102: Parasites and Change Your Approach

Hello, and welcome to season two, episode 102 of the Physician Assistant Exam Review Podcast. This week, we’re covering parasites. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where we teach core medical content and how to dominate school and then ultimately pass the PANCE. That’s our goal. That’s what I want for you. That’s very much the direction that this entire program is for.

This podcast, everything I do on the website, everything I do through, basically everything I do here is to get you comfortably through school and to pass the exam. So you can go out into the workforce and get the position that you want and actually start treating patients, right? That’s the ultimate goal. And I want you to make sure that you keep that in mind. So many times we miss the forest for the trees. We spend all of our time down in the weeds in the incredible details. We get tired, we get frustrated, and we forget to look up and remember why you’re here, what your goals are, how long the journey has been, how close to the finish line you are.

There’s so much more to this than the quiz you have next week, than studying one small section of the topic that you’re struggling with. There’s so much more. So yes, there’s frustration. Yes, there’s anxiety. Yes, there’s exhaustion. There’s all of these things. But I think if you keep in mind where you’re heading.

We’ll get out in front of a lot of these.

Okay. If you haven’t been over to the website, check out physicianassistantexamreview.com. That’s where you can find all of the notes for these shows. All that’s right on there. A lot of people like to follow along as they listen to the show with the notes. It makes it a heck of a lot easier to sometimes follow if I speak too quickly or mispronounce things as I’ve been known to do. Also over on the website, you can sign up for the email list.

I strongly recommend that you go ahead and do this. I send out daily information on passing the PANCE, on getting through school, on rotations, all kinds of different things that we cover on the email list that I do not cover in this show. That’s one of the best places to get information. If someone just emailed me this weekend saying, hey, I didn’t pass my exam and I’m looking for some information as far as approaches to taking the PANCE, maybe what I’m doing wrong. The best place to start with my material is going to be the email list. That’s where I cover so much as far as test taking skills, strategy approaches, all of those things come out daily through that email. So if you haven’t gotten on there, check it out, physicianassistantexamreview.com, and you will find multiple ways to get on there.

But I do think it’s a huge asset to you if you go ahead and take care of that.

All right, so this week we’re going to be covering parasites. We’re moving through infectious disease, and this section is actually kind of gross, as you’ll see as we move through it. But we’re going to start off with our priming questions, as always. What is the first-line treatment for malaria? What is the first line treatment for malaria? What organism is the reason we warn pregnant women about changing cat litter boxes? Cat litter boxes?

What organism is the reason we warn pregnant women about changing cat litter boxes? There’s got to be a better name for that. I don’t know. What medication do we use to treat pinworm or hookworm? What medication do we use to treat pinworm or hookworm? What’s the treatment for trichomonas? What’s the treatment for trichomonas?

And this one’s just a touch longer, but I want you to see how this develops. A patient presents with fever and chills that seem to come and go. During the history, you learn that she just traveled two weeks ago to Africa on business. What test should you order or be considering? A patient presents with a fever and chills that seem to come and go. During the history, you learn that she’s just traveled two weeks ago to Africa on a business trip. What test should you be considering?

All right, well, let’s jump in to our discussion of parasites. Pinworms are first. These are found all over the globe. The eggs are initially swallowed, and then the worms live in the cecum, and the females travel through the anus at night in order to lay their eggs. Told you this section is not the most pleasant. Clinical presentation. A few symptoms, especially at first, right?

Itching around the anus, restless sleep because the irritation happens at night, abdominal pain, and nausea. Diagnosis. Worms may be visible with examination at night or after a bowel movement. The tape test is where you stick a piece of adhesive tape over the anus at night, and you will trap these worms that come out at night. And then a fecal analysis, and you can actually count the eggs in the fecal matter is going to be how you diagnose this. Treatment. There are multiple medications you can use.

