100: Bacterial Infections Part 2 & an app I’m loving

Hello and welcome to season two, episode 100 of the Physician Assistant Exam Review Podcast. This week we’re going to be continuing with infectious disease. My name is Brian Wallace. I’m the founder and creator here at Physician Assistant Exam Review, where we teach core medical content and how to dominate school and ultimately pass the PANCE and land your dream job. There’s a whole lot wrapped up in that, right? So part of it is core medical content. And that’s what this show is mostly about.

But then there’s also the dominate school, pass the PANCE and land your dream job, which is a little bit further in depth that we go in this show and in the, and throughout the emails I send on a daily basis and everywhere else that I produce content for you to explain some tips, techniques, philosophy, strategies to improve your test scores, to improve your studying, to improve your ability to retain information long-term so that you can dominate in school. Your scores can go up and you can pass the PANCE. And then we talk about how to get your dream job and function as a PA, which is really the goal of all this, right? Just to go out and start treating patients, start helping people. That’s really what we all want to do. So that’s what the goals of this show are. And I created this show, wow, we’re going on 11 years now ago, as I started to get ready for my PANRE and wanted to place it, post my notes and talk about some of the things I needed to cover and some things I needed to do better.

And this has helped me stay accountable to continue my education, continue growing, continue learning. And that’s one of the things I really enjoy about doing this show. You know, that’s one of the reasons I love to write for the Physician Assistant Exam Scholars newsletters, because it pushes me to continue to grow each and every month. When I put out that content, it forces me to think through my ideas, think through how I would handle something, and really drill down hard on a particular topic. Last month, the July issue that just went out was on, you know, someone had asked me my top five ideas are things that might help a student in their didactic year. And I sat down, I was actually, I was out in Nebraska a couple of weeks ago for a baseball tournament in Omaha. So I have, you know, about that.

And on the plane, I sat down to think about, okay, what are the five top things I would do for the didactic year? Things I could tell someone that would really change what they do. And I immediately, well, not immediately took me about 30 minutes, came up with 26 ideas. So it’s hard to narrow it down to just five. They do believe in keeping things simple, but the last issue of the Physician Assistant Exam Scholars newsletter was the first 12 of those 26, covering it in a little bit more detail. The 12 things, I think, would dramatically improve your scores as you move through didactic year. And obviously, that would help you throughout clinical year, because it has to do with studying, retention, test taking, those kind of things.

And the July issue is going to be the next 12 to 13, depending on if I cut one out or maybe even add one, depending on how the writing goes. So I’m sorry, that would be the August issue is going to be covering the next 13 things to help you get through your didactic year and really improve your scores and make things a whole lot easier for you, right? Everyone complains about how little time they have. That is true. Things are difficult. Things are tough. Things are very time consuming, but it’s also not true.

I’m finding in my own life now, I am busier than I have ever been. This week alone, I have a, well, I’m not going to get into my schedule, I guess, but I’ve suffice it to say I’m busier than I’ve ever been. And I’m still producing not quite as much content as I would like, not quite as far along as I’d like, but still producing a fair amount of material and spending a lot of time on Physician Assistant Exam Review. And there are ways to get more time out of your day. There’s a way to get things done more efficiently. And I know most people have spent a little time covering this, but as you’re forced into it, you find that there’s more and more down that rabbit hole. So anyway, that’s a little bit I want to talk about where this show comes from, where we’re coming from, where the ideas come from, what we’re trying to accomplish.

We’re trying to accomplish you passing your PANCE, getting through school and passing your PANCE. That’s my number one goal for you. So I want you to understand that as I go through the content material, especially if you’re new to the show. The number one thing I want for you is to get through school, stay in school and pass your PANCE. Those are my goals for you. So the way I cover the material is designed exactly to make those things happen. So there are things I leave out.

There are things I emphasize. There are things I don’t talk about. Most of that is done intentionally to aid you in your path to stay in school, pass your tests, improve your scores, and get you to a point where you can pass your PANCE. That’s really my goal.

Now, if you’re interested in more shows, I had someone reach out to me this week saying, hey, you know, I’m struggling to find the shows on cardiology. Well, all that stuff can be found in the Physician Assistant Exam Review app. So it’s at physicianassistantexamreview.com/podcast. You can download there the PAER app, and you have access to every single podcast that was ever produced. You can find it right in there. It’s really easy. physicianassistantexamreview.com/podcast.

Also, if you’d like to get more information about the show, about what I cover, about everything going on here and what I do, and techniques for you to, like I said, to improve your scores without necessarily doing any more work, you can find that at physicianassistantexamreview.com and sign up for the email system there, and you will be given daily emails with all of that information in there. Really just more than I could ever put into the show because like I said, I write them every single day and they go out to everybody on that list and I think you’ll find it really, really helpful. I get emails from people every day saying how much they look forward to getting those emails.

