099: Infectious Disease Part 2 & When It isn’t Easy

Hello and welcome to season two, episode 99 of the Physician Assistant Exam Review Podcast. This is where we teach core medical content and how to dominate school and ultimately pass the PANCE. Those are not the same, by the way. We’re working a lot toward learning things like study skills and test-taking skills and how to be a better student, how to be more organized, how to get things done is really a major focus for PA school. As I’m sure you’re finding out, if you’re in school, things can tend to be a little overwhelming. And that’s another place where we focus our attention both on the medical content and then on all the other things you need to both pass and stay in school and then, of course, to pass the PANCE.

Now, before we jump into today’s content, which will be bacterial diseases part two, if you find anything in today’s show helpful, if you find the content something that you think is inspiring or puts you in a position to win or cover some material in a way that you think is a little different, a little interesting, a way that makes it help stick, then please share the show with somebody in your class. Please share the show with someone else you think it could help. That’s really important for me. It’s really important for them. And that’s honestly the only way that I grow the show. The only way that people find out about this is through your word of mouth. I didn’t do any advertising.

I didn’t do anything like that. It’s solely through you telling people about the show. So I’d really appreciate it. And so would they if you’d go ahead and do that.

All right, let’s go ahead and get started. Today, we’re going to be picking up on bacterial diseases. We’re moving our way through infectious disease. And it’s really just in an alphabetical order kind of way. And we’re starting with, like I said, bacterial diseases, which you’re going to see. Well, I’ll get into it as we get there. I don’t want to give anything too much away.

If you’d like to get every single episode of the podcast, you can go over physicianassistantexamreview.com/podcast. And that will take you all the way back to the beginning, season one, episode one. And you can find everything there inside the PAER app. I think you’re going to love it. It’s a great way to listen to the show. It’s really, really something I’m very proud of and very thankful was created and that we’ve put to good use here. So with that being said, let’s go ahead and jump into our priming questions.

Describe Neisseria gonorrhoeae under the microscope. Describe Neisseria gonorrhoeae under the microscope. List one medication you can use to treat methicillin-resistant staph aureus. What’s the name of the criteria used to diagnose rheumatic fever? What’s the name of the criteria used to diagnose rheumatic fever? What medications do you use to treat a gonococcal infection? What medications do you use to treat a gonococcal infection?

All right, all right. So let’s go ahead and get started. Gonococcal infections will be first today. They are caused by Neisseria gonorrhoeae, which is a gram-negative intracellular diplococci.

Now, the reason why I point that out is because it’s such an easy one to get right. It’s such an easy one to see on your exams, on your test papers, on the reports back from the lab. Gram-negative intracellular diplococci, that should just jump off the page of you from throughout all of medicine on your PANCE all the time. It should just be something stored inside your brain, and you should know that really, really easily.

Now, this bug infects the mucous membranes of the reproductive tract, including the cervix, uterus, and fallopian tubes in women and the urethra in men, in women and in men. It can also infect the mucous membranes of the mouth, throat, eyes, and anus, secondary to direct inoculation. Systemic gonococcal infections are disseminated gonococcal infections, right? So we get a gonococcal infection that then enters the bloodstream. And then a chronic case may lead to prostatitis and pelvic inflammatory disease. We talked a little bit about pelvic inflammatory disease before. And part of the difficulty, I think, for students learning about medicine for the first time is understanding that over the years, diseases got names, got descriptions, and then we started to discover why they were caused.

And what we found is that different bugs cause different diseases depending on where they’re located, right? So one bacteria in one part of your body can cause one issue, but if it’s in a different part of your body or in a different tissue, it’ll cause a different issue. Well, before we really understood all of this, we might call those two different diseases, two different things, right? So it gets a little convoluted and complicated as you’re trying to learn the names of the organisms and then learn the diseases that they cause and then separating out those two and then mixing those two back together as people use different names for things. I think that’s one of the main difficulties and focuses as you do infectious disease or even pulmonology or even ENT. The things that have bacterial causes tend to trip people up and I think that’s the main reason is because they don’t initially see that one bug in a different spot in your body or maybe even just more infectious in a specific area will have a different name for that disease. And I think you know that, but I think most of us need to do a little extra work, especially initially, to separate those things out in our head.

To me, even on the blueprint here, it had gonococcal infections and it had gonorrhea. That seemed a little silly. If you’re going to cover gonococcal infections, you’re going to cover gonorrhea, right? That’s basically what we’re talking about here. But it’s the same idea that you can get strep throat or you can get impetigo, which is a skin infection, both caused by strep. Right? They have different names, but it’s really the same bug in a different place on your body.

And the more you can see that, the more you can understand that, the easier it is to categorize and then reference all this stuff down the road. So anyway, let’s keep going. Clinical presentation for a gonorrhea infection. In men, this is usually abnormal discharge from the penis with a yellow, creamy, and excessive amount of discharge. I’m not sure what excessive discharge would mean, honestly. Blood-tinged, the discharge may be blood-tinged, and they can have painful or frequent urination. Women may be asymptomatic, and again, that’s a major problem just like we talked about with chlamydia, asymptomatic carriers.