Albendazole, mebendazole, pyrantel. All members of the household must be treated. Decontamination of all sheets and bathrooms is a great idea. And then hand washing, hand washing, hand washing. A big part of understanding treatment for parasites is going to be, why can’t I adjust my notes here, is going to be, hang on. That’s why, because I’m not in edit mode.

All right, a big part of dealing with treating and being careful of parasites is going to be hygiene, right? Hygiene is a big, big part of this. Helminth infestation. So this used to just be called hookworm. Hookworm is the most frequent of these soil-transmitted parasitic worms. There’s also Ascaris and whipworm, but hookworm seems to be the most prevalent all over the place. It has gone down tremendously in the United States due to improvements in sanitary living conditions.

This is found mostly in warm tropical areas. The larvae enter through the bottom of your feet. When you walk on contaminated soil, you can get some pruritus at the entrance point. And here’s where it gets really gross. They move through the bloodstream to the lungs. Once in the lungs, they are carried by the cilia to the mouth and swallowed. They attach the small bowel and lay their eggs there, and then the whole cycle gets repeated.

Clinical presentation, again, you can get itching from the entry point at the bottom of the feet. Non-specific GI complaints, right? Because if you consider what’s going on here, you get some pain, nausea, constipation, diarrhea, vomiting, that kind of stuff, but nothing that’s really going to help you, right? So again, the way that I always look at this stuff is to think, well, how am I going to tell different parasites apart? How am I going to differentiate them? How am I going to see what makes them different? Well, the itching at the bottom of the feet is a huge flag, right?

Like, like, that’s going to be tremendous. Where what was the difference with our pinworm? There was itching, but where was it? Was it the anus, right? So we have two things that cause some abdominal pain, some nausea, and give you kind of similar GI symptoms. So the question is, how do you separate those two? How do you pull them apart?

And how are they going to write them on a test question where they’re going to have to include some itching around the anus or some itching around the feet. If you’re going to have those two things, most likely that’s how they’re going to present to you in the office. That’s most likely how they’re going to present to you on a test question. Right? I mean, that just makes sense. Diagnosis is going to be a CBC may show some anemia, but really you’re going to do a microscopic microscopic fecal exam for the eggs and a fecal occult blood might be positive as well. But here’s the good news.

And this is one of the things that I point out a lot of times. The treatment here, whether you’re talking about pinworm or hookworm is going to be the same. Mebendazole, albendazole and pyrantel, right? The treatment is pretty much the same. So what are you going to get? What are you most likely to get a test question? And you’re most likely to get a test question here.

To me, I would be looking at it as if I’m going to get a diagnosis question to separate these two. Maybe not. Maybe that’s not what you’re going to get, but that’s how I would approach it. And again, how would you separate these two? Well, I’d separate them by how they infect you and where you are going to have the symptoms, right? Those symptoms should be able to separate these two. And then you’re going to diagnose it through finding those eggs.

But the symptom in the stem is where you’re really going to be able to tell these apart.

All right, now we make a big move to malaria. Malaria is obviously a tremendously important disease to know about. It really doesn’t have a foothold in the United States, but because it is estimated to kill more than 400,000 people per year across the globe, it’s extremely important to have an understanding of this. There are four species of plasmodium that infect humans. They all have slightly different characteristics of their infections. I don’t think it’s worth, as far as the PANCE is concerned, I don’t think it’s worth separating them out and spending time on each of them. There are differences in their, in how they present, there are differences in the, of course, the infection goes, how long the incubation period is, all of those things.

But for me, this is where I’m going to choose if I’m studying for my PANRE, I’m not going to spend time there. Can you get a question on it? Of course you get a question on it. Is it going to be more than one? No. Is it probably going to show up on your test? No.

Is it possible? Yes. But for me, I know that there’s a limited amount of time I have. I am not going to spend time on that, so I’m not going to give it to you here. The mode of transmission for malaria is through mosquito bites by an anopheles mosquito, right? Hopefully you know that. You can also get it through a blood transfusion from an infected person or mother-to-child transmission during pregnancy.

