. Right? Penicillin V can be given orally penicillin G can be given IV. You may wonder why say that we don't give penicillin G orally? Well, the thing is penicillin G is not very acid-stable. Your stomach acid is going to absolutely obliterate it. So it just generally makes sense to give penicillin V if you're trying to go the oral route. But if you're trying to do IV penicillin, just go ahead and give penicillin G penicillin G can be given IV. And penicillin covers a bunch of things, right?

Like penicillin covers strep pneumo very well. Covers were based strep, strep biogenes covers it very, very nicely. Even you know, amoxicillin is another example of a penicillin. Amoxicillin is a very good penicillin because we can use it for many things. You can use it for certain cases of pneumonia, believe it or not, for patients back to your pneumonia. You can use amoxicillin for that. You can use amoxicillin for ear infections so they can give you that in the context of a person having acurotitis media. You can give that person amoxicillin as the first line of the way if amoxicillin doesn't work. You should consider amoxicillin plus clavolaniac acid. That's going to be a second-line agent. That's augmenting. That's going to be a second-line agent in those circumstances. So amoxicillin is pretty high yield. It actually covers a fair number of things. Believe it or not, amoxicillin is pretty good at covering gram positives and gram negatives. So you can use it for many different kinds of infections. You can use it for many different kinds of infections. Another penicillin that's high yield to noise and picellin. Amoxicillin is pretty high yield for many things. The big, big, big thing to know about amoxicillin is we see it in the treatment algorithm for, come on, divine thing, for Choremionitis, right? An infection of the amniotic fluid. Remember this is a C genomonic with that, right? The C for Choremionitis is going to be treated with amoxicillin and gen tamaisin.

And something you want to keep at the back of your mind for exams. And another thing, again, with ampeicillin, again, is listeria. Ampeicillin is amazing for listeria. In fact, ampeicillin is the drug of choice for listeriosis of any kind. In fact, this is why if you have a neonate that has meningitis or a person that's over 50, that has meningitis, and you want to treat their meningitis empirically, typically we're going to put them on safe triaxone plus vancomycin plus ampeicillin. Why do you think we put them on ampeicillin because it covers listeria? Because remember, listeria can cause meningitis in neonates. That's the first 20 days of life. But listeria can also cause meningitis in people that are over age 50. And if a prescience listeria meningitis and you're not treated, the risk of death is almost 100%. Ampeicillin is the drug of choice for the management of listeriosis, and prescience is the drug of choice for that purpose. And I guess since I talked about amoxicillin a few seconds earlier, I should also not neglect that amoxicillin is also part of the triple therapy for a person that has H-pilory. Remember, there's this nice nomonic, the capnomonic for H-pilory treatment. This claritromycin, which is a macrolid, there's amoxicillin, which is a cell wall inhibitor, inhibits transpeptidase, and then you'll use a PPI, a proton pump, inhibitor.

Now, one thing I certainly do not want you to forget is that another name for transpeptidase on your exams is penicillin binding protein. Okay? Penicillin binding protein. Because literally penicillin binds to transpeptidase to inhibit the synthesis of the cell wall. Because one of these gnarly things our friends at the MVM is love to do to people is this. Why use the term transpeptidase, where you can put penicillin binding protein as an answer? So you're just going to keep that at the back of your mind as you're preparing for your exams. And then I guess if we're kind of still talking about penicillin. So these drugs I'm talking about, they pretty much all work the same way. They all in EBB transpeptidase. Think of drugs like methecellin. Think of drugs like napcellin. Think of drugs like oxacillin. Think of drugs like that, that clocks acillin. Think of drugs like clocks acillin. These drugs are penicillin, these resistant penicillins. The thing is, there is a certain enzyme that can be expressed by searching bacteria known as penicillinies. And penicillinies can literally break down penicillins, like the classic characteristic penicillins like regular penicillin or a penicillin or a moxacillin. So if you want to give a person a drug that will not suffer in the presence of penicillinies, you can give a penicillinies resistant penicillin like methecellin. We don't really use methecellin, we use it more for research purposes these days.

