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

Um and again this is not gonna be in any particular order. Things are gonna be kinda strewn all over the place, but again, it's really gonna help you if you keep these things in mind. Uh there's gonna be many questions you're gonna get right just from paying attention to this podcast. So what if they give you a question about a person and this person you're told that um uh the person has a history of some kind of uh Prosthetic vowel.

And the person recently had a dental procedure when they went to a foreign country. And then now for the past two weeks they've been having fevers. They've been short of breath, they'd be having some mild chest pain, they'd be having night sweats, and they tell you that their ESR and CRP is elevated. Um, and they're telling you that you're hearing like increased sound. um around where the person had the previous prosthetic valve. I'd really hope in this case you're thinking of this person.

having some kind of uh some kind of endocarditis, right? And they're having this endocarditis because uh they've recently had a dental procedure and now they've gotten in trouble. So remember that typically if you're talking about just infectious endocritis overall, the most common cause is generally going to be staphorium.

But sometimes uh you you you you can get endocritis from dental procedures, especially things like uh strep mutants, for example. Strep mutants can certainly put you in trouble. And uh typically strep mutants is gonna cause issues for you when you have a bad valve at B. Um if you have a normal valve, you know these dental flora don't usually do a number on you, but if you have a valve that is abnormal at baseline, then you can get in trouble.

Contrast this with staff warriors that can go after obviously a bad valve at baseline or you can go after a completely normal valve. Remember staphyros endocrintitis we usually find it in IV drug users because again we Lo look at the name IV and usually w what what valve may you see with IV drug use and endocreditis? At least which one is pr pretty specific many times for Staph Warriors. I would hope you're saying divine, it's usually gonna be like trichospid valve endocreditis.

Well why is that the case? Well if you think about it. Um if you're an IV drug user, IV intravenous, you literally inject drugs into When you inject drugs into your veins, where do veins drain into? Where do all the veins in your body for the most part drain into? They drain into the right side of the heart. Right, so since they dream to the right side of the heart.

The first valve that if you inject bugs into your veins, the first valve they're going to encounter is going to be the tricuspid valve, right? It's going to be the tricuspid valve. So um that's why they can get tricospid valve endocritis. Something we want to keep in mind. Um, I guess bringing another logical thing with the right side of the heart. Uh many people memorize that uh central venous pressures are a surrogate for your right atrial and right ventricular pressure.

Um and that's true. Uh you know, and some people many people have memorized that man, central venous pressure, how do I remember this? Well again think about it. Your right atrium is like a central hub for all the veins in your body. The veins in your body drain into the right side of the heart. So it makes sense that central venous pressure is gonna be your right sided heart pressure. All right.

And uh again, uh since we're I guess we're kind of talking about that, hey, you know, if you have a dental procedure and you get endocarditis, especially if you have an abnormal valve or baseline.

Uh think of uh strep mutants, you know, think of strepmutants, um, you know, think of strep viridants. Um I guess let's talk about some of the numoflora we see at different parts of the body, right? So remember For example, like your nose, your nose many times is gonna be pretty well colonized by staph orange.

Right. Your nose is gonna be pretty well colonized by Staph Areas. Um In fact, they can give you a question on your exams about reducing risk of MERSA infection in a person that has like uh nasal colonization upon admission to the hospital. And you wanna consider using the answer that talks about topical mupirosin in those people.

use the answer that talks about topical muperosin in those people. Although you can also find staph epidermidis in the nose, but typically on the USMLEs, they like to go after staph warriors. Right? Staph epidermidis we tend to find it more in the skin. We tend to find it more on the skin. And then remember your colon, right? Your GI tract. What are the bugs you're gonna find a tunnel?

in the GI tract. Well you're gonna find things like anaerobes, right? Like Bacteroides species, you know, like Bacteroides fragilis. You're gonna see a lot of E. coli, right? You're gonna see a lot of E. coli In fact the thing is if you have some of these microbiological foundations, you'll notice that it's no big surprise where Man, for a lot of GI infections, we tend to use either like ceftriaxone plus metronidazole to treat it, or ampicillin, gentamycin, and metronidazole.

You know, I know many people memorize these drug regiments, but to be honest with you, they are not necessarily things I mean, I guess you have to memorize them. But if you really think about it, these regimens make sense, right? If we know that anaerobes and E. coli are the big, big, big things that sting your GI track.

And you have an infection of your GI tract and you want to treat empirically, it just seems like a wise decision to cover gram negatives like E. cola. E. cola is a big time gram negative. So something by giving something like ceftraxon. Ceftraxon is phenomenal for covering gram negative infections. And then metronidazole is is pretty amazing for covering gram negative infections as

So, and safe traction also happens to cover grand positives, you know. And one thing I'm just gonna say about Metronidazole, you know, many people will learn this. crazy thing about uh anaerobes above the diaphragm, clindamycin, anaerobes below the diaphragm, metronidazole. Yeah, that's a good rule to know. Works for the most part.

But it doesn't mean that you cannot use cleindamycin for infections below the diaphragm. And it doesn't mean you cannot use metronidas or for infections above the diaphragm. Just be careful about that. It's not like metronitis or like uh When you give metronidazole, it stays below the diaphragm. It it doesn't ascend past the diaphragm. That that's pretty ridiculous, right? So just something you want to keep at the back of your mind as you prepare for exam.

And then one association I want to talk about here. Again, I told you that this is gonna be this is basically gonna be like a rapid review micro podcast. But again, lots of questions you're gonna get right from this on your exam.

But what if they give you a question about a person that just takes antibio recently took antibiotics like two, three weeks ago? And then now this person Is having uh like a discharge from the vagina. Uh, what box should you be thinking about? I hope you're thinking about candidiasis. Hope you're thinking about candidiasis. Um the thing is many people do not realize this. Many people are just aware of hey, post antibiotic diarrhea with um C diff.

But many people forget this that I like to think of uh candida as like the C D diff of the vagina actually. Candida as the C Div of the vagina. Whenever you alter the micro environment in terms of just book flora and in terms of uh sugars in the in a person's like vagina or whatever. You're actually going to raise your risk of candidal infection. And make sure you can identify those pseudo-hy fee pictures that you love to throw on the USMLE exam. Right.

If you take a bunch of antibiotics you you kill off a lot of your vaginal flora. Then candida can have a failed day, candida can overgrow and you can get in a lot of trouble, right? So the person will end up having like a vaginal candidiasis, right? Um I remember obviously you're gonna treat that with an oral azole of some sort.

Now remember, that's not the only thing that raises your risk of vaginal candida infections, right? You can also get that if there's just too much sugar in your vagina. Why can they why would you have too much sugar in your vagina? Well if for example you're taking an SGLT two inhibitor, like a canaglyflosin, dapaglyflosin and impaglyflosin.

