098: Bacterial Infection Part

Hello and welcome to season two, episode 98 of the Physician Assistant Exam Review Podcast. This week, we’re going to begin infectious disease with bacterial diseases, part one. My name is Brian Wallace. I’m the founder and creator here at Physician Assistant Exam Review, where we’ve been at this for over 10 years now. It seems amazing, right? And this is where we teach core medical content and how to dominate school and ultimately pass your PANCE. That’s really the goal here, right?

Is to get you through school and through your exam. Obviously, we want you to learn medical content along the way. That would be fantastic, but we want to turn you into a great practitioner and into a great human being, quite honestly, along the way. Those are not the same thing, right? And that’s what we talk about here today. We lean more toward medical content in this particular podcast, But in the same feed, I also talk about, in the Dominating Medicine podcast, how to really excel in school and on your exams and to really move forward. That’s the goal of that show in particular.

But, before we get started, if you find today’s show helpful in any way, if you like the way I teach, if you like the way I cover the material, if you find it inspirational, please do me a tremendous favor and share the show with your friends, with your classmates, with other people that you know who could, in turn, benefit from this material. I really do appreciate that. It goes a long way to help me. It goes a long way to help the show, to get me to continue to produce these episodes and everything that I do at Physician Assistant Exam Review. And it also helps everybody who you share it with, obviously. So I’d love for you to please participate in the community in that way. It would be a tremendous benefit.

Now, if you’d like to get every single episode, every episode ever recorded of the Physician Assistant Exam Review Podcast, you would go to physicianassistantexamreview.com/podcast. And there you will find a way to access all the way back to season one, episode one. In fact, I’m almost halfway through, a little over halfway through the blueprint for the second time. But if you’re looking for information not in the podcast feed, that’s where you go ahead and get it.

All right. So let’s go ahead and get started. As you know, I’d like to start off with the priming questions. And the reason for the priming questions is to get your brain functioning, get you involved, to keep you from being a passive learner on this show. The main goal I have for you is to actually become someone who knows medicine, not someone who’s studying medicine, not someone who can memorize a few lists or facts, but someone who actually knows medicine. And one of the ways to do that is to be engaged as you’re learning. The priming questions force engagement, provided that you pause and think them through.

They make you have to think through what we’re doing, what we’re talking about. So don’t just let them slide by and assume you’ll pick up the answers later. Spend some time thinking about the answers, even if you don’t know the answers yet. You’re not going to know all the answers, right? That’s not what we’re shooting for necessarily. It’s very difficult to know all the answers to all of medicine. I don’t expect that from you.

You shouldn’t expect it of yourself. We’re growing your body of knowledge, but you’re not going to have all of it. Not for a very long time anyway. So what I want you to do is think through these questions, pause and think, and just the act of processing the data will help you. Even if you don’t come up with the answer, even if you come up with the wrong answer, that’s okay. We’re just getting the brain flowing. We’re getting the neurons connecting.

We’re pushing through some ideas. And then as we come across those during the run, as I’m going through the information, they will light up the neural networks in your brain. You’ll start to build more connections.

So let’s go ahead and get started with that. A patient presents complaining of a huge volume of diarrhea, which he describes as milky and very thin. He’s a little blue when you look at him. What’s the most likely diagnosis? What is the first-line treatment for all diarrhea? What’s the first-line treatment for all diarrhea? What infection should you consider if a patient presents with descending symmetrical muscle weakness?

What infection should you consider if a patient presents with descending muscle weakness? And lastly, a college-age male comes into your clinic with arthritis, conjunctivitis, and urethral inflammation. What organism should you be considering?

Now, obviously, that’s not how they’re going to write the questions. I’m doing that just just to get you started with how we’re going to see them here today, but that’s not how they’re going to come. Right? You know that.