Napcellin, oxacillin, clocks acillin or that clocks acillin. So what are the classic things that we use these drugs for? We use these drugs from a stytus, mastytus, mastytus. That's something you want to lock in your mind, for example. We use them for mastytus. You see a woman that has just delivered a baby is breastfeeding. She has a fever, her breast is tender, she has a one tender breast. How do you think of lactation on mastytus? The drug of choice from lactation on mastytus is going to be something like clocks acillin or dichloxacillin or napcellin or oxacillin. So these drugs, we use them specifically to cover MSSA. Methylsins sensitive staphoreus, methecellin sensitive staphoreus. Obviously there's methecellins sensitive staphoreus and there's methecellin resistant staphoreus. Obviously these drugs are not going to work for merstead, they're going to work for MSSA. But again the big, big, big use of these drugs on the exams is for staphoreus lactation on mastytus. Lock that into your brain for your exams. Now the other penicillin I'm going to talk about. Don't worry, there's several sporeins in my comment on those. But the other penicillins to think about are going to discuss this more for just completeness seek. But don't forget things like papyracillin and tizobacter. So peep tizob. Many people know this as zoosin in the hospitals. But to be honest with you, I'm going to tell you this right now.

These drugs you should pretty much never pick them as answers on the USME Ls. In fact, picking these drugs as answers is almost like consulting the ethics committee on your USMEL exams. It's almost like I'm going to get it wrong guarantee. Don't get me wrong, could these drugs ever be used ever? Yeah, but honestly just in my years being intertwined with the USME Ls. And I'm telling you this, I've been intertwined with the USME Ls now for almost a decade. I have never seen this be the right answer ever. I don't know, they just maybe have this personal vendetta against peep tizob. So please just, you need to have some very strong earth shattering reasons to pick peep tizob as an answer on your exams. But since we're talking about peep tizob, you know, because it's like there's the papyracillin part, there's the tizobacter part. There's actually another basic science association on our friends at the MGM is love to kind of throw in here. And I want to use this to introduce that. And that's the concept of a beta lactamines inhibitor. This is one of the best modes of resistance to a penicillin. You pretty much have these bacteria that express this enzyme known as beta lactamines. Beta lactamines literally cleaves the penicillin and makes it useless. Because remember your penicillins are generally called beta lactams. Another name for your penicillins are beta lactams. So a beta lactamines literally chew up that penicillin and that penicillin stops working.

So it so happens that drug companies were wise enough to figure out that hey, maybe we should give a penicillin together with a beta lactamines inhibitor. That beta lactamines inhibitor will go and sacrifice itself and neutralize the beta lactamines from the bacteria. So the penicillin can do its job and kill this bacteria. So what are the classic examples of beta lactaminesis you may see on your exams? Don't you think of clavolanic acid? That's a big one. Clavolanic acid on the USMEL is usually paired up with amoxicillin. Again, many times we're going to use that as a second line agent for the management of acurotitis media. Remember the first line treatment of acurotitis media is amoxicillin. But if amoxicillin does not work, go ahead and slide in some clavolanic acid. The clavolanic acid part is a beta lactamines inhibitor. I know some of these things I'm talking about here. I think that there is absolutely no way to leverage this on step two or step three. Okay, take step two, take step three and come back and report to me. And let's see what you think about that. So just kind of keep that in mind. Clavolanic acid is a beta lactamines inhibitor. So if amoxicillin doesn't work as first line for acurotitis media, if you are clavolanic acid, it actually kind of improves the effectiveness of the amoxicillin. Because it basically makes it resistant to resistant, not resistance resistant to beta lactamines degradation.

Another high-yield beta lactamines to know for your exams is so back time, so back time, so back time. Many times on the USMLE's so back time is paired up with ampecile. So back time is paired up with what? With ampecile, with ampecile. And ampecile is so back time as a combination. Our friends at the MBM is loved to use it for certain infections, right? Like acute mastoiditis, you can use ampecile and solbactam to manage acute mastoiditis. And even that ampecile and solbactam is actually pretty good for managing certain GI infections, right? Certain GI infections respond very beautifully to ampecile and solbactam. In fact, if a child has epiglothitis, that's another respiratory infection. Epiglothitis responds very beautifully to ampecile and solbactam. Remember, obviously, if a child has epiglothitis, what should be your first step in management? I hope you're seeing divine. We're going to go ahead and intubate this child on the controlled conditions. Because those kids, they are always are closing up. They're going to have strider, right? It's an upper-early obstruction. So those people need to be intubated on their controlled conditions. What in the world do I mean by under-controlled conditions? Well, the thing is, many times when you're intubating someone, you feel pretty reasonably confident that, hey, I'm going to get this endotracheal tube down their throats and all is going to be well. No problems.