Those bugs, uh I mean those drugs, whoops, those drugs, they work at the level of the proximal convoluted tubule. They inhibit the reabsorption of glucose in a person's proximal tubule. So by doing that, you're gonna have sugary urine. So they actually raise your risk of UTI. But it also raises your risk of a vaginal candidate. And then also just being a diabetic, if you ever see vaginal discharge in a person that's a diabetic.

Always think of candida, right? Always think of candida. Because again, if you're a diabetic, you have a lot of glucosuria. That can certainly cause quite a number of problems uh for that uh individual. So again, too much sugar in your vaginal area.

or you're taking an SGLT2 inhibitor or you've recently taken antibiotics, those are all high yield associations to know with a vaginal candidiasis. Because remember normally in your vagina, the normal flora that's usually there is going to be like lactobacillus.

You can see E. coli, and I guess if you're a pregnant woman, um, or about twenty-five percent of women, right? Uh Groby strep, right? Groby strep, groby strep is a big time colonizer. of most women.

Um so about yeah, about a quarter. About a quarter of women's vaginas uh for sure colonized by groby strep. So something you want to keep at the back of your mind for exams. Uh that's why between thirty-five to thirty-seven weeks gestation, uh we're gonna go ahead and screen you for groby strep for strepigalactia.

Right. And if you come back positive, you're gonna have this temptation on your exams to immediately go ahead and treat the groupie strip. Don't do that. If you do that you you'll be wrong on your exams. You you wanna wait until the woman is intrapartum. Wait wait until she's in labor. And then after that you can go ahead and give her uh

Uh groby streprophylaxis. No, I guess in that case you're actually trying to treat. Although we're not really treating for the mom, we're trading for the newborn, so the newborn doesn't get in trouble. Right. So we're gonna treat with uh you know you can use ampicillin, you can use ammoxicillin, you can use penicillin, um you you can use any of those things. That is totally fine on on your exam.

And one thing I'm also gonna say is this, if you see any major infection in a newborn, right? Especially like in a new knit, like first twenty days of life, be it like pneumonia, be it meningitis or whatever. You really wanna be thinking about group B streps, Strepigalactia as the cause, right? And again, they can tell you, hey, how did this newborn acquire this infection? You wanna pick the answer that talks about, you know, passage through the birth canal or passage through the vaginal.

Right. Something you want to keep at the back of your mind. Again, don't don't don't uh don't don't forget this. And I guess since we're kinda talking about flora and newborns, another association you want to keep at the back of your mind for your test is why we're told uh

W what if they give you a question about some child, you know, and they tell you that his parents are um you know, are against getting vaccinations, you know, which is not wise, which is very unwise. And then they tell you that, oh, this child for the past two days um uh has been having like a decreased cry, has been having a um having a decreased cry, not doing very well, and they tell you that the child has diffuse hypotonia on physical exam. Uh when you see something like that,

Uh I'd really hope you're thinking about and they tell you that oh his mom recently started giving him uh uh you know to soothe the baby because the baby has been having increased crying. The mom has been giving him his pacifier dipped in a sweat substance or whatever.

in a sweetener. If you see that, I really want you to think of botulism, right? So this child, I try to mask the question as much as possible, as the MBMEs will do every now and then, right? But this child has botulism, right? And the thing is many people do not realize this, but our friends are the MBMEs. They do actually care about how people get uh botulism, right? They do actually care about how people get

They care about the mechanisms. Many people tend to ignore this. Many resources do not cover this, but it's actually pretty high yield to know, for exams, right? So the thing is. If you see a newborn getting botulism or a person within the first year of life getting botulism, it's gonna be from honey on your exams. Because if you really think about it as a newborn, you pretty much have like no GI flora.

So because you have no GI flora, um any bog that is able to set foot, be a first settler in your GI track. It actually has a pretty easy time. It can just overgrow quick and have like no problems, right? Because in a normal adult that has a pretty abundant GI flora, if that normal normal adult consumes honey why is it i mean i i consume honey i mean i'm not a big honey consumer but

I c consume honey every now and then. Wha why did I not get botulism? Well the thing is, you know, I'm an adult, you know, and I have like an actual G.I. flora. So it's not like C. botulinum can just come in and just you know, feel at home in my GI track. No, because there's other bugs that will keep the crowding and population of C. botulinum down. That's something that's pretty high yell to know for examples, right? So a newborn does not have enough GI flora.

So because this newborn does not have enough GI flora, this newborn, if they're exposed to anything that contains Clostridium botulinum, they're gonna get in trouble. You're literally gonna get in trouble, right? Because It's like there is very limited competition in the newborns GI tract. Especially that first year of life. Because think about it, your your food is not very diverse when you're born, right?

Chugging a bunch of milk. There's not much flora you can get from chugging a bunch of milk. Yes, it has probiotics and all that fun stuff, but again, there's not much uh floral diversity you can get from chugging a bunch of milk. So the thing that can happen in those circumstances is that you give that and the spores just overgrow in the child's GI tract, elaborate a ton of uh you

toxin and stuff and the child gets in hot water, right? But it's from spore overgrowth. There's gonna be an overgrowth of spores for a child. But for an adult that gets C. botulinum, right, the way they're gonna get it is from improperly canned food. Right? Improperly canned vegetables and whatnot. Right? The thing is the Clostridium botulinum is growing in that improperly canned food and it's elaborating the toxin.

And then you as the adult, you consume the actual toxin and that's how you get in trouble. It's the toxin that gets you in trouble, not necessarily the bug. I'm gonna say that again. For an adult, it's the toxin that gets you in trouble, not necessarily the bug. But for a newborn, right, for first year of life.

right the thing that's happening is you're consuming the bug the bug can grow nice and easy in your gi tract elaborate toxin and you're gonna get in trouble again you may walk you may be saying divine okay you've talked about this for two minutes we get it Again, if you see me spending a lot of time on one topic, it's probably a topic you should know pretty well for your exams. And I guess since we're on this again, whole topic of GI flora, right? Let's not forget.

Uh people can also get into trouble with uh uh that that's why when you when you're newborn, before you leave the hospital, one of the first shots you get is a vitamin K shot. Well why do you get that vitamin K shot? Makes sense. You get the vitamin K shot because again, vitamin K is literally produced by your GI flora. Vitamin K is literally produced by OGI flora.

Again when you're new when you're newborn, you literally have no GI flora. If you have no G.I. flora You cannot make vitamin K. And vitamin K is very important for the gamma carboxylation and activation of factors two, seven, nine, and ten protein C and S. So if you cannot gamma carboxylate and activate those stains, you're gonna be c you

Your cloning factors are not gonna work, right? And because your cloning factors do not work, you're gonna have a high risk of bleeding. Because basically, uh Secondary hemostasis is essentially not worth it. Right. In fact our friends at the MBA means they can literally give you a hematology question involving newborns.