Now, as we start with infectious disease, I’m really just going to go through the way the blueprint has it this time. And one of the reasons for that is just to make things easier. So, you can read along the blueprint, you can read along through other books as you’re listening to this. That’s what I want to have available to you. It’s going to make us jump around a little bit with types of infections, but that’s okay. I think that may be helpful, and we’ll talk about that as we go. So we’re going to start off today’s discussion with botulism.

Botulism is Clostridium botulinum is the anaerobic organism. It’s important to remember that it’s anaerobic because of the places that you’ll find it. Botulism comes into play in a couple different places, really three. Infant botulism, adult botulism, and wound botulism. So this is when that organism infects the patient, but the real problem is that it has a toxin that inhibits the release of acetylcholine at the neuromuscular junction, causing weakness and paralysis. In infant botulism, this is where we get floppy baby syndrome. This occurs between the ages of 2 and 6 months old.

And this is caused by ingesting spores. So this is also the reason why we don’t have babies eat honey during the first year of life, because honey has been known to carry the spores of botulism, of Clostridium botulinum. Adult botulism is also caused by ingesting the spores, but in this case it’s more likely that it’s in canned food. And then wound botulism is when you get that actually just into a wound. This can be, the first one particular, can be medical emergencies and can be fatal. So, they’re they’re definitely a concern here. Clinical presentation in an infant, ptosis with upper eyelid droop, slow pupillary reactions, flaccid expression, and poor anal sphincter tone.

Then you get that floppy baby syndrome. That’s we were talking about. In adults, these are going to be afebrile. Symmetric neurological symptoms. The symmetric neurological symptoms is a good one, right? Because it happens on both sides. That’s going to be a way to differentiate it from other issues.

Things like a stroke, for example, which are more likely to happen on one side. They can have nausea, vomiting, abdominal cramping, dry mouth, diplopia, dilated pupils, facial weakness with drooping eyelids, slurred speech or a weak voice, dysphagia and drooling, dysarthria, diaphragmatic paralysis, so trouble breathing, and then descending weakness. Again, that’s sort of one that separates this out, right? So for your diagnosis on physical exam, all of the things we talked about above, but those signs of descending symmetrical muscle weakness or paralysis is a big one. And then decreased or absent pupillary reflex. Obviously, if it’s a wound infection, culturing the wound is going to be part of your diagnostic technique here, right? There aren’t really tests that are run to diagnose botulism.

It’s really looking at the patient and then the patient history, right, are going to be ways that we do it. And the other important part here is that it’s also going to be that we need to start treatment immediately if it’s suspected. Because the timetable, because of that toxin, matters. Our treatment in this case is the antitoxin, but the antitoxin prevents binding of toxin to nerve cells. It does not do anything to the cells that have already been bound by the toxin. So it can be a real issue for these patients. You’re sort of stopping the progression of the disease once you start the antitoxin, but you are not curing the disease.

I hope that makes sense. So we want to start that as soon as possible. You may also need breathing assistance in these patients. The real concern is as you get that descending muscle weakness, you get that diaphragmatic weakness, you interfere with breathing, right? That’s the main issue here. So you may need to intubate these patients or be prepared for that. And then part of the treatment is going to be rehabilitation therapy as they get their strength back, but it takes time.

Campylobacter jejuni. This is a gram-negative bacilli. It is also foodborne. It’s most commonly associated with poultry. Generally speaking, this is a self-limiting diarrhea, but it does can have some complications. One of those is it’s associated with the development of Guillain-Barre syndrome due to the cross-reactivity. Clinical presentation, watery and possibly bloody diarrhea.

You don’t see bloody diarrhea for all of these, so that may be one you want to put a little mark next to. Abdominal pain and headaches are also possible. Diagnosis for campylobacter is going to be stool culture. And again, treatment here is it’s typically going to be a self-limiting diarrhea, right? So then treatment isn’t really going to be necessary. But what is our most important thing with anything that causes diarrhea? Well, our most important thing is fluids and electrolyte balances, right?