But the thing is, there are certain situations of life where you kind of feel that, hmm, I'm going to try to put the endotracheal tube down first. But man, if I'm not successful and this person is crushing and burning, I'm going to go ahead and do a surgical airway. You know, something like a crack-authority daughter me. Obviously, you're going to do a crack, hopefully, in a place like an operating room. So when a child has epiglothitis because they have a very ten-watt airway, you generally don't want to just say, let me just do this in any location. You want to do it in a place where you have access to resources in case you need to do a surgical airway. Believe it or not, that may sound like a low-yield point. It's actually a pretty high-yield point to know for purposes of your exams. And, you know, how did I get off on this bitter lactamase inhibitor tangent? Well, it was because I talked about, I remembered, oh, it's Tisobactam. That goes with paparacelin, pip-tisob. The Tisobactam is a bitter lactamase inhibitor. Yeah, but paparacelin Tisobactam is pretty awesome. I don't know why the USM is just don't love it. Covers graven negatives, covers graven positives, covers anerobs actually. Covers anerobs very, very well. Covers anerobs very, very well. Okay, so I think I've kind of hit the penny cellings in a pretty satisfactory tone. So let's go ahead and go to another topic. So what if they give you a question about like a ten-year-old boy?

And this boy has like tremors, has movement problems. They tell you that he has these well-flally movements of his arms. And they tell you that his parents have noticed that he has become very forgetful and he's not doing very well in school. And then they tell you that you check some labs and his LF Ts are elevated. What should you be thinking about here? Well, I hope you're saying divine. This sounds like this child has well-sensed disease. Well-sensed disease. Remember, well-sensed disease is an autosomal recessive disorder. It's a problem in a genunus ATP7 B. ATP7 B. It's an autosomal recessive disease. Another mutation in ATP7 B. When you have a mutation in ATP7 B, you're going to be unable to excrete copper from your liver into bile. So those people are going to have a lot of problems. They're going to have a lot of problems. And you know, typically on the exams, they'll have Parkinsonism. Because the thing is all this copper that cannot be excrete into bile is going to start collecting in many parts of the body. So like you can collect in the bizzoganglia. You can have Parkinsonian symptoms. You can collect in the subthalamic nucleus. You can have hemipalismus. Remember hemipalismus is a contralateral subthalamic nucleus lesion. They have these wild, flailing movements of their arms. They can have dementia. They'll have a lot of LF Ts. Because all that copper, remember, copper can also lead to ferratic odamage. That can damage the person's liver.

Again, don't forget it's autosomal recessive inheritance. Now, what are some things you may see in a person that has well-sensed disease? Well, the first thing you want to keep in mind is their eye finding. If you look at these people's eyes, you're going to see the Kaiser fly sure rings. The Kaiser, I think it's K-E-Y-S-E-R, fly sure. Let me see if I can spell that right. I think that's F-L-E-I-S-C-H-E-R. That kind of sounds like the right spelling to me. But hey, I may be way off here. So the Kaiser fly sure rings. Right? The Kaiser fly sure rings in the eye. So remember, these people have copper excess. So how are we going to fix your problem? We're going to give them like a copper-key leader. So something like penicillamine. Many people remember that with an harmonic copper penis. Penicillamine is a copper-key leader. That's very helpful for well-sensed disease. You can also use another drug known as triantine. TR-T-R-I-E-N-T-I-N-E. Triantine. It's also a copper-key leader that can help. Believe it or not, because the thing is our friends at the MVM is they know that many people have memorized penicillamine, triantine, they know those. Do you know one weird unusual treatment that you may see on your exams? For well-sensed disease, you may see literally zinc as the answer. Maybe like what? Wait, wait, what? Divine, you're going to use zinc to treat a copper excess? Absolutely. Because the thing is zinc competes with copper for absorption in the gut.