And ask you which of the following will be expected. Uh you should expect, you know, for a newborn that their PT and their PTT should be elevated. Why? Because again, uh they are pretty much in an anticoagulated state because their clotting factors are not you know.

active especially two seven nine and ten. Again it's pretty high yield to know for exams. I know it's a micro podcast, but again I love to make these integrations so you can see all these uh connections And then what if they give you a question about a person that, you know, consumes

food, right? Again I'm trying to focus on patterns here. You see a person that consumes food. And within a few like an hour, few hours, they have like really nasty gastroenteritis, they have like a lot of vomiting, they have a lot of diarrhea. Um, if you see something like this, I want you to think of food poison.

And there are two bugs you should target on your exams. What are those two bugs you should target on your exams? Number one, you should target staph aureus, especially when you have like um food that's been left out, you know, like mayonnaise, cheese. uh you know picnic associations keep those in mind but if you see anything about like rice

Fried rice, jolof rice, right? Uh the people that are Nigerians listening to this podcast are Ghanaians. Um and by the way, if you're Ghanaian listening to this podcast, Nigerian fried rice is better than yours. Just yes, Nigerian fried rice is better than yours. I guess a ongoing war between Nigerians and Ghanaians about who has

The best fried rice. But anywho, okay, let's get back on task. Right. So you see reheated rice and you see a person having uh rapid onset gastroenteritis that comes right after. Think of Bacillus Sirius. Okay. So what's the pattern I'm trying to emphasize here? I'm trying to emphasize the pattern. of rapid onset and offset gastroenteritis. So it's like not too long after exposure, you get the gastroenteritis.

Not too long after the gastroenteritis starts, it stops. Think of gastroeneuritis from staph aureus and gastroeneuritis from bacillus serious. I'm gonna say that again. Staph aureus be serious. If you see anything about, so how are they gonna test? Right. If you see like a picnic association, food that has been left out for too long and all those things, think of Think of uh think of Staff Warriors. It's gonna be the most common one they're gonna test on exactly.

Now, if you see a reheated rice association, you know, rice that has been left out, right? And then, you know, obviously, right, we live in the in the world of microwave, right? You you microwave the rice, you eat it, you get gastroenteritis, not too long afterwards, you only think of bacillus serum. Now, one devious thing our friends at the MBMEs can do is they can give you a question about a food that has been left out for a long.

And you'll notice that, you know, it will be a picnic association. And you notice that Staff Warriors is not an answer. If you get that kind of question, that'll be another situation where Basila's serious.

Is not a bad idea to pick. Okay. That would be another situation where Bacillus series is not a bad idea to necessarily pick. Okay. So please kind of keep that at the back of your mind as you prepare, as you prepare for exams, right? You see this pattern of rapid onset, rapid offset gastroenteritis.

Uh think of Staphurus or B serious. But B serious, the more classic association you're gonna see on your exams, probably more than 90% of the time, is gonna be with reheated rice, right? I'm pretty sure I've had this before. some family member of mine uh cooked rice for me and I really loved the rice, right? Uh I really love the rice. So I just ate it. I'm like, gee, I'll have like thereafters. Gee, eat it thereafter.

I didn't get the point until a few times, you know, you think that man divine would kinda learn his lesson. But I guess I didn't learn the first, second, third. I think I ate that rice like four or five times. I was like Yeah, it's probably the rice that's causing these problems and then I stop. But you know, you gotta do what you gotta do. Sometimes the love for rice exceeds the uh the problems with the diarrhea. But anyhow, okay, so let's go ahead and continue.

Now, what if you see like reheated meat? What if you see a reheated meat association on your exams? Uh then you want to be thinking about clostridium perfringent. You want to think about clostridium perfringent, right? Well I guess if we're since we're talking about meats, if you see on the cooked meats on your exam.

Um, especially if you see a person having like bloody diarrhea after eating undercooked meat, or they give you a question about a person that has bloody diarrhea, you know, they've been exposed to undercooked meat, and then they give you other things, right? They give you things like the person having like uh they show you like a blood smear and you see fragmented erythrocytes you see schistocytes on your exam Right. And the person's split late count is extremely low.

Um then you want to think about this person having exposure to E. coli O one five seven H seven. E. coli what? O one five seven H seven. Right? It has a very strong association with undercooked meat. Very strong association with undercooked meat on the exams. And why we're why we Why did I give those other labs that I just kinda started mentioning? Well, in that case I'm thinking about uh hemolytic uremic syndrome, right? Remember H U S. Um, it can be caused by uh

by uh microbes that make the sugar toxin like E. coli O157H7 or Shigella, right? E. coli 0157H7 or Shigella, right? Although the one that is way more common is going to be E. coli O157H77. Right. So remember, they're going to have very high fevers. They're going to have anemia. And that anemia is going to be a microangiopathic hemolytic anemia.

Right, so they're gonna have things like uh schistocytes on a blood smear. You're gonna notice that they will have an increase in indirect biliarubin. You're gonna notice that their LDH is gonna be elevated. Remember, LDH, whenever you see high levels of it.

You may see that in inflammation, right? You may also see that when a person has um a lot of hemolysis going on. So they'll have a maha, they'll have a microangiopathic hemolytic anemia, right? They'll have thrombocytopenia, right? They can have like renal issues, so you may see elevated creatinine in those kinds of circumstances.

Right. Uh again, just kind of keep those things at the back of your mind for exams, right? HUS. Remember HUS is supportive care. You don't give antibiotics, right? Your your your classic uh error on exams is to give antibiotics. Again, it's the toxin that's causing the problem. If you give antibiotics, you'll kill more bug. As you kill more bug, you release more toxin. As you release more toxin,

The child is gonna get in some very serious trouble, right? Uh because you you're pretty much gonna sentence that child to a really, really awful, awful, awful uh outcome. So don't do that, right? That's not a smart thing to to do. All right.

And then I guess I kinda talked about Shigella and I said that ooh Shigella is like probably gonna be the second more common cause of hemolytic uremic syndrome on your exams. I said E. coli 157H7 is the big big one.

Uh, what's I guess the claim to fame with Shigella? Well, Shigella, just like E. coli 157H7, can cause HUS, right? And remember, Shigella can also cause bloody diarrhea, can also cause bloody diarrhea. Now, one high yield but weird microbiological association you want to know for your exam. Is that as few as 10 organisms can give you trouble, right? You don't have to be exposed to a ton of Shigella to get in hot water.

Right. Literally, if you have as few as ten shigella, uh you can get in trouble. Right. The thing is again, one of the easy ways they can test that to kind of mess your mess up your head on exam. Is use the term ID50. ID50, right? So it has a very, very low ID50. I like to think of ID50 as being pretty similar to KM. Uh if you're kind of thinking in terms of Michelis Menting Kinetic.

Remember, KM relates to how much of the substrate you need for the enzyme, for the reaction to be going at like 50% of VMA. Right. So the thing is ID fifty is kind of a similar term, right? Uh it's like, hey, how much bulk do you need to deliver symptoms in this patient? Right. So the ID fifty For Shigella is very very very low. The ID50 for Shigella is is extremely low, right? As few as 10 can literally get you in hot water very very quickly.