We want to make sure that we’re providing enough fluids to these patients because you can get very overwhelmed by how much fluid your patients lose through diarrhea and vomiting. It can be hard to quantify it. So always overestimate. Always assume you need to be pushing fluids.

Now, if you have cases that last for longer periods of time or result in more severe disease, you can use azithromycin. Or if you have a patient who’s, let’s just say, is immunocompromised or elderly or something along those lines, azithromycin may be used, but generally speaking, it’s not necessary. Chlamydia is our next one. Chlamydia trachomatis is the bug we’re talking about. It’s the most commonly sexually transmitted bacteria. Sexually aided. I’m making up words now.

Most common sexually transmitted bacteria. The most common cause of non-gonococcal arthritis in men. And in women, it may cause cervicitis, salpingitis, and pelvic inflammatory disease, which is a major cause of infertility.

Now, let’s cycle back through. Cervicitis is just an infection of the cervix. Chlamydia is a very common cause of cervicitis. It’s an infection of the cervix, right? Salpingitis. What is that? That’s when the fallopian tubes become infected.

And then in pelvic inflammatory disease is when that infection moves up through the cervix, through the fallopian tubes and out into the pelvis, and you get this nasty infection in the pelvis caused by chlamydia. And it results in what we call pelvic inflammatory disease. And what I see, my end of it is when I’m in the operating room, is we put a scope in to look into someone’s abdomen and it looks like a bomb went off. There’s scar tissue and adhesions everywhere. And it’s a complete nightmare if you’re trying to perform surgery.

Let’s say you have someone who has a cyst on their ovary and you want to try to alleviate that and get rid of the cyst for them. Well, a lot of times you can’t even find the ovary because there’s so much scar tissue and so much adhesions and there’s things stuck to everything where it should be a nice, clear picture. That’s the end result on my end of pelvic inflammatory disease. But all that scar tissue is what causes infertility and scars in the tubes and scars down the uterus and makes it hard for people to get pregnant. And it causes a lot of pain down the road. So chlamydia can do a lot of damage if left unchecked in that manner. At one point, it was the leading cause of blindness in the world.

And then something else to point out here, And it’s mostly, you may see this, but it’s also just something that jumps out when you go through review books. It’s that it can cause a triad of arthritis, conjunctivitis, and urethral inflammation. So those three things kind of go together because chlamydia can cause a couple different issues. And that’s certainly three of the issues. And when you see them together, it should definitely cue you in, especially in a sexually active individual. And that’s how I would expect, not expect, but that’s how you might see it in a test question. A description of someone who is complaining of joint pain, has conjunctivitis, and concurrently has urethral inflammation.

Clinical presentation. Surprisingly, as we go through this, if you’ve never dealt with chlamydia before or are just learning about it, and I’m going through all these symptoms and all these problems it can cause, surprisingly, it usually has no symptoms at all, and that’s one of the problems with it. It’s a sexually transmitted disease that typically has no symptoms. I think it was like 70% of people that are estimated to not have any symptoms at all. So that’s one of the reasons it can spread and cause a problem, right? Because if you’re, if you have urethral discharge or cervical discharge, you may prevent sexual transmission, right? But if you have no symptoms whatsoever, then it, people don’t know that you’re sick, then it can be a problem.

In men, you can get watery discharge. It’s less painful than gonococcal urethritis. You get a burning and itching around the opening of the penis and pain and swelling around the testicles. In women, abnormal vaginal discharge that may have an odor, bleeding between periods, painful periods, abdominal pain with or without a raised temperature. Pain with sexual intercourse. Itching or burning in or around the vagina. Pain with urination.

So a lot of kind of, I don’t want to say vague symptoms, but a lot of sort of GYN symptoms that have pain and burning, either in the vagina or in the cervix. How do we test for this? How do we prove it? So some of the labs and studies, what they use are nucleic acid amplification tests, so like PCR, polymerase chain reaction tests, TMA, which is transcription-mediated amplification, SDA, which is strand displacement amplification. So one way or another, we’re going to perform a nucleic acid amplification test on a sample. So either a discharge from the woman’s cervix, discharge from the male urethra, or a urine sample. Treatment, number one is going to be prevention, right?