All right, well, let’s go ahead and get started with our priming questions. And again, for new listeners, the priming question section of this show is designed to get your brain thinking. I do not want you sitting in your car, staring off into space, letting this material wash over you. I think that’s a mistake. I want you actively engaged, sitting on the front of your chair, just like you would be in school, ready to learn, ready to absorb, ready to actively put this information somewhere in your brain and attach it to other things that you’ve been thinking about, that you’ve been learning about. Even if you don’t know the information yet, the priming questions get you thinking about where you should be storing this information, where it should be associated with, where it should go inside your brain so you can find it later. That’s really the goal of the priming questions, to get you ready to go.

So don’t just sit and listen to them, even if you don’t know the information. Just thinking about it will increase what you retain from this particular episode.

So let’s go ahead and get started. A patient spends time in the woods and now has a rash on both wrists and arms and a high fever. What diagnosis do you suspect? What’s the first-line treatment for Rocky Mountain spotted fever? Trismus is a sign of what disease? What are the two disease states caused by salmonella? What are the two disease states caused by salmonella?

All right, so we begin with Rocky Mountain spotted fever, which is a tick-borne disease. So that would be what I asked earlier in the priming question about someone who spends some time in the woods and then finds themselves with this rash. We’re looking towards Rocky Mountain spotted fever. It’s a tick-borne disease. The organism is Rickettsia rickettsii, and this causes small vessel vasculitis, which can cause serious damage to internal organs and can be lethal. But that’s where that rash is. It’s that small vessel vasculitis.

So that can all merge into a petechial rash and into a larger, larger, what are they called? The lesions can kind of coalesce and become bigger and bigger. This may be found throughout the Western Hemisphere, despite the name. It can be found anywhere in the US, in Central America or South America. Clinical presentations. So these patients come in with a high fever, nausea, vomiting, severe headache, muscle pain. And then they get that macular papular rash, which is about two to five days after the fever begins.

And it begins on the wrists and ankles and then spreads to the trunk. So that’s your differentiator here. That’s your way of learning Rocky Mountain spotted fever is how that rash appears, right? So they get that petechial rash. They can get abdominal pain, joint pain, injected conjunctiva. As this progresses, things can get substantially worse. So they can get hypotension and then some neurological issues like restlessness, insomnia, delirium, and they can even wind up in a coma.

Physical exam findings, again, you’re looking for that maculopapular rash several days after the fever begins. And then in severe cases, you’re looking for jaundice, hepatosplenomegaly, and acute respiratory disease. Diagnosis. So when you do a blood test, they’re going to have low platelet count, low sodium, and possibly elevated liver enzymes. Not diagnostic, but just some information. You can biopsy the rash itself and look for the organisms, and then a PCR test will help. Treatment.

The number one way to deal with this is prevention, right? So long sleeves and high socks, if you go out hiking or in the woods, they talk about tucking the ends of your pants into your socks. That’s one way to go. Bug repellent, including DEET, is really going to be helpful here. And then we get into the actual treatment medications. Doxycycline is first line treatment. Anyone older than eight and anyone who’s not pregnant, right?

Those are our concerns. Amoxicillin can be used in cases of younger patients and pregnant patients, but it’s not as effective. So, from one of the material I went through, it kind of said, listen, doxycycline is going to be the most effective treatment. And you kind of have to weigh the concern that you are going to cause a problem for the whether it’s teratogenic enough in in pregnant patients, because it really hasn’t shown a real significant teratogenic effect in the dosages. And, of course, you would need to treat Rocky Mountain spotted fever. And the same thing, I think it was what that might stay in the teeth of kids younger than eight. And again, the same thing.

It was like for the course you need to give, that risk is extremely low. So that’s something you need to weigh with your patients, with the parents. Doxycycline is clearly the best treatment and nothing seems to work as well, but you can use amoxicillin and then also chloramphenicol as the second line treatment. So something to think about if you’re actually in the clinic. Next we have salmonellosis. Salmonella enterica. This is a gram-negative rod.

And the problem here is ingestion of contaminated food or water. And it can cause two different disease states. Gastroenteritis, which is your more common thing. This is an incubation of 8 to 48 hours. In a course of 3 to 5 days, you get this stomach infection. Then you have typhoid, which is your enteric fever, which lasts 5 to 14 days. Our clinical presentation for gastroenteritis.

Hang on just a second. I’m going to go into focus mode here. I’m getting too many interruptions.

Okay. Ingestion of contaminated food or water. I’m sorry. So clinical presentation would be for gastroenteritis, just what you would think. Crampy abdominal pain, fever, nausea, vomiting, and then bloody diarrhea. Again, that’s the more common situation with the salmonella infection. Then you can have typhoid, which is enteric fever.