Right. And then uh since we're I guess talking about meats, remember there are other books that are sort of like poultry, meat and eggs, right? Um, think of salmonella in those circumstances. Salmonella, right, can cause bloody diarrhea, can absolutely cause bloody diarrhea, especially when again you eat like.

you know, chicken products, right? Poultry, meat, eggs and things like that. Although remember another thing that's associated with like meat and poultry, um, is gonna be um Campylobacter jejuni, right? C. jejuna. Remember that's the thing that grows at I think uh 42 degrees or something like that. Um, I'll probably talk about that later. But CJ Juni, right, it can cause bloody diarrhea as well, especially when you're exposed to like meat and uh poultry products.

Right. The thing is you may wonder, Divine, how do I differentiate one from the other? The thing is thankfully The USML is many times they will not put all these things, they will not give you like a poetry question and put like Campylobacter as an answer and put like E. coli O one five seven H seven as an answer or put like uh Um, someone else and answer. They are usually loath to doing stuff like that. The only time Radio will do stuff like that is when they give you some kind of memory hook.

That should guide you in one direction versus the next, right? So, say for example, they give you a question about a person that has bloody diarrhea, poultry products. And you're seeing antecedents of like thrombocytopenia, renal failure, you know, maha, then in that case they are clearly getting you towards E. coli O157H7 um or Shigella, right? And you may be like divine.

Dude, you you said that uh a memory hook. Well HUS can be caused by both Shigella and E. coli O one five seven H seven. Well that's where epidemiology comes in, right? E. coli O one five seven H seven is a more common cause of HUS. than Shigella. So E. coli O one five seven H seven is gonna be the correct answer, right? In that case, even if they give you both as answers, right? Uh Samonella, right, causing bloody diarrhea.

After exposure to poultry, um, you know, they may again put salmonella alone as the only thing then, and then you're like, oh, of course it has to be salmonella. Or if they give you a stack with other bugs that cause the same issue like E. coli or whatever, then they will have to give you some hook. So what's the hook that should guide you towards uh Salmonella? Well, there's a few things you you may see on your exams, right? So uh

There's this thing that Salmonella seems to have this uh kind of association with, uh, called a pulse temperature variation. Pulse temperature variation. So you see this person, they have a very, very high fever, but they're kind of bradycardia. That doesn't really make any sense, right? Typically whenever people have fever, they're gonna be pretty tachycardic, right? If you've worked in hosp in a hospital, right, or if you you you you even see this with obigan questions on the USMLE.

you see a fetus that is tachycardic, right? So the fetal heart rate is over one sixty and mom has a fever. Makes sense. Whenever uh your your body's cooking, right, your your heart rate usually kinda goes up, right? Because that's kinda like an indicator of of sepsis, right? And typically when you have sepsis, I mean your cardiac output actually rises, especially in early sepsis. But again I don't want to go deep in a cardio discussion right now. That's for different parts

But uh so whenever you have fever, you you should have a tachycardia, right? So in that case, the there is no dissociation. There is no dissociation between your pulse and your temperature, right? Your your pulse is pretty high, your your tachycardia, and your temperature is pretty high. But with Salmonella things are a little different, right? There's this phenomenon. It doesn't always obtain with every Salmonella question on the US ML.

But if you see something like this, you really want to think about salmonella. This concept of again pulse temperature dissociation. The person is febrile, but they are not just febrile, they're bradycardic. That doesn't make any sense. When you see that in a person that has bloody diarrhea being exposed to poultry products, then you absolutely positively want to think about salmonella in that circumstance. Another thing you may also see with salmonella on your exam. Maybe a person.

That has sickle cell disease. Right. You see a person that has sickle cell disease, they have bloody diarrhea after exposure to poultry products, then you want to think about salmonella. Because remember, salmonella tends to cause quite a number of problems in people that have sickle cell disease.

The one I'm sure many of you are used to thinking about is osteomyitis, right? Salmonella on the USMLEs is gonna be the most common cause of osteomyelitis in a sickle cell patient. There are a bunch of resources these days that are saying things that are otherwise. They are saying oh staphora, staphora, staphora. Uh I wish you all the best if you go with that. Uh you're you're gonna be getting uh in a lot of trouble on your exam. The most common cause is very high yield.

And this is divine saying this in 2025, April 2nd, 2025. The most common cause of osteomyelitis for USMLA purposes in a sickle cell patient is gonna be salmonella. Keep that in mind, please. Keep that in mind, please. All right.

Right. So we've talked about hey what's gonna be the memory hook for Shigella. Um we've talked about the memory hook for Salmonella, we've talked about the memory hook for E. coli one five seven h7. Um and honestly, if they just give you bloody diarrhea after a poultry product.

And they really don't give you much of any hook, right? E. coli is probably gonna be a pretty pretty classic cause there, right? But let's talk about the memory hook for Campylobacter, right? If they give you a lot of neuromuscular weakness, right? Especially that symmetric ascending paralysis. Then you want to think about Guillaumbury syndrome, right? Cambylobacter jejuni has a very strong association with Guillaume Burrese syndrome. Now remember though.

Um, it's not only Campylobacter that can cause Guillaumbury syndrome. In fact, uh, friends at the MBMEs, they know that many people have memorized bloody diarrhea and symmetric ascending paralysis, Guillomboray syndrome, campylobacteri. So these days they've started getting a little more creative. So remember you can actually get CJUNA after a UT.

you can get CJUNI after an upper respiratory infection, right? So again, if you just generally see a mucosal infection and you see a symmetric ascending paralysis, arising afterwards, then on your exams I would really, really strongly, strongly encourage you to uh consider uh to consider uh uh uh Guillaume Bore syndrome under those circumstances. Under those circumstances. Alright, let's continue. Okay, now what if they give you a question about a pregnant woman?

And they tell you that um she's at 36 weeks gestation. Uh and uh you know they tell you that um you know she has a phospholine amniotic fluid and you're told that uh the woman has been uh you know she went on a vacation recently. and eat a lot of uh like daily meats or a lot of assorted cheeses, right? And she has a fever. If you see that you wanna think about listeria, you wanna think about listeriosis on your exams, right? This is why when you're pregnant you shouldn't eat daily meat.

You shouldn't eat soft cheese S right because that can get you in a lot of trouble with Listeriosis. Right. Uh Listeria can cause coriamnonitis, right? Listeria can cause uh um a lot of uh you you see the feeders being stillborn and they have abscesses in many uh

you know, they have like infection in many body cavities. I'm sure many of you have heard of granulomatosis, infantisepticum. That's pretty strongly as your listeriosis, right? And w what's the drug of choice for treating listeria infection? And the drug of choice is gonna be ampicillin, right? The thing is ampicillin is the way you treat listeria infections, right? If you have a listeria infection, especially listeria of the brain, and you don't um You don't uh

You don't get um pisselling, you're you're you're probably gonna die actually. You're probably gonna die actually, right? So it's pretty high yield to know that for example. Right. So what's another hook you may see with Lister on your exams? You can be mom that consumed daily meats, soft cheeses, you know, maybe like two, three weeks before she delivered a child or during pregnancy. And then now she has delivered a newborn and this newborn has been ingested.