Parasites travel to the liver once inside the bloodstream and reproduce there. Then they enter the bloodstream and infect red blood cells where they break open and infect more red blood cells. It’s kind of a cycle. If you haven’t gone and pulled up the images for that, you really should. It’s a much better way to understand this than for me to describe that path to you. The images and the way that it moves is a much more clear image than I could ever give you in spoken word. Possible complications if left untreated.

You can get hemorrhagic anemia. You can get kidney failure. You can get liver failure. You can get meningitis. You can get pulmonary edema. You can get hemorrhaging, and you can get cerebritis. So it can be pretty nasty.

Malaria is a really, is a very dangerous, dangerous disease across the globe for sure. Clinical presentation. Classic symptoms are a cycle of coldness, shivering, fever, and sweating that occur every couple of days.

Let’s say two to four days, based on the reproductive cycle of the organism, right? So as the organisms reproduce and die off and reproduce and die off, you get these flashes of fevers. You get flu-like symptoms, fever, headache, joint pain, vomiting, jaundice, polyuria, all kinds of just nasty stuff here. The diagnosis on physical exam, you may be able to feel as the progression of the disease goes on. So it may not initially, but as days and weeks go by, you can get an enlarged liver, and an enlarged spleen, you can get jaundice. This is going to be diagnosed through a blood smear. You’re going to be able to actually see the organisms, a complete blood count to identify anemia, and then the travel history to places where malaria is a problem is really going to be important.

So again, I’m always looking for how are we going to differentiate diseases, right? How are we going to tell them apart? How are we going to tell which one is which? How are we going to know that they’re asking about malaria on a test? And again, some people might say, well, I don’t want to just focus on the test, but this is also how are you going to go through your differential diagnosis in the office? It’s very much the same way, right? So what are the things I’ve said so far that will help you differentiate this?

Well, if a patient comes in with flu-like symptoms, that isn’t going to give you anything clear to work with, right? That’s going to give you, okay, he’s got flu-like symptoms. This patient comes in with a fever, a headache, multiple joints are hurting. So they got a lot of stuff going on. So how do I narrow this down from the huge world of things that can cause flu-like symptoms down to one thing I can treat? Well, in this case, what separates malaria from everything else? Well, there are two things, really.

Well, there’s a handful, of course, but there are two things that jump out to me. One is that cycle of coldness, shivering, fever, and sweating that occurs every few days. That cycle is very very becomes very obvious, right? The other is the travel history. You’re not going to find someone who comes down with malaria living in Pittsburgh if they haven’t traveled somewhere. It seems really unlikely. Or Alaska, right?

It seems very unlikely. So, it’s travel history is going to probably be somewhere in your stem. Right? It’s going to happen. Could a patient with malaria have pruritus on the bottom of their feet? Absolutely. But do you get my point?

That’s probably not going to be in there. They’re not going to try to fool you in that sense. Itching on the bottom of the feet is going to push you towards pinworm. Cycling every couple of days of fever and history of travel is going to push you toward malaria. It doesn’t mean that it’s true, and that’s 100% of the time. It just means that’s direction it’s pushing. And I want you to see how those stories develop.

Treatment. Number one is going to be preventing mosquito bites. That’s number one. Wear protective clothing over the arms and legs, use mosquito netting while sleeping, and using insect repellent. Anti-malarial drugs, but drug resistance patterns are extremely important. So depending on where the area that you’re in, where you’re going, where you’re traveling, there’s a lot of different caveats to treating malaria because of resistance. So the two drugs that seem to be at the top of the list, and I’m going to mispronounce this horribly, so I’m going to ask your forgiveness in advance.