Here you have a prodrome of a general malaise, cough, and fever, followed by abdominal pain and distension. You can get constipation and or diarrhea with pea soup stool, a high fever, elevated heart rate, abdominal tenderness, pink papular rash on the trunk, delirium, and hypovolemic shock. So this is somebody who’s much sicker, right? This is not just a stomach bug. This is somebody who’s really, really sick. Diagnosis is going to be a stool analysis and fecal analysis, blood cultures, and urine culture. Treatment is going to be the number one treatment whenever we have a patient with significant diarrhea or vomiting is going to be replaced with fluids and electrolytes.

For gastritis, it’s really going to be a self-limiting disease. You can give Bactrim or Cipro. And then for enteric fever, you’re going to want to give a fluoroquinolone like ciprofloxacin or a third-generation cephalosporin like ceftriaxone. Shigella is our next one. It’s a gram-negative facultative anaerobe. It’s a gram-negative rod. Its mode of transmission is oral-fecal route.

This is often found in the daycare centers, nursing homes, refugee camps, and other places where conditions are crowded and sanitation is poor. Again, the mode of transmission is the fecal-oral route. Patients with an HLA-B27 may develop reactive arthritis. That’s sort of an interesting caveat here and something you may want to consider sticking into your brain a little bit more solidly because that may come up on an exam in sort of a weird way. Signs and symptoms, you can get abdominal discomfort, abdominal cramps, diarrhea, presence of blood, pus, or mucus in the stool, fever, and then rectal tenesmus. Diagnosis here is going to be stool analysis for red blood cells and white blood cells. You can get to do a stool culture, and a sigmoidoscopy is going to help with the diagnosis.

Treatments, again, fluids and electrolytes. Whenever you come across a question that has vomiting and diarrhea, of fluids and electrolytes are going to be key. Medications, again, we can give Bactrim, Cipro, or ampicillin. And then our last organism for today that we want to talk about, our last disease state, is going to be Clostridium tetani or tetanus. This is a gram-positive obligate anaerobe. And the issue with Clostridium tetani is that it releases a neurotoxin which causes uncontrollable muscle spasms. Generally speaking, this how this affects humans secondary to a wound contamination, so a puncture wound.

We generally think of it like stepping on a rusty nail, right? That seems to be the story everyone’s told. It’s not that rust has any particular problem, it’s just that dirt and rust give kind of a nice home for this bacteria to live and grow and proliferate. So, that makes it a very nice place for it to live. And that being said, because of that, one of the mainstays of treatment is going to be to debride the wound and make sure you get all of that contaminant out, both the organism and the things the organism likes to grow on. So, that dirt and everything else in there. So that’s going to be a main source of treatment for tetanus.

Signs and symptoms, pain and spasticity at the site of the inoculation. Jaw stiffness is a frequent early sign. Later you get that full trismus, which is that lock jaw, that spasms and stiffness along the jaw muscles. You can get stiffness in the neck muscles, difficulty swallowing, maybe in more early signs, stiffness of the abdominal muscles, and then painful body spasms lasting for several minutes. And then finally, the big problem is spasms of the respiratory muscles, right? Because without, with those muscles going to spasm, we cause issues with respiration, which is a major issue. Diagnosis is really a clinical diagnosis.

The only other test that’s really going to be helpful is to look at the cerebral spinal fluid and see that there’s no changes in it, that it’s normal. And that will rule out a few other things. But really, it’s going to be a clinical diagnosis. Treatment. Treatment here is going to be prevention, right? That’s our number one thing for tetanus. And we’ve done a really nice job with this.

The vaccination with a booster every 10 years, it’s three initial shots with exposure there will provide, I think I read, 100% protection in the population. So that’s really been a very valuable vaccination for the people of the world, really. Our next step is going to be wound debridement. You can do antibiotics, metronidazole or penicillin to have some effect here. But the real problem is that once the toxin is released into the body, that’s our problem, right? So you want to kill off the organism, but the organism is only part of the problem. The real problem is when that toxin is released into the body and then it binds within the neurons.

So that’s where you get that muscle spasm from. So a tetanus immunoglobulin intramuscular is going to be a mainstay of treatment here because you want to basically soak up or bind all of that circulating neurotoxin.

Now, any of the neurotoxin that’s been is bound to those cells will not become unbound by this immunoglobulin, right? So we want to make sure we get that early so we can bind up as much of that circulating neurotoxin as possible. You can also use something like diazepam or magnesium to help control muscle spasms. And then obviously our last effort here is going to be supportive care. So you’re going to intubate the patient if they can’t breathe on their own. That’s going to be where we wind up in some patients.