Literally, the transporter that absorbs copper in your gut, your GI tract, is also the same transporter that absorbs zinc. If you give zinc, zinc will be absorbed preferentially over the copper. That's a nice effective with a lower-your-serm copper level. Keep that at the back of your mind with well-sensed disease. If you have a female with well-sensed disease, this person is seeking contraception. If there are particular kind of contraception, they'll be contraindicated in this person. I hope you're saying, oh, divine, of course, the copper IUD. You already have copper excess. It doesn't really make much of any sense to get a copper IUD. So I say that I'm going to talk about the cephalosporines. I think it's kind of helpful to kind of talk about those as well. Now, the thing is the cephalosporines in terms of mechanism of action. They work pretty similarly to the penicillins. That's the truth. Again, they're cell wall synthesis inhibitors. They're pretty much for the most part in hibit transpeptidase. The inhibite one, transpeptidase. But our friends at the MBM is the love to test, so that's the mechanism of action part. But our friends at the MBM is they are certain indications that are very, very helpful to keep at the back of your mind with these cephalosporines. I'm telling you this stuff I'm about to discuss right now is extremely high yield. I'm telling you, antibiotics, that's a very big arrow focus on step two and step three with the USM Ls. Let's go by generation.

Again, I'm going to discuss the high yield. I'm not going to discuss everything about these things. If you want to learn everything about these things, then you're probably taking the step one example. But if you're not learning everything about these things, then just know what I'm going to discuss here. Pretty much. The first one we're going to talk about is the first generation. The first generation, the two big ones, to know they are cephalzolin and cephalexin. So what's the deal with cephalzolin? Cephalzolin is also known as ANSF. If you're a person that is going into surgery and you don't know ANSF, you should rework your surgical knowledge. I'm just kidding. But cephalzolin is known as ANSF. This is a beloved antibiotic by many surgeons. Cephalzolin is giving 30 to 60 minutes before most surgeries. 30 to 60 minutes before most surgeries. This is very high yield to know. If you're getting any kind of surgery, they're asking you about antibiotic profile access. ANSF, ANSF, ANSF, ANSF, Cephalzolin, Cephalzolin, Cephalzolin. You want to give that 30 to 60 minutes before the first incision is meet. Cephalzolin does the big use on exams. And it actually does cover gram positives and some gram negatives, but it mostly covers gram positives. Now, the other one to know is cephalexin. Cephalexin is another first generation cephalosporing. The big thing to know about cephalexin for purposes of the USM in the exams is that cephalexin is very good for what? For UT Is.

It's very good for what? For UT Is. Even in pregnant women. For whatever bizarre reason, our friends at the NBM is they love to give cephalexin to pregnant women for their UT Is. So just something when you keep at the back of your mind on exams. Okay, now let's go to the next generation, the second generation. The second generation, the only one to keep in mind here. This one is actually pretty low yield. It's cephyroxym. Cephyroxym, you can use that sometimes for acurotidysmedia. If you don't see amoxicillin or amoxylin plus clavolanic acid as an answer. But honestly, the second generation for purposes of step two and step three, they kind of wash the pretty low yield. So I'm going to skip those. Now let's go to the big kahuna. Let's go to the third generation cephalosporins. All the third generation cephalosporins are high to know for your test. At least the three of them that you're going to see me mention here. Number one is cephyaxym. Number two is cephalexym. Number three is cephtazidym. Cephyaxym, cephotaxym, and cephtazidym. So let's start with cephiatym. Cephtazidym is a third gen cephalosporin. And again, what is the big, big, big thing to know about cephtazidym? It's going to be nice seria, nice seria, nice seria. Cephtazidym is amnesian for covering both my seria, gonorrhea. And it's amnesian for covering my seria meningitis. In fact, you can use it as prophylaxis. You can use it as prophylaxis.