Right, uh you absolutely want to give and p silling. In fact, this is why When you see a newborn with meningitis, empirically you're gonna treat with cephotaxin or ceftriaxone. Usually we're gonna do cephotaxin because ceftriaxone can uh uh killate calcium and cause uh intrahepatic cholesthesis, especially newborn.

Right, but that's a different discussion, right? But you give cephotaxin or ceftriaxone plus vencomycin plus ampicillin. We do that because we specifically want to cover listeria. Because again, if you have listeria meningitis and you don't treat it, uh the mortality is almost one hundred percent with with that. Right. And also this same CVA mnemonic of ceftriaxone, Venc, and Ampicillin for meningitis also applies to people over age fifty.

If you wanna empirically on the US MLE's treatment in GIS in a person over age fifty, you wanna give them ceftriaxone, venc and ampicillin because ampicillin is also found in increased quantity in people that are over the age of fifty.

Okay, now what's another memory hook you may want to keep at the back of your mind with listeria infections? Well, if you see a person that has meningitis and this person is on a TNF inhibitor, a TNF inhibitor, people that uh People that take TNF inhibitors, they can get very serious listerial infections.

It's one of these kind of weird random associations. You may not see many resources, but it's very, very high yield to know for your exams, right? So you see a person that has meningitis and they take TNF inhibitors. It is floridly high yield to know that whatever regimen you're giving those people on to you get cultures and sensitivities back, you better make sure that those people are getting some kind of umpicelling. They're getting some kind of ampicillin. Because again

And picillin um covers listeria and listeria causes issues in people on TNF inhibitors. People on TNF inhibitors they can get very, very serious infections with listeria, right? Very very serious infections with lister.

with uh Lister. So one of these are random things I cover um in my uh in in in one of my review classes that I teach for uh step two, step three. All right, let's continue. All right. So um so what are the again just in quick summary, Lister, Lister, Lister, what are the big associations? Uh pregnant woman daily meat soft cheeses. Bad idea, right? Uh Pressing taking TNF inhibitors, right? And then uh pressing over age 50 with meningitis.

neonit with meningitis, you absolutely want to cover Listeria with with uh those things, right? Um so again just kind of keep those at the back of your mind. And one thing I guess I want to say, since I who was very, I guess, astute, uh, in making this connection with uh toxin.

Um, because the USMLEs they love to test uh toxins from time to time, right? I said that hey, it's the toxin that will cause a person to have botulism as an adult if you consume undercooked uh Um i i if you consume our poly canned goods. Well, remember I said rapid onset, rapid offset uh dira gastroenteritis. The the reason that it's rapid onset rapid offset with Staff Worse and Basilla series.

is that the toxin has already been made. So it's almost like you have like a ready to go problem, right? It's not like the bug gotta grow and then the bug has to make toxin and cause all these issues. No. The toxin is already there, right? And then you just kind of get in trouble quick, right? Remember like Bacillus cereals makes this toxin uh I think is known as cereul.

uh it's spelled as C-E-R-E sor sorry C-E-R-E-U-L-I-D-E. Cerulite. Cerulite is is a toxin that can cause the gastroenteritis. And Stafarus has like a bajillion toxins, right? It can make different kinds of toxins that can cause a gastroeneuritis.

Right. Uh so kind of keep that in mind as you as you prepare for your exams, right? And then what if they give you a question about like a like a cirrtic? A cirrhotic, right? You see a cirrtic with really, really nasty gastroenteritis, especially after they've consumed seafood, right? Or they've gone to a sushi restaurant on your exam.

you absolutely want to think about these vibrial species, right? You want to think about the vibral species, right? Vibrio parahemolyticus and Vibrio vulnificus. Although usually on the USMLEs for gastroenteritis they tend to focus more on para hemolytica. And then for volnificus, they tend to focus on like neck fashion of the skin, right? Like a necrotizing wound infection, necrotizing skin infection in cirrhotics that have been exposed to seafood, right?

seafood, shellfish, contaminated water. So let's say you went like swimming in a bay of some sort. That's usually not a very good idea, especially if you're cirrhotic. If you're cirrhotic, many people do not keep this in mind, but cirrhosis actually compromises you from an immunologic perspective. So just kinda be careful about that, right? Like you're a cirrhotic, you're a diabetic.

Be very careful. You can get some very, very, very, very uh gnarly infections, right? So cirrhotics, you see like neck fashion of the skin. You see like a necrotic infection. You see like gangrene on their skin. After exposure to contaminated water, seafood, shellfish, think of vibrio vonificus. under those circumstances. Again, I just said that diabetes compromises your immune system.

There are many different ways they go after diabetes and infections on the USML exams, right? Like, for example, I already gave one association in this review, right? I talked about vaginal candidiasis. Being a diabetic, right? And also, I guess the diabetic association of you taking an SGLT2 inhibitor, you get in trouble there. I've explained those already.

But don't forget that diabetes, right? Uh you you you can see them getting the short end of the stick from many different kinds of infections, right? So like for example, you say a diabetic um polycontrol diabetes, they have like a lot of facial pain. They have a lot of facial pain. And they have very high fevers. They have like insane leukocytosis.

In those circumstances, what should you be thinking about? You wanna be thinking about mucromycosis, right? You wanna be thinking about mucormycosis for your test, right? Caused by like those rhizopospes.

Remember you you want to be make sure you can identify those wide branching uh high feet, right? Uh branching off at wide angles. Again, make sure you can identify those pictures on the USMLEs. Something they absolutely love to test on on exams, right? And then uh I guess since we're talking about diabetics, remember

Typically, um, you know, if you see a person that has like flunk pain and fever, right? We know that we're talking about um uh flunk pain, fever, you know, you see pyuria, you see white blood cells in their in the person's aurus. Uh sometimes you see white blood cell casts, right? Leukocyte cast.

You're thinking about acute pylonephritis. I remember the most common cause of acute pylone nephritis is going to be E. coli. It's going to be E. coli. Right. But typically, if you give a person antibiotics for pilone nephritis, the person is going to recover very, very quickly. Very, very quickly.

Very very quickly, right? It's one of these miracles of modern medicine. Within like a day or two, you've turned a corner, right? And typically pylonophritis were gonna treat you with like ceftriacone or uh A fluoroquin alone or an amino glycoside, very amazing coverage there, right? But you notice that a person is a diabetic and it's like three days, four days.

Five days. They're not getting better. When you see something like this, uh, you want to think about that person developing some kind of nasty complication of pylonephrine. They may have this thing called Emphysematus Palonifride.

Where they have like air in the wall of the kidneys, like a very bad gangrenous infection. That thing's actually pretty deadly. In fact, you actually have to resect those people's kidneys in addition to giving them IV antibiotics, right? Or they can actually get an abscess of the kidneys. They can get a perinepheric abscess. They can get a perinephrine abscess.