All right. So that’ll bring us to the end for bacterial diseases. We’ll get into fungal diseases and mycobacterial diseases. Parasitic diseases, prenatal transmission of disorders, sepsis, spirochetal diseases, and viral diseases a little bit as we move through the rest of the summer here. But for now, that’ll wrap us up for bacterial diseases. One thing I want to point out is that your mainstays of treatment are going to be fluids and electrolytes. The next big thing with a lot of these bacterial infections, especially the fecal oral ones, is going to be clean water supplies.

It’s going to be washing your hands. You know, there’s a vaccination for cholera, but really what they’ve discovered is that the vaccination is not as important as sanitation. That vaccination has not really been as helpful. If we just get clean water to everybody, then we’re fine. We don’t really need to worry about the vaccination and what comes along with that. So understand how this works within the world, understand how it works within the system of bacteria, understand how it works within your body. Different bacteria affect different areas of the body.

We saw with salmonella, we can wind up with a couple different variations there, whether it’s typhoid fever or just gastroenteritis. It’s hard to picture that, especially as you’re first learning about different bacteria, that they can cause multiple diseases. We’ve talked about over the last couple of shows, but it’s something that took me a long time to wrap my head around. That’s why I sort of harp on it a little bit. But if you can get that idea that it’s not one bug, one disease, right? As this was developing historically, we didn’t understand that. We didn’t know where it was coming from.

You know, I know I talked about the cholera outbreak and there was some discussion at that time in London as to whether it was coming from the air, whether it was coming from the water, whether, you know, they just didn’t know what was causing it. So to find out that it was a specific bacteria and then find out that maybe this bacteria can infect it in a different way. You know, those are all things that have happened over history. You’re getting all of this at the end well, maybe not the end, that’s a little arrogant to say, you’re getting all this at a different point in time than the people who first discovered it. So I think it’s helpful to think about that historical perspective a little bit and understanding how this stuff gets categorized, why it’s important, where it fits in, how we name things. I think that helps you to understand how the whole picture fits together.

All right, so let’s jump into our study tip for today. Our study tip for today is actually a little, well, it’s kind of a study tip. I just discovered this week, an amazing little app for Macs. I’m sorry if you’re a PC user, I don’t have an equivalent for that, but it’s called Horo, H-O-R-O. And first of all, it’s free, which is cool, right? I have not purchased the paid version, although I can see it’s coming very quickly in my future. And Horo sits in the menu bar in the top right, and it’s a simple timer, which is all I’ve been looking for for months and months and months on my Mac, because I generally use an app called P-Clock, P-C-L-O-C-K, which the P is for presenter, right?

So it makes a big, bold clock on your phone or your iPad with big block letters. And it’s supposed to go either on your desk or in the back of the room while you’re doing a presentation. And it has a nice countdown timer. It’s really, really good. But I was looking for something, an equivalent to that, that would sit in my menu bar. So it’s something I could see all the time at a glance when I’m working on any project. And Horo, H-O-R-O, has really done that for me.

If you download it from the app store and then you put it into the menu bar, it just sits up there and it just has a very easy way to enter the amount of time you want to have it as a countdown timer or a stopwatch. You can do it either way. And then the pro version, like I said, which I’m probably going to wind up getting, you can actually tag the time that you’re spending. So as I record this, I have hashtag podcast on it, right? So that when I go back later, I can look at how much time I spend working on the podcast as a total. And I think that’s going to be a cool feature I’m going to be testing out soon. But just the ability to have that countdown timer, really simple, really unintrusive up in that menu bar has been nice.

So I strongly recommend you check it out. Again, H-O-R-O in the app store.

All right, let’s just answer our priming questions and then we can get you out of here. Patient spends time in the woods and hasn’t now has a rash on both wrists and arms and a high fever. That high fever is one that should clue you in. Here we have Rocky Mountain spotted fever. What is the first line treatment for Rocky Mountain spotted fever? Our answer there, doxycycline. Again, remember, I don’t know how it’s going to come up on your PANCE and I apologize for that.

I wish I did for a pregnant person or for a child, but from what I was reading through, it really said that’s something to discuss with your patients, whether just to use doxycycline or move on to amoxicillin. Trismus is a sign of what disease? Tetanus. What are the two disease states caused by salmonella? Gastritis, which is more common. And then typhoid fever, which is the enteric disease, which is less common, but obviously much more severe.

All right, so that’ll take us out. Thank you so much for joining me today. Thank you so much for recommending the show to your classmates. It’s really been a tremendous help to me. I ask that you please continue to do that. That’s the only way that I’m growing the show currently. So that’s really, really helpful.

Get over to physicianassistantexamreview.com to get all the notes and to get on the email list, which I think you will find substantially helpful.

All right, until next time, and when we pick up with fungal diseases, take care and good luck. We’ll see you next time.