You can obviously go look at the website for the notes, if it’s that unclear. Artemether and lumefantrine. Sorry, that’s the closest I’m going to get. It’s going to be the most commonly used to treat, and chloroquine would be the next most commonly, but just because of resistances, those are going to be issues. And then fluid replacement may be necessary and hospitalization, depending on how these patients are doing. We have two more parasites to get through. Toxoplasmosis is next.

And toxoplasmosis is a, Toxoplasma gondii, right, is the cyst-forming protozoan that causes this. And normally, well, maybe not normally, most of the time you get very few to no symptoms. Some people may have some symptoms, right? Describe like a mild mononucleosis with some lymphadenopathy. Where this really comes into play is for two places. One is for pregnant women and the other is for people who are immunocompromised because this can progress to a life-threatening infection. Mode of transmission.

So waste from an infected cat is a major one. So you get fecal-oral route with cats as a primary host and then eating infected or undercooked meats. This is why pregnant women are warned against cleaning out the cat litter box. Because an infection during pregnancy can result in spontaneous abortion, stillbirth, or birth defects. Another way you can pick this up is very rare is receiving an infected organ transplant or blood transfusion. So again, normally this is an asymptomatic issue with a mild flu-like symptoms, but immunocompromised patients or children may become very ill. Clinical presentation, fever, aching muscles, tiredness, sore throat, can progress to blurred vision, confusion, loss of coordination.

For people with weakened immune systems, they can progress to headache, confusion, poor coordination, seizures, lung problems that may resemble tuberculosis, blurred vision due to severe retinal inflammation. And in babies who acquire congenital toxoplasmosis, they can get seizures, enlarged liver and spleen, jaundice, and a severe eye infection. Treatment. Well, again, number one is going to be ensure proper hygiene. Cook food to safe temperatures. Don’t let pregnant women clean out the cat litter box. And then medications are permethrin and sulfadiazine are going to be your treatments here.

So again, what’s our red flag? I don’t even want to use the term red flag. What’s the thing that jumps off the page at you for toxoplasmosis? Well, its main host is cats, right? And then they discuss pregnant women, and you discuss people who are immunocompromised. So all those should be tied together. So when you see a question that involves a cat, the first thing that should jump out at you is toxoplasmosis.

And then if there’s something about a pregnant woman involved there, it should bring you even further in that direction. And that’s how you need to start thinking about these, is what’s the whole picture look like? What’s the story look like? Don’t memorize the terms, right? Because again, I’ve got fever, aching muscles, tiredness, and sore throat as my presenting signs. Well, that sounds a heck of a lot like malaria. It doesn’t really sound like pinworm, but it certainly could cross over with some of the same issues as malaria.

Not exactly the same, of course, but if you’re writing the question, it wouldn’t be that far off. But what are the things that separate it? That’s what you’re looking for. Trichomonas is next and last on our list for today. This is a flagellated protozoan that is sexually transmitted, typically causes urethritis or vaginitis. Clinical presentation, a little different in males and females. Males tend to have no symptoms, but may have urethral discharge and irritation.

Females have pruritus. A yellow-green discharge that is malodorous and frothy. Severe vaginal and perineum inflammation. Dysuria, dyspareunia. So this should stand out pretty clearly in a clinic setting or in a test question setting, right? In females. Labs and studies.

You can do a wet mount that you see a motile flagellate. That should indicate to you that it’s trichomonas. You can also do a nucleic acid amplification test or NAAT. And it looks to me, from what I went through, I’m not in a field where I deal with this a lot or ever. But then males, they do a urine culture or urethral swab. And it seems like the urethral swab comes back. It’s more accurate from what I read at this time.

But you can certainly let me know if those of you who work in the field can correct me on that. Treatment. Metronidazole, two grams, one time, may be repeated if not cleared, should take care of it. Two grams of metronidazole PO and all partners should be treated.

All right. That should, not should, does wrap us up for parasites. Again, as we move through infectious disease. Before we answer our study tips for today, we’re going to move in, I’m sorry, before we answer our priming questions for today, we’re going to move into our study tip section. And this is important and difficult for some people to realize how important. The study tip for today is to be positive as you study and take your exam. To be positive as you study and take your exam.