Right. Or you see a diabetic that has like infection under the breast. That that can actually be candidiasis, right? Inter trigo. Right. Candidiasis, inter trigo, like infection under the breast. We tend to see that in diabetics on the USMLE exams, right? Or you see a diabetic. that you know it's probably on chemotherapy. So the person is neutropenic. And then you notice that they have like uh

Like neck fashion of like the skin. So I'm not focused on the face now. I'm focused like on the skin. You see that? Think about a pseudomonal infection. We call that ecthemagangrinosum. Ecthem gangrinosum.

We tend to see it in a diabetic patient that is neutropenic, right? We're gonna manage that with IV antibiotics. Actually a very serious infection. So you can give something that covers pseudomonas. So what are the drugs that cover pseudomonas? Well think of things like IV cefapine, right? That's a fourth gen cephalosporin that covers pseudomonas. Think of Ivy Seftazidim. Remember Seftazidim is the only high yield.

Third generation is basically the only third generation have low sporing. You need to know for your exams that covers Sudomonas, right? And then remember you can also give an IV carbapenem, right? I remember like Mero Penem, Ime Penem, all those ten. Or you can give a monobactam like astrionam for example, you can give a fluoroquinolone. Fluoroquinolones are good for covering a pseudomonas, although these days.

We try to avoid fluoroquin alones because they cause a bunch of problems, you know. They can prolong your QT interval, they can explode your Achilles, right? So if you're an athlete, taking a fluoroquin alone is a terrible idea. Um, so just kind of keep those things at the back of your mind uh for example. And also remember aminoglycosides like gentamycin can also cover pseudomonas. They can also cover pseudomonas. All right. Now, um I I think one thing that

kinda helpful is let's kinda talk about the most common cause of certain things from like a kind of a bog perspective, right? Kind of a bog perspective. Right. So again if you see a newborn, right, so the th these kinds of questions when they present them on exam

They won't give you many clues at all, right? They'll literally give you they won't give you many many many clues at all. Right? But you notice that whoo they'll give you a bunch of bugs that all cause the same issue. But because they expect you to know the most common cause, you you gotta pick the right out.

Right. So for example, right, you see like ring warm, right? Or you see like uh so like tinea corporates, or you see like tiny involving like the head, tinea capitus, or you see like tina involving the nails, onicomycos.

Right, and then they give you like hey, what's the most likely cause or whatever? And they give you like a bunch of answers, and you know, one of your answers has trichophytin in it. Uh, and then they also put microsporum and then they also put epidermophytin. You want to pick the trichophytin answer, trichophytine species. are the most common cause.

Very high yield. They're the most common cause of tinea on the exams, right? The second most common cause are going to be the microsporum species. Um the third most common cause are going to be the epidermophytine species. So trichophytine is number one, microsporum is number two. Epidermal fighting is gonna be is gonna be number three.

Right. Okay. Now what if you see again a newborn, like most infections in a newborn? What's gonna be the most common cause? Like meningitis, pneumonia, sepsis in a newborn, right? Especially again the first four weeks of life, the neonatal period. You want to think about Groupy Strep. Strepigalactia again, they acquired it from passage through the vaginal canal. Right? If you don't see Groupy Strep as an answer, go ahead and pick the answer that says E. coli. Pick the answer that says E. coli.

If you don't see E. coli as an answer, then consider picking listeria as an answer. Consider picking listeria as an as an answer, right? Okay. What if you see a child within the first two years of life having like gastroenteritis? Then what should you be thinking about? I'd really hope you're saying, ooh, divine. I should think about a rotavirus infection on the USMLE exams. Think of rotavirus infection on the USMLE.

And remember if you're caring for a child that has rotavirus, what kind of precaution are you supposed to take on the USMLEs? Well, you want to wash your hands with soap and water, right? They'll they'll try to tell you to pick uh they'll give you an answer that says to pick an alcohol based. Don't do that. Don't do that. If you do that, you you think as an adult you cannot get rid of virus.

Boy, you could not be more sadly mistaken. You can absolutely positively get that, right? And alcohol-based solutions don't do diddly squat to rotovirus. You need to wash your hands with soap and water. You need to wash your hands with soap and water, right? So you see gastroenteritis in a child.

Think of rotavirus on on the exams. Think of rotavirus on the on the exams. Although rotaviral gastroenteritis. The incidence of it amongst kids has started decreasing because there is more and more vaccination going on there. Right. There there are certain things that we're beginning to see a decrease incidence of these days. because of vaccination, right? We're beginning to see a decrease in incidence of hepatocellular carcinoma.

you know, secondary to Heb B just because of head B vaccine. In fact they can throw a question on your exams and sorry I'm gonna get back to the most common cause. Just give me a moment here. I don't wanna forget these associations that are kinda kinda bubbling in my brain right now. So um

The the the intervention, the the most effective intervention for decreasing the risk of hepatocellular carcinoma uh that the uh on your exams is actually getting the HEB vaccine. Believe it or not, this is something they absolutely test on the USML exam. Believe it or not, this is something they absolutely test. on the USMLE exam. Believe it or not.

This is something they absolutely test on the USML exams. I'm telling you, this podcast is extremely high yield. This podcast is extremely high yield. There's so many questions you're gonna get right from this, right? If you see the they ask you a question, they literally will frame it as an epidemiology question.

They can kind of formulate something and again they're not gonna make it a direct question. They're gonna give you like a biostats question, right? They'll say, Oh, hepadocellular carcinoma, you know, like incidence in the fifties, you know, they can say, uh 500 per per per million in the US. And then they say in the 1990s, uh 400 per million in the US. And then they say in the 2000s.

150 per billion in the US. And then they'll say which of the following interventions has mo is most likely explains the trend in the observed data. The answer is going to be Hebbi vaccination. The answer is going to be what? Hebbi vaccination. The answer is going to be what? Hebbi vaccination. It's something you want to keep at the back of your mind for exams, right? So that intervention, because when you get Hebe vaccine, when you get the Hebbi vaccine,

It massively that's why you get it before you leave the hospital. You get like your first shot of Hebee before you leave the hospital, right? By getting the Hebe vaccination, you're reducing your ri pretty much your lifetime risk of getting Hebee infection. So you're highly unlikely to get Hipalocello carcinoma, at least from that. I mean if you drink or you have hemochromatosis, then all better off, right? But then also when you get the heav vaccine.

You're also protected against HEP D. Don't forget that HEP D can also cause hepadocellular carcinoma. But the thing is, HEP D, for it to survive, it needs some components of HEP B. So you're gonna need to be co infected with a B.

to get a HEP D infection. So by literally protecting yourself against HEP B, you're also protecting yourself against HEP D, so you will not get hepadocellular carcinoma from those things. All right. So Remember, uh, so again, we we've talked about hey, reduced incidence of stuff, right?