They can have abnormal purulent vaginal discharge, abnormal vaginal bleeding during or after sex or between periods, genital itching, painful or frequent urination, painful sexual intercourse, irregular menstrual bleeding, lower abdominal pain, and fever. So again, a lot of that doesn’t really give you a lot of things to differentiate Neisseria gonorrhoeae from any other issue, right? A little bit, but not a lot. In males and females, you can get an eye infection, which will usually be unilateral with copious purulent discharge or septic arthritis. If it gets into the bloodstream, you can get knee, ankle, or wrist are the most common joints affected. The diagnosis here is going to be with a polymerase chain reaction PCR test, culture, gram stain, urinalysis. And in women, you may want to do a pelvic ultrasound, again, depending on the severity of the disease.

If we’re talking about something like pelvic inflammatory disease, then yes, of course, you’re going to want to do a pelvic ultrasound. Treatment is going to be that one problem is that there’s widespread antibiotic resistance. So for something like gonorrhea, you’re going to give an IM ceftriaxone with doxycycline or azithromycin. And all sexual partners need to be treated. That’s important. Again, just like chlamydia, you want to treat everybody, especially for those asymptomatic carriers because you want to pick those up.

Next, we have methicillin-resistant staph aureus, which again is just a strange thing for, as far as I’m concerned, for them to have pulled out here as a separate thing because staph can cause a lot of different infections. And this is just a staph infection that is difficult to treat, right? Methicillin-resistant staph aureus doesn’t, we can’t treat it the way we normally do. They’ve acquired a resistance to a beta-lactam antibiotics like methicillin, oxacillin, and cephalosporins. It also may be resistant to tetracyclines, macrolides, fluoroquinolones, and Bactrim.

Now, one of the interesting facts, and this is something that took me a long time to get my head around, is that Staph aureus is normal human flora on the skin and mucous membranes. It can become a problem if there’s like, let’s say there’s a break in the skin and this bacteria gets into that. That’s how you get a skin infection, right? And 75% of staph infections are skin infections. You know, my wife had one in her shin a long time ago when she got bit by, I think it was a mosquito at the beach or something. And then slowly we noticed it getting more and more red over a couple of days turned out to be a staph infection. And you’re like, oh, how did you get that?

Well, it’s just a breakdown in the skin. And for whatever reason, your immune system doesn’t fight it off as the bacteria get into that wound. And like I said, it seems like such a simple concept, but somehow it’s hard for us to wrap our heads around that these bacteria are all over the place. And usually your immune system is fighting them off and doing an amazing job of maintaining homeostasis throughout your body. But sometimes it loses and needs a little help. But a lot of this stuff is ubiquitous. So when we talk about staph infections, we’re talking about things like skin infections, pneumonia, endocarditis, osteomyelitis, which is infection of the bone or infection of the heart, and then a septic arthritis.

Those are all possibilities from staph. And again, MRSA is just a staph that is very difficult to treat with normal antibiotics. Labs and studies, you’re going to get cultures and treatment. There are a couple of different ways to treat it, but for now, I’m just going to stick with vancomycin as our treatment. But you really need to take some time and dive into staph and strep and understand what they are and what diseases they can cause. So, for example, we’re going to move into acute rheumatic fever, which I think is a little bit strange that we have that on this list, because this occurs after a strep pyogenes infection, usually after a strep throat. The weird part here is it’s an immune response, not really an infection, although it’s studied under infections because it tends to follow strep.

So, there’s a reaction within the immune system that makes sort of the immune system go a little haywire following a strep pyogenes infection, which is also, by the way, why we are sort of, I don’t want to say aggressive, why we treat strep throats. From what I remember and from what I’ve studied, strep throat tends to be self-limiting. Giving antibiotics doesn’t really affect the course of strep throat. What it does is it reduces the incidence of rheumatic fever and scarlet fever. Those are the things we’re trying to avoid, not really the strep throat per se. As you would imagine, this most commonly affects children ages 5 to 15. Symptoms begin about 1 to 5 weeks after the initial infection.

And the important part here is this is the most common cause of cardiac issues in childhood. It can cause valve stenosis, valve regurgitation, heart muscle damage, atrial fib, and heart failure. Clinical presentation here is a fever. Actually, we’re going to get a little bit deeper into the physical presentation. You’ll see why in a little bit. But painful polyarthritis, multiple large joints is what that means, painful polyarthritis. Chorea, which is weird involuntary movements.

Erythema marginatum, which is a pink ringed rash. And then they get these subcutaneous nodules. You can also come across a new or changing murmur. Signs of heart failure or pericarditis. Labs and studies, you’re going to want to do an antistreptococcal antibody test, a C-reactive protein, ESR, chest X-ray, ECG, and an echo, because again, we’re looking for heart issues with rheumatic fever. Now here’s the thing. That antistrep antibody test can come up positive, and that’s really just going to tell you that they’ve had a strep infection, right?

But how we diagnose rheumatic fever is purely clinical. So there’s a criteria that people have set up over time to help with the diagnosis of rheumatic fever. There’s no test, right? We can’t do a blood test for rheumatic fever. It doesn’t work that way. It’s an immune response. We’ll get an elevated C-reactive protein, but those aren’t going to be proof that it’s rheumatic fever.