Prevention is always going to be the easiest way to avoid something like chlamydia. How do we prevent it? First is abstinence, right? It’s a sexually transmitted disease. So if we avoid having sex with someone who’s infected, then we don’t have a problem. So if we avoid having sex, then we can sort of assure that we’re not going to catch this. Beyond that, barrier protection, and then limiting sexual partners.

So how else do we detect this? Well, because it is a typically asymptomatic infection, screening of women under 25 who are at risk is generally a good idea. And then we also do a screening of pregnant women because it can be passed to the infant, to the baby during vaginal delivery. It can be treated with azithromycin or doxycycline and all sexual partners need to be treated. Right? Because again, you don’t know if they have the infection because they don’t demonstrate symptoms. Our next one, our next bug, we’re going to jump back to diarrhea.

And that’s what I was saying. You can go in alphabetical order here, but you miss sort of some connection, so I don’t know that I love it, but that’s the way we’re going to handle it this time through. Cholera is our next one. Cholera is, the organism is known as Vibrio cholera. It’s a gram negative comma shaped comma shaped organism with a single flagellum. Generally transmitted through the fecal oral route, and it’s common in places with poor sanitation and crowding. Toxins produced by the bacteria result in hypersecretion of water and chloride.

Interestingly, as I was going through this this time, I came across the little fact that the last outbreak in the United States was in 1910. So a lot of the things we learn that are important for medicine, you may not be seeing in the office, but are important throughout the world and are important from a historical standpoint. And one of the things I think is really cool about cholera is the recommendation I have for a book called The Ghost Map by Stephen Johnson. The Ghost Map is a fantastic book, and I recommend reading for a number of different reasons when you’re in PA school, even though I know everyone thinks you don’t have time for it. And I’ve had this conversation multiple times. You do, and it’s actually really important if you can spend some time reading something outside of your textbooks. But The Ghost Map was a fantastic read because it was about the cholera outbreak in London before they understood bacteria.

So they were still trying to determine what was causing these deaths around the city and it was all, and all the different hypotheses and all the different ways to try to prove it. And it goes through how Dr. Snow came up with the idea that it was being caused by the drinking water. And actually it’s called The Ghost Map because he mapped out exactly where everyone had passed away and then looked at the map and tried to give some commonality, some, you know, find what was the link between all of these people. And he wound up figuring out that the link was one water pump that they all used and that that water pump had become infected. It’s a fascinating read from a couple of different standpoints. One, just because it’s an interesting story.

And two, looking back to before the bacteria were understood as a cause of infection, right? So they were arguing over whether it was coming from the air, whether it was coming from the water, whether it was coming from the humors, you know, that kind of thing. So it was very, very, so it was a ton of fun, really interesting and really solidified cholera and how it works and where it came from. And it’s important, I think, as you read through your textbooks, as you read through your review books to try to make this stuff real, to understand that someone struggled to figure out what these organisms were, struggled to find out how to test for them, struggled to find out how to treat them. You’re being handed this information in a book, right? Someone’s just saying, here, if this test comes back positive and they look like this, then this is probably what it is and this is how you’re going to treat them. But understand that’s not how it was, right?

You’re being handed 100 years of data and kind of the solution. But for me, I think it’s really interesting and important for you to take some time to think about how these things came about, how it was first discovered when a patient came in with diarrhea, what was the cause, and how we didn’t have tests for certain things and how it took a long time to get there. So anyway, The Ghost Map by Steven Johnson. I strongly recommend getting hold of it. Really, really good book. Clinical presentation. We have rice water diarrhea and lots of it.

These patients… it’s going to have 10 to 20 liters per day. That’s three to five gallons per day of diarrhea from cholera. It is tremendous volume. So what’s our problem here? Our problem is dehydration. Dehydration is what kills people.