If you've been exposed to a person that has many gochokomeningitis, you can give it as close contact prophylaxis. Now, cephtriaxym. What are some other uses of cephtraaxym? You can use cephtraaxym for the management of SBP, the management of spontaneous bacterial peritonitis, spontaneous bacterial peritonitis. And again, remember I said that man, if a person has many anxieties, and you're looking for imperial treatment, if you're a new unit or you're over age 50, you're going to be doing cephtriaxym, because that's going to give you very good gram-negative coverage and also some very good gram-positive coverage. Venchomisin, that's going to give you a mercer coverage, and then a moxicillin, that's going to give you a posterior coverage. But if you're not a new unit or over age 50, and you're looking for imperial meningitis treatment, you're still going to use cephtriaxym and venchomisin. You're still going to use cephtriaxym and venchomisin. So again, don't forget that cephtriaxym is the drug of choice for the treatment of spontaneous bacterial peritonitis. Another thing to know with cephtriaxym for purposes of your exams is that if you combine it with metronidazole, that's an amazing cocktail for most GI infections. In fact, if you're like divine, I want to memorize something that can help you with most GI infections, like management, remember cephtriaxym and metronidazole? They love that combo.

Something that may replace that on your USML is that is analogous to that as well, is ampicillin, gentamysin, and metronidazole. So cephtriaxym plus metronidazole works amazingly for meningi-gen infections, but amp-gen-tem metronidazole also works amazingly for meningi-gen infections. Obviously, we're going to throw in metronidazole there because it helps us with some anaerobic coverage, with some anaerobic coverage. So keep that at the back of your mind for your exams. Now, one other thing to know about cephtriaxym, in fact, we try to not give it to new needs if we can avoid it because cephtriaxym has this nasty habit of binding calcium. It can actually be chilefero, or chile calcium itself. When it does that, because I think it's worked on by many of your liver enzymes, it can collect in your bile. So it can form sludge. It can cause an intra-ibatic holostasis. So that can present as jaundice, an increase in dread-belly-robin, or an increase in an outforce, increasing gamma-dotamil transfer, and in GGT. That's something we want to keep at the back of your mind, for example, with cephtriaxym. Yeah, cephtriaxym is, man, it's just pretty high yield. It's just one of these things you don't want to ignore for your test. Now, another one I talked about is cephotoxym. cephotoxym. cephotoxym. I like to think of this as the baby cephtriaxym. Newborns can do very, very well with cephotoxym.

Besides newborns, sometimes on the US semilies for SBP, they actually like you to use cephotoxym as well. So if you don't see cephtriaxym as an answer for SBP spontaneous bacterial paritonitis, think of cephotoxym for that. cephotoxym can literally slide in wherever cephtriaxym works. And again, remember, I said that cephotoxym is amazing for gonococcal infections. So if you're pressing aceptic arthritis from nicer gonorrhea, you can use cephtriaxym for that. If a person has many gonococcal meningitis from nicer meningitis, you can use cephotoxym for that. Another weird thing you can use cephotoxym for your exams is actually for Lyme disease. Remember, most things involving Lyme disease on your exams, doxycycline is what you're doing. Literally, doxy is your is your jam. But if you're dealing with Lyme disease that involves the heart or the brain, so for pressing has Lyme meningitis or for pressing has Lyme myocarditis, the drug of choice in that circumstance on your test is going to be what? What if you're not a cephtriaxym? I'm going to say that again, if a person has Lyme meningitis or for pressing has Lyme myocarditis, like a heart infection or a head infection with Lyme disease, but really I'm going to be free. Pull out that cephtriaxym. Okay, absolutely pull out that cephtriaxym. And then, don't forget cephtazidym.

The key thing to know about cephtazidym is cephtazidym is amazing, because it's the only third gen cephlo sporing you need to know for your exams that covers through the monos. So you can even use it in a person that has fibrointitropenia, because remember, whenever a person has fibrointitropenia, the drug you want to pull out on your exam is an antisodominal, right? So something like a carbapenem or something like cephtazidym. It's the only third gen cephlo sporing that you need to know for your test that covers through the monos. So you can even use it in a person that has fibrointitropenia, because remember, whenever a person has fibrointitropenia, the drug you want to pull out on your exam is an antisodominal, right? So something like a carbapenem or something like cephtazidym or something like a cephepym, which we're going to talk about here in a bit. But just know that cephtazidym covers through the monos, right? So they can even give you a person that has cystic fibrosis and they have pneumonia. Remember, people that have CF over age 20, the most common cause of pneumonia in a CF patient over age 20, is going to be pseudomonas. That pseudomonas responds very beautifully to cephtazidym, or it sounds very beautiful to cephtazidym. Okay, this is going to get easier. We're almost done with the cephalosporins, but let's go to the fourth generation, cephepym, cephepym, cephepym. cephepym is pretty much covers a lot of stuff, right? It covers through the monos.