Not one or the other, but both. Because here’s the deal. I run into a lot of people who complain and I know when I was in PA school, I was one of them, and certainly my classmates were on the list about taking this test. You say, I can’t believe I have to do this. This is so dumb. We do all this other stuff. I can’t believe this.

This is so annoying. That’s not going to work. It’s not going to serve you. It’s going to put you in a much worse position. The answer is you have to take the test. So complaining about it, although it may make you feel better initially, puts you in a bad position. It doesn’t get you out of it, but it does tell your brain that you don’t want to do it, that you don’t want to do a good job, that you don’t want to remember the stuff that you’re studying, that you don’t want to pass.

You sort of line yourself up in that direction when you go in with a bad attitude. When you go in with a positive attitude, as silly as it sounds, it lights your brain up. People who study in good moods remember more of what they learn. And that only makes sense. I know that you may not want to think it’s that simple, but it really is. It makes sense. You’re going to want to remember the things that make you happy, right?

You’re not going to want to remember the things when you’re upset, angry, frustrated, or when you sit and tell yourself you’re not, you don’t need something, you don’t need to remember something, then you’re not going to remember it. It’s really, really simple. The more you can embrace this, the more you can enjoy it. I know that may be a stretch, but find a way to like it. Find a reason to get through it, you will not only feel better while you’re doing it, but you will do better, both when you study, when you sit down to study, and when you sit down to take your exam. Your attitude plays a major role. And the more people I talk to, the more I communicate with people, the more I’m in touch with people through the 33 Days to pass your PANCE program when I have group coaching calls and I’m actually in live conversations with lots and lots of students who take their exams.

I’m shocked at how much weight I put on this and then how much more I see it coming back to me. And it’s so simple. It’s something you have control over. You have control over how you feel. You may not believe that. You may not think it. But if you practice a little, if you try a little, I’m not going to go into depth here on it, but there are plenty of places where you can find out more.

You have control over how you feel about a given situation. And if you can feel better about a given situation, it only stands to reason you’ll do better in that situation than if you feel bad about that situation.

All right, let’s answer our priming questions. What’s the first-line treatment for malaria? What’s the first-line treatment for malaria? Well, remember, we did talk about it being a little fluid depending on resistances, right? But I can’t believe I set myself up to have to say this twice. Artemether and lumefantrine, a combination, and then chloroquine would be the other one. What organism is the reason we warn pregnant women about changing the cat litter box?

Remember, cat litter should just be linked in your brain to toxoplasmosis. What medication do we use to treat pinworm and hookworm? Mebendazole. What is the separator between pinworm and hookworm? What makes them different? If you see them on a test question. I know that wasn’t one of our priming questions.

I’m going off the script here. Pinworm should have itching in the bottom of the feet from where they enter. Oops, I got that backwards. Pinworm should have itching around the anus from when the female comes out at night to lay its eggs. And hookworm should have itching at the bottom of the feet from where it enters from that infected soil. What is the treatment for trichomonas? Metronidazole, two grams, PO, right?

And then we had that longer one. Setting up the story, a patient presents with fever and chills it seemed to come and go. During the history, you learned that she traveled to Africa two weeks ago on business. What test should you be considering? And it’s the peripheral blood smear. We’re thinking about malaria here.

All right. Well, that’ll wrap up our show for today. Thank you so much for joining me. Thank you so much for being here today. I really do appreciate it. It makes a tremendous difference to me. And I would love for you to share the show with anybody who you think could use some help.

If you found that this show has been helpful, if you found that the website’s helpful, please share it with your classmates, share it with your cohort, share it with your professors. That’s how I grow the show. That’s how the show continues to do well and allows me to continue to make these shows. So please go ahead. And again, if you got a lot of it, please share it with somebody you know who could use it.

All right, take care.