Reduce incidence of um rotavirus gastroenteritis in kids because of vaccines. Reduce incidence of hepatocellular carcinoma because of the Hebe vaccine. What's another weird thing they can test reduced incidence of or on the USML exams? They can also test reduced incidence of of um ear infections from uh haemophilos influenza type B and just infections in general from Haemophilos influenza type B because we now have a vaccine against it. We now have a vaccine against

Again, that's something you certainly want to keep at the back of your mind for your exams. All right, so now let's go back to the most common causes, right? So we stopped that. Ooh, most common cause, they give you like watery diarrhea like in a in a in a child.

you you want to think about rotovirus in those uh circumstances, right? Uh but again, what if they give you a question about a child that has, you know, they had like URI symptoms for a few days and now they're having a lot of wheezing, right? They tell you you have you see some infiltrating the lung.

especially like a child with within the first like two years of life. I want to think about RSV, right? RSV bronchiolitis. RSV is like the m for the most part, the most common cause of like interstitial pneumonia, especially in uh in little kids, especially within the first two years of life. Within the first two years of life, right? And then uh r remember in general, once you become like an adult,

Most pneumonias, most meningitis, you're gonna get it from strep pneumo. Once you become an adult, most pneumonias, most meningitis, you're gonna be getting that from strep pneumo on your on your exams. You're gonna be getting that from strep pneumo on your on your exams, right? So kind of keep that in mind.

For tests. Although, if you see an adult with walking pneumonia, right? So those people they have like low-grade fevers. You see a lot of interstitial infiltration. So it's not going to be low bar, it's going to be interstitial infiltration.

Then on your exams, I would strongly encourage you to think about like mycoplasma, right? Mycoplasma pneumonia, right? Is the most common cause of walking pneumonia. And we're gonna cover that with uh macrolid. We're gonna cover that with uh macrolid. We're gonna cover that with what? With uh macrolid. So those people they they're gonna have low grade fevers.

They may have like a mildly productive or a non-productive cough and you're gonna see interstitial infiltrates on a chest x-ray. Think of mycoplasma infection under those circumstances. If you don't see mycoplasma as an answer, then pick the answer that talks about like chlamydia uh Uh chlamydia pneumonia, right? Remember, chlamydia can also cause uh pneumonia, or think of legionella, especially when you see uh associations with.

Like contaminated water supply, right? Like contaminated water supply, humidifiers and things of that sort. Uh think of legionella infection. And again, all these atypical organisms can be covered with macrolides. Uh there's this nice mnemonic, right? Like if you spell out the word macrolid, right? Uh macrolid has an M in it, uh has a C in it, and has an L in it. Surprise, surprise, guess what? Um

M for mycoplasma, C for chlamydia, L for legionella. It's almost like macrolides have this manifest destiny of uh covering these uh atypical uh organisms, right? So kind of keep that at the back of your mind for exams. All right. Um, so let's let's uh Let's keep going here, right? So what if you see again, uh let's let's talk about some more associations, right? Um again remember I said that Campylobacter

You know, Guillaume Buret syndrome and it grows at 42 degrees Celsius, right? It's like a comma shaped uh organism. It's just one of these rare things you may see them thrown exam.

And I and I know some of you may think that this will all only be on step one. Once you see it on step two and step three, especially step three. And you're like, what? Yeah. So just kind of keep that at the back of your mind as you're kind of preparing for for tests. Okay. Now what if they give you a question about a person?

That um, you know, has a long history of Girth and the person was switched uh four weeks ago. from having the person was switched for four four weeks ago from taking like uh an a uh you know From taking those those histamine blockers uh to a new drug for their for their GERD and now this person has been having like very significant uh watery diarrhea.

Um, what should you be thinking about under those circumstances? I want you to think of C diff, right? So the USMLEs, excuse me, the USMLEs, they're not stupid, right? They know that everybody knows post-antibiotic gastroeneuritis and C diff. Everybody knows that. But don't forget that taking PPIs also raises your risk of C diff. I'm gonna say that again. Taking PPIs, proton pump inhibitors also raises your risk of C diff.

Why? Well, think about it. A PPI, a proton pump inhibitor, inhibits that hydrogen potassium ATP pump that we find in the stomach. So by doing that, you're pretty much not gonna make Acid is a very strong deterrent to preventing the growth, the overgrowth of C diff. But if you're taking a PPI, then you're not making that acid deterrent because you've shut down that transport.

So the thing that that ATP is pump. It's not a transporter, it's a pump. So because you're not making that, um, because you're not making asset, then you don't have that deterrent anymore. CDF can strictly overgrow under those circumstances. And remember, C-div does not only cause watery diarrhea. C-div can absolutely cause bloody diarrhea on the USMLE.

Right, so just kind of keep that in mind. All right. Now what if they give you a question about a person that has like a bloody diarrhea? But this person also has like right upper quadrant pain. They have like significant right upper quadrant pain. And they tell you that you see like a space occupying lesion within the person's liver.

Uh if you see something like that, you you want to think about entamoeba histolytica. Entaba histolytica, right? Amoebiasis, amoebiasis. Remember many times he's gonna cause bloody diarrhea. In fact he's like the

higher protozoan you need to know for your exams that causes bloody diarrhea. But in addition to causing that bloody diarrhea, it can also cause a liver abscess. It can also cause a liver abscess, right? The bloody diarrhea we're gonna control it with metronidazole. Remember metronidazole can cover uh

uh amebiasis very well, right? There's this mnemonic you probably know get gap on the metro for the things that are covered by metronidazole, right? So the the G for Giardia, the E for inter amoeba histolytica, uh the T for trichomoniaasis, right? So the GET and then the gap. The G,the other G,I'm kind of wondering what that is

Right, and then the A stands for anaerobes, and then I think the P stands for protozoans. Right, uh, metronidazole is pretty good at covering those things, it's pretty good at covering those things. And then don't forget that metronizazole can cause that disulfine effect from inhibiting acetaldehyde hydrogenase. That's why if you're if you're taking uh metronidazole, shouldn't take alcohol at the same time. But again, different discussion, right? And then the liver abscess that you can get.

With uh amibiases. Uh, how do you treat it? Well, you're gonna use an intraluminal agent like paromomycin or iodoquinol, like pyromamycin or iodoquinol. Right. Again, like paramomycin or iodoquinol. And then again, uh since we're talking about the liver, remember the uh th there are certain strains of uh malaria, right? The Plasmodium species, Plasmodium uh falsiparum.

sorry plasmodium species that that that can stay dormant in the liver uh like plasmodium vivax and plasmodium ovali right those are the plasmodium uh species that can stay dormant in the liver Right, if you want to eradicate those, remember you're gonna have to use a prima coin. Primaquin kills the hypnozoid forms of those organisms, right? The hypnozoid, very high yield, the hypnozoid forms of those organisms, so that can help you help you out.