These people come in looking a little bit blue. And the reason for that is that severe, severe dehydration. When you have dehydration, what are some of the symptoms? Well, rapid heart rate, loss of skin elasticity, dry mucous membranes, low blood pressure. They’re thirsty and muscle cramps. I mean, these people are stuck in bed, can’t move and eventually die of dehydration. Diagnosis is physical assessment, stool cultures, and you can do a cholera dipstick.

Although I’m thinking since this hasn’t been seen in the United States in 1910, I’m not sure where you would find one of those. Treatment. Fluids. Oral is sufficient in most cases, but there has to be lots of fluids. Electrolyte replacement. Again, these people are losing three to five gallons of water per day. That needs to be replaced, right?

If you can get that replaced, most patients will do very, very well. So if severely dehydrated, obviously you’re going to move from oral fluids to IV fluids, but in most cases it’s self-limiting as long as you provide fluids. Antibiotics may shorten the course but are not necessary. In this case, you could use doxycycline or azithromycin. Our last bug for today is diphtheria. Again, this is not something you’re going to see very commonly. From what I found, you there have only been two cases between 2000 and 2012 reported in the United States.

This is the Corynebacterium diphtheriae. It’s gram positive and it’s a facultative anaerobe. It most commonly causes a pharyngeal infection. Severe cases may have a gray pseudomembrane that covers the pharynx and may cause obstruction. The reason why we haven’t seen a ton of these is that vaccinations have been very successful in this country. One of the major issues with the, two major issues with diphtheria, one is that because you get that, you get significant lymphadenopathy and that and the gray pseudomembrane, you can get an airway obstruction. In addition to that, diphtheria produces an endotoxin which may affect the heart and nerve tissue.

So although most patients do just fine, and most are actually asymptomatic, this can be fatal in 5% to 10% of patients diagnosed with diphtheria. Clinical presentation, fever and chills, sore throat, they get a barking cough, stridor, hoarseness, difficulty breathing, bloody nasal discharge, and malaise. On physical exam, that adherent gray pseudomembrane covering the tonsils is a giveaway, and then significant lymphadenopathy. Diagnosis is going to be a throat swab for culture and the growth of diphtheria. Treatment. In this case, again, we’re going to be given antitoxin, which prevents the toxin from binding, but does not affect toxin already bound to tissue. So, same as before when we were talking about botulism.

Right? So, that endotoxin I’m sorry that antitoxin needs to be given right away, maybe even before you have a clear diagnosis, because, again, it stops the toxin in its tracks, but it does not unbind it. It does not reverse it. So that antidote needs to be given right away. Antibiotics can be given, but they really don’t show improvement in the patient after receiving antitoxins. But what they do is decrease the transmission rates. You’re going to want to do a laryngoscopy.

Laryngoscopy, I can pronounce it laryngoscopy, to remove the pseudomembrane, and you may need to intubate these patients. It’s also important that these patients are isolated and all contacts are treated. These also need to be reported to the CDC.

All right, that’ll bring us through the first half of infectious disease. I’m not in infectious disease. We have a long way to go for infectious disease. That’ll bring us through the first half of bacterial infections for infectious disease. We’ll pick up with the second half at the next show. But for now, let’s move on to our study tip for the day. This is something that came more to light for me this week than it previously had because of a student that I was working with.

And the idea here is about habits and building up the mindset and building up the way that you take tests or even study. But I’m going to focus on taking tests, but it also has to do with how you study. And one of the people I look to for to tell this story is Michael Phelps. Michael Phelps in 2008 won more gold medals than anyone has ever won in the history of the Olympics, right? And one of the ways he did this was that every night his coach, Bob Bowman, had him, in quotes, play the tape of the perfect race. How many perfect strokes it would take to create the perfect race. Excuse me.