So what we do is we look at the symptoms the patient is having, and then what happens is you give point values to each of those symptoms, and if they add up to enough points, that leads you to the diagnosis of rheumatic fever. So that’s called, in this case, we call that the Jones criteria. You should have a history of strep infection, number one, and then two major criteria, or one major criteria and two minor criteria. So a history of strep infection is key. The major criteria are carditis, polyarthritis, chorea, erythema marginatum, and those subcutaneous nodules. So if you have a history of strep throat and any two of those, it really points you towards a rheumatic fever diagnosis. But let’s say you only have one of those major criteria, like carditis or polyarthritis.

You have aches, you had strep throat, now you have aches in every joint. Well, we move on to minor criteria, and then you would have to have two minor criteria, which would include things like a fever, arthralgia, which in our example, example would be the same, polyarthritis and arthralgia, previous rheumatic fever or rheumatic heart disease, acute phase reaction, so an elevated ESR, CRP, or leukocytosis, or a prolonged PR interval. You would need two of those minor criteria plus one major criteria and a history of strep infection to point you towards a rheumatic fever diagnosis. Like I said, or two of the major criteria would be enough to get you over that hump. I hope that makes sense. We don’t have a clear laboratory test, right? So we put together the physical examination signs that lead us towards a diagnosis of rheumatic fever.

Treatments, you are going to use antibiotics in most cases to treat that strep, so something in the penicillin family. And then anti-inflammatories like aspirin, naproxen, NSAIDs, or steroids if really necessary.

All right, that’s going to wrap up our content for the week. I don’t want to go any further down this road because we’re going to do bacterial diseases again in the next episode. So I want to make sure that we have enough room to process what we have and then enough room to move forward. Remember, I talk a lot about repetition. So go back through some of these episodes, go back through some of this content, hear it again, hear it again, hear it again. That’s what’s really going to sink it in. That’s not our study tip for today, by the way.

Our study tip for the day is something I came across this last week, which is the idea that it doesn’t get any easier. I’m very guilty of this, and I want to share it with you because I’m so guilty of it, is the idea that it doesn’t get easier. If you’ve chosen a path to grow, you’ve chosen a path to improve, once you’ve done that and you’ve committed to that, it never gets any easier. I hope you understand what I’m saying because as you grow, you’re going to need to grow more. As you learn, you’re going to need to learn more. If you were happy staying static, if you were happy just sitting on the couch all day, it wouldn’t get any harder, right? Eventually, you’d figure out how to do it.

You’d live right there. But who wants to do that? You’re in the process of growing and improving and getting better, which means tomorrow is going to be hard. The day after that is going to be hard. The day after that is going to be hard. But that’s what you’ve chosen. That’s what you’ve decided to do here.

It’s not supposed to get easier. You’re supposed to improve every day. And the easiest example of that I can use is that I’ve been doing longer and longer runs, right? Well, every day it gets harder because that’s the plan. It doesn’t get easier. I don’t want it to get easier. That’s exactly the point.

Some days that’s frustrating, like super frustrating. I know some days you want to call it quits because you’re dying and it’s so hard and it never lets up. It’s relentless. But that’s kind of the point. Right? That’s what PA school is. That’s what a life designed to grow and learn is.

A life designed to get better is. It’s going to be hard every day. And I hope you understand that. I hope you look at the people around you and understand that they are also struggling. It’s also hard for them. It’s not easier for you or easier for them. It’s hard for everybody who’s trying to get better every day.

That’s the way that this works.

All right, let’s jump in and answer our priming questions. Describe Neisseria gonorrhoeae under the microscope. I hope you saw that at the beginning. Again, this should just pop right into your head, gram-negative intracellular diplococci. List one medication you can use to treat MRSA. There are more. I’m not going to go deep down the list.

Right now, I’m just going to pick vancomycin. Name the criteria used to diagnose rheumatic fever. That was the Jones criteria. Remember this, those symptoms used to diagnose rheumatic fever. A list of symptoms, right? If you only have one symptom, we’re not going to think it’s rheumatic fever. You need to have a conglomerate of symptoms.

What medications do you use to treat a gonococcal infection? And the ones we covered here were ceftriaxone with doxycycline or azithromycin.

All right, perfect. Hey, I’ve been getting some fantastic news back from the members of the 33 Days to Pass Your PANCE cohort from the April group. The June group is rolling along and doing really, really well. I’m excited to see how they’re turning out. Just have actually the first couple of people starting to take their exams very soon. So I’m excited to see how they do. But I want you to understand that the work we do here is valuable.

The things we’re covering here will help you to improve your scores, will help you to do better, will help you to grow. And that to me is the most important message I can get out there is that there are ways to do better. There are ways to grow. There are ways to stop struggling throughout PA school and then again on your PANCE. So stick with us here. And I can’t wait to see you in two weeks. Again, share the show if you found it helpful.

Share the show if you have somebody in your class who is struggling or could use a little help. I would love to have them within the community.

All right. Take care. Thank you.