All right. So again kinda keep those things at the back of your mind as you as you prepare for for exams. Uh, this podcast is whoa, fifty minutes. This podcast is kinda getting long. Um, so we probably need to shut things down uh pretty quickly here. But again, what if you see a person that has uh kind of like a radapocent pain?

And they tell you this person has a lot of vaginal discharge on your exams, right? They have vaginal discharge. They have like bilateral lower abdominal tenderness. Then on your exams, you want to think about pelvic inflammatory disease. PID. Pelvic inflammatory disease. PID, PID, PID. Uh so what's the deal there? Well remember P I D Um pevio inflammatory disease um is a kind of sexually transmitted infection, right? And we tend to find this in people that are sexually active on the exam.

Um so many times they're gonna have like vaginal discharge, like puriline vaginal discharge, and they're also gonna have like bilateral adnexal tenderness. But sometimes the inflammation when a person has PID can spread to the liver capsule and cause rhythroper caution pain. In that situation, we call it Fits Hugh Curtis syndrome. Fits you Curtis syndrome. Fits you Curtis syndrome. Okay? Fits you Curtis syndrome. Fits you, Curtis syndrome.

All right. Um so just I guess kinda keep these things at the back of your mind as you prepare for your for your exams. Um I think this is probably a good stopping point uh for tests. Uh I guess uh since I talked about the vibral species, I talked about vibral para hemolytica. I talked about Vibrial volnificus. Don't forget vibral cholera, right? Vibrill cholera causes uh Right. It's gonna be like uh watery diarrhea. It's gonna be uh rice water diarrhea

Uh many times on your exams is going to be from you consuming infected seafood, right? And then it kind of gets you in kind of gets you in trouble. That's another bug that is common shaped. So remember we've talked about two comma-shaped organisms today. We've talked about Campylobactery Jonah.

Right. And we've also talked about uh vibro cholera. Right. Remember people that have vibrocolary, those people need oral rehydration therapy, right? They're gonna need like a salt sugar solution. Um to kind of help them out, to to help them out. They're gonna need a short salt sugar solution. I you may wonder gee divine why why why? Again our friends at the NBM means they can slap in some patho face here. Sorry, I I cannot stop this podcast and not talk.

Right. So remember when I talked about canaglyflosine, empaglyflosin, and dapaglyflosine earlier. Right? I said that those are SGLT2 inhibitors that we use to treat diabetes. Right. Um remember just like this SGLT2, uh there's actually SGLT1. SGLT1 sodium glucose so look what what do you think SGLT stands?

Sodium glucose link transporter one. We tend to find that in the GI tract, right? The thing is when you have cholera infections, right? The cholera, uh one of its toxins is pretty much, I believe, an an adenylite. So it's gonna cause you to put a ton of chlorine in the lumen of your GI tract. Water follows you have this rice water diet.

But don't forget that one of the few transporters that can help you because these people are losing so much fluid, one of the few transposers transporters that can still help you is gonna be your SGLT1 transporter. It still works even if you have a cholera infection. That's why we give a salt sugar solution because Transporter uses the gradient energy of sodium. Remember sodium is primarily an extracellular ion.

So sodium flows down its gradient into the cell, glucose is pumped in, right? Water is going to follow, and that's going to help you can kind of hold some volume, right? So that's why we use that salt sugar solution. That's actually the mechanism behind us using oral rehydration therapy.

when a person has uh uh gastroeneuritis. I I certainly remember uh when I was growing up uh back in the day, I definitely had or had to take ORT sometimes uh when I had like some cases of a gastroenauritis. All right. So just again pretty high y'all to know these things for exams. Again

I I know this podcast may have seem kind of discomvoluted, but uh again as I've explained on your USML exams you wanna be able to think in multiple dimensions. Uh many people get frustrated at my podcast making style where it's like Divine, can't you just say, Okay, talk about diarrhea alone, talk about this alone? And I I I I do that from time to time. But the thing is that may help you It may make you feel comfortable as you're learning, but I'm not helping you for your exams. I'm really not.

Because the USMLEs they don't test things in a linear fashion. They test things in a multimodal fashion. They test things in a multi-dimensional fashion. on your exams, you'll notice that most questions you see will look like a kind of a like a joke to you.

Uh let me not say like a joke, but it'll seem a lot easier on exams if you can make integrations. So sorry again, that's the reasoning. I I don't just make these integrations because I like to make people's life hard or to seem disorganized. No, it's because this is what the USMLEs Demand. This is the way they want you to be able to think, right? This is the way they want you to think. So don't get me wrong. I organize things a lot, but again, I like to use scenarios, veneer.

associations, integrations to get these points across because again, that's just a lot more realistic for what you're gonna see on your exams. And if you love the way I teach, you love the way I make integrations, you're probably gonna be interested in the classes I offer.

Um, I have a bunch of classes coming up in the month of April. Um, I have a you know, for step one to step three, I have a test-taking class, I have a four-hour biostats class, I have Social sciences, ethics, quality improvement and hospital medicine class.

Um that's for step one to three and then for step two and step three specifically I have a 20 hour step two step three review and I have a last minute review. Again, many people have taken these classes and they found them to be extremely helpful. I literally had somebody that took the exams last week that took my class just before they took the exams and they were like, ah divine, I wish I had known. I'd have taken it much earlier in my prep so I could have seen this material multiple times.

This thing really really helped me on my test. Again, I've had a lot of people take my 20-hour step, two, step three class, and they've got in like two fifties, two sixties, two seventies, very, very high scores on the exams. Obviously, I cannot I can offer any guarantees, but the overwhelming majority of people that take my classes they do extremely well.

And then there's this 50-hour class that's taking place in the first two weeks of June. It's gonna be held only once this year, but oh my goodness, it is my most comprehensive class. Extremely, extremely, extremely high Yo class 4, step two and step three, or level two and level three. Um, if you're interested, again, there's still some spots, shoot me an email and I can give you some more information.

And then I also have these podcasts on Apple, Google, and Spotify. And I also, by the way, I have a step one review taking place in the first week of May, a 25 hour step one review. So if we're taking step one or level one, or people taking step two, step three, and you have poor basic science foundation. Um because believe it or not, these step two, step three exams these these just a lot of basic a lot of basic science.

So I also have this podcast on Apple, Google, Spotify. I have a YouTube channel where I post the videos that I make. And then um I also help with you know do a lot of one-on-one tutoring and also help with ERAS applications, personal statements, rec letters, and things like that. And then I also have another website called Divine Intervention Life Lessons.com. Divine Intervention Life Lessons.com. Every week.

Uh I typically post like two to three podcasts right from a biblical perspective address a life lesson. Um there's actually an Apple podcast associated with that called the Divine Intervention Life Lessons podcast. All right. So thank you for listening to me today. Please, I will strongly encourage you, don't ignore this podcast.

We're in a full almost a full hour, but again, a lot of high-yield stuff here. A lot of easy points on your exams if you know this stuff. So I will see you in episode 500 and I think 80 87, I think. Um so have a wonderful day. Uh God bless you and uh bye for now. Thank you.