And he’d run through that image every single night in his mind, not in the pool, in his mind, about that perfect race and exactly how it would go. But in, what’s the word I want to find here? In intricate, that’s the word, intricate detail. Not, oh, I would win, but how many strokes it would take, how the turn would be. And he would do this over and over and over. He would eat the same breakfast every day. He did the same stretching and warm-up routine every day.

He listened to the same music before every race. So in 2008, during the 200-meter butterfly, his goggles filled with water and he couldn’t see. And you know what happened? He won the race because he knew how to do it. He’d practiced it so many times, both physically and mentally, that he was able to perform even without the ability to see. This is a case of incredible preparation and showing how creating a routine can have a tremendous impact on your performance when it comes to the day of career performance. I was talking with a student recently who had gone through the 33 Days to Pass Your PANCE program, and she’d wound up passing her exam moving up from the high 200s, actually, to passing, which was phenomenal.

And I spoke with her, and one of the things that stood out to me that really blew me out of the water was when she talked about that she followed one of my recommendations, which is to drive to the testing center the day before the test, or not the day before, but just before your test so that you’re comfortable. That it doesn’t take any… It removes a little anxiety. And we’re just trying to remove a little anxiety for everywhere we can. So by driving over to the testing center before the day of your test, you know where to go. Everything feels good. Even though you have your GPS and I know you’re going to get there and everything’s going to be fine.

It takes work if you don’t know where you’re going. There’s a little anxiety if there’s traffic, there’s a little, you’re not sure, is it turn at the next light? Is there at this light? If you’ve driven there before, it’s easy. So I recommend everybody to drive to the exam site before your test day. Well, she took that up a notch. I think she said two weeks before, she started driving to the testing center every single morning, and she would study there, either in the parking lot or somewhere nearby.

And for two weeks, she drove to the testing center. How do you think she felt when she showed up there on test day? Do you think she felt nervous or worried? Or do you think she felt like it was just another day? Well, she felt like it was just another day. She told me that. She got there and she didn’t feel any of the same things she had felt the first two, three, four times she’d driven there.

The first time, I think she said she had a panic attack and actually had to pull her car over. Unexpectedly, she didn’t think she was nervous, didn’t think she had anxiety. But all of a sudden, she found herself in that position. And then after two weeks of driving there every morning, And by the time her test came, it was easy. And she blew it out of the water on her second try, where most people who don’t pass on the first time, the majority of people struggle again on the second time. And she absolutely blew it out of the water. And I think this is a major reason she did.

So I encourage you, when you study, when you get ready for your exams, build yourself a routine. Build yourself a practice to get ready. So that it feels like you’ve already won. So it feels like you’ve done it before. So it feels like it’s easy because you’ve done it so many times. Put yourself in that position and I think you’ll find that you perform a whole lot better.

All right, let’s move on and answer our priming questions. A patient presents complaining of a huge volume of diarrhea, which he describes as milky and watery. He has a little blue. What is the most likely diagnosis? Cholera. What is the first line treatment for all diarrhea? Fluids.

What infection should you consider if a patient presents with descending symmetrical muscle weakness? Botulism. A college-age male comes into your clinic with arthritis, conjunctivitis, and urethral inflammation. What organism should you be considering? As we said, it won’t be stated this way so nice and clearly, but you should be considering chlamydia.

All right, that’ll wrap us up for today in our first session of bacterial diseases and our first session of infectious diseases. So happy to be back, happy to have you on board. If you have any questions, anything you want to find out more about, head over to the website, physicianassistantexamreview.com, and you’ll find everything you need to know over there. If you have not yet, I strongly recommend that you sign up on there for the email system. I send out emails giving tips, tricks, and techniques every single day of how to get through school, how to pass your PANCE, and how to move forward in your career. So definitely go ahead and check that out.

All right, until next time and when we pick up bacterial diseases part two, good luck. And if you have your exam coming up between now and then, good luck to you and please keep me informed of this, how you’re doing. Take care. Thank you.