That's like the big, big, big use on exams. Covers through the monos, covers, covers, covers ground positives, covers ground negatives. It can cover a lot of stuff. It can cover a lot of stuff. That's pretty much all you need to know about cephepym. The big thing to know about cephepym though is that it causes GI upset. Gaster intestinal upset. Now, the fifth generation, this one is pretty low yield. This is probably something that may not show up on step two, but it's something that could absolutely show up on step three. And that's cephtaroline. cephtaroline is a fifth generation cephalosporin. It's a fifth generation cephalosporin. There are two critical things to know about cephtaroline. One, cephtaroline does not cover through the monos. Because I know some people may say, oh, because it's fifth generation, and we had a third gen that covered through the monos. That's cephtazidim. We had a fourth gen that covered through the monos. That was cephepym. Oh, this fifth generation most covers through the monos. That is absolutely incorrect. cephtaroline does not cover through the monos. But what is the big thing to know about cephtaroline? cephtaroline covers mersa. Mersa, mersa, mersa. Friends at the end of the end of the end of the end of the end of the end is the love you to know the drugs that cover mersa. What are those drugs? We've talked about cephtaroline. So, let's talk about cephepym. We've talked about cephtaroline. It's a fifth gen cephlu spore that covers mersa.

There is a tetracycline known as tigaecycline. Tigaecycline covers mersa. Venkomaisen obviously covers mersa. Daptomaisen obviously covers mersa. There is others. There is others. There is others. Klingamaisen, that 50th inhibitor also covers mersa. Okay. There are many things that cover mersa. Venkomaisen obviously covers mersa. Daptomaisen obviously covers mersa. Venkomaisen obviously covers mersa. Venkomaisen obviously covers mersa. Venkomaisen obviously covers mersa. Venkomaisen obviously covers mersa. Venkomaisen obviously covers mersa. Okay. There are many things that cover mersa. You better make sure you know those things for your test. I would not slip on the drugs that cover mersa. Don't forget, linizulid. Linizulid is a 50th inhibitor as well. It also covers mersa. It also covers mersa. Okay. And again, if you love the way I'm making integrations, I'm not going to spend time talking about this, but I have a step two, step three class coming up next week Monday. Right? Larry coming up next week Monday. That's like the 26th of August. And then I have a step one class coming up the week after that. So if you're pressing starting for step three, and you're like, man, I want to get a very strong basic science background. I want to get a very strong step two, step three background. I'm telling you, those classes will be exactly what you need. Just listen to my recent podcast on Divine Classes.

I go into detail on what those classes offer, the materials that are available, everything you're going to get from my classes. I talk about them in that podcast. Okay. So let's go ahead to our next video. This is a very interesting question. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this. I'm going to tell you about this.

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Phlebotomy (blood removal).

Deferoxamine or Deferasirox (Iron chelators).

Syphilis (Treponema pallidum), Lyme disease (Borrelia burgdorferi), and Leptospirosis (Leptospira interrogans).

Penicillin G must be given IV because it is not acid-stable; Penicillin V can be given orally.

Chelating agents like Penicillamine or Trientine, which bind excess copper. Zinc also works by competing with copper absorption in the gut.

Kayser-Fleischer rings.

Cefazolin (or Cefazolin/Cefalexin).

Cell wall synthesis inhibition by binding to transpeptidase (also called penicillin-binding protein, PBP).

Ampicillin.

Ceftriaxone (or Cefotaxime).

Otitis media; Clavulanic acid inhibits $\beta$-lactamase enzymes that would otherwise degrade amoxicillin.

Cefepime (4th generation).

To neutralize bacterial $\beta$-lactamases, allowing the primary antibiotic to remain active.

Ceftaroline.

Cell wall synthesis inhibition by binding to transpeptidase (also called penicillin-binding protein, PBP).

Ampicillin.

Ceftriaxone (or Cefotaxime).

Otitis media; Clavulanic acid inhibits $\beta$-lactamase enzymes that would otherwise degrade amoxicillin.

Cefepime (4th generation).

To neutralize bacterial $\beta$-lactamases, allowing the primary antibiotic to remain active.

Ceftaroline.