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Speaker 1: Okay, So I've been getting a lot of requests for

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some more infectious disease topics, So today we're going to

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go over bacterial diseases. Yo, there's lots of them, and

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to focused on the high steel topics that are frequently

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tested on bartonella, batchelism, chlamydia, cute roumatic fever, can pull

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bactor jay Juni, as well as many others. Got plenty

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of nomonics in here, maybe too many. So we'll get started.

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But as always, a quick thank you for all of

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the nice comments, the support everybody who's bought a T

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shirt donated to the channel. I really do appreciate it,

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so thank you so much. Let's go ahead and get started,

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starting first with cholera. So when you see cholera C

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H O L E R A on an exam question,

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the first thing I want you to do is put

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a two between the H and E O. You put

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a two between the H and E O. That makes

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H two O. Why Because every time you see cholera,

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I want you to be thinking of water as everything

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you need to know about this disease from the infectious organism.

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The mode of transmission, treatment clinical menifestations involves water. So

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if you can remember H two oh, you can likely

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get the question right on the exam. So. Cholera is

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a life threatening infection caused by toxin producing strains of

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an organism called vibrio cholera. Fibrio choler is a comma

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shaped gram negative rod and again everything ties back to water,

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just like we talked about before, and even with fibrio

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rio rio, if you speak Spanish you may already see it,

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but vibrio ends in real, which means river in Spanish.

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So when you see vibrio rio, think river, think water,

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think H two O. So where are people typically expose

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to this organism? This will most commonly be through the

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fecal to oral route through consumption of contaminated water. Ingestion

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of water contaminated with feces is often cited as one

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of the most common sources of transmission of cholera, and

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it's why this is more common in settings with poor

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sanitation and limited access to clean drinking water. Water water water.

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With that being said, contaminated food is another one, so

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consumption of specific contaminated foods can also spread the disease.

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And while there are a number of foods that can

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become contaminated. Contaminated shellfish is an exam favorite and I

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personally got a question on this in school. And luckily

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for you, me and my namonic shellfish live in you

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gott it water. So for transmission, remember contaminated water and shellfish. Next,

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let's talk about clinical manifestations. The main thing you need

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to know is this infection can cause profuse watery diarrhea.

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So the hallmark of this disease is profuse watery diarrhea.

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It will sometimes be described as rice water stool, which

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is this pale and cloudy looking with little flecks of mucus,

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basically looking like the water that's left over after you

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rinse or cook rice. So once Fibrio gets into the

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small bowel, it releases a toxin, which is the main

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issue as this toxin hijacks the cells lining the intestine,

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which can lead to massive amounts of water and electrolytes

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being dumped. This disease can be fatal if it's not treated,

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as it can lead to rapid dehydration and electrolyte loss

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from all of the fluid being dumped. There can be

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a symptomatic cases depending on the strain that's involved. There

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can be nause of vomiting and fever is actually uncommon

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and the presence should prompt the search for concombinant infection.

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But most importantly know your profuse watery diarrhea and or

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rice water stool water water water diagnosis. I won't go

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too deep into it as it's pretty Straightford often made

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clinically and confirmed via stool culture. But treatment is very important,

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and I'll give you a second to think about what

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the treatment might be. That's right, water and to be

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more specific, IV fluids or oral rehydration solutions. So fluid

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management is the cornerstone of cholera treatment, reducing mortality and

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severe cases from over ten percent to less than zero

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point five percent. The type and amount of fluid depends

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on the degree of dehydration. Mild dehydration can be treated

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with oral rehydration solutions composed of water and electrolytes. Moderate

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and severe cases require IV fluids, often using ringers lactape,

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which is water, electrolytes and sodium lactape. Antibiotics can also

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be used as adjunctive treatment in more severe cases as well.

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But remember the main state treatment for cholera is water

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aka your fluid replacement. That's what you need to know. Okay, cholera,

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Remember add a two between the H and the O.

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You get H two. Oh. Remember, transmission is often through

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contaminated water. Clinical manifestations are profuse watery diarrhea or rice

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water stool treat with water aka fluid replacement. And the

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organism here is Vibrio cholera rioaka river and that's cholera.

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Let's talk about lamydia next, specifically chlamydia trichomitis, which is

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a gram negative bacteria and is the most commonly reported

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STI in the United States. What do we need to know.

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Let's start with clinical manifestations. Surprisingly, a great majority of

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chlamydia infections are asymptomatic, but that's not what you'll be

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tested on, so let's focus on the symptomatic patient. So

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when symptoms do occur, they most commonly involve the eurogenital tract,

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leading to classic eurogenital syndromes such as eurethritis with mucoid

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or watery urethral discharge and dysyria, serviceitis with vaginal discharge

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or purulent endocervical discharge, and epididymitis with testicular pain and swelling.

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There are extragenital manifestations depending on the zero type involved,

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including conjunctivitis, pharyngitis, perihepatitis, among others. And while these are

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important to know, the next two complications are tested on

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far more often, so make sure you know them well.

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If Chlamydia trachomatis goes untreated in FEMA, it can lead

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to pelvic inflammatory disease presenting with lower abdominal or pelvic

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pain and cervical motion tenderness, and ultimately can lead to

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infertility and chronic pain. Another high Yueld association is reactive arthritis.

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Chlamydia is actually the most common sexually transmitted pathogen linked

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to reactive arthritis, so this connection is absolutely worth knowing.

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Moving onto diagnosis nexts, which will be made with nucleic

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acid amplification testing or naat net, a test which detects

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the genetic material DNA or RNA of viruses or bacteria

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by amplifying it to detectable levels through sample obtained. For chlamydia,

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samples are typically obtained via a vaginal swab and female patients,

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or a urine sample in male patients. One other important

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thing to consider when conducting diagnostic testing is that Niceria

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gannorea coinfection is common, so all patients with chlamydia trichomitis

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infection should also be tested for Nicia ganorea as they

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have similar clinical manifestations and coinfection is common. Finally, let's

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talk about treatment. One med to commit to memory here

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is going to be doxy cycling. Doxy is your treatment

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of choice in non pregnant individuals. As compared with a zythromycin,

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which is an alternative, doxy has better microbial cure rates.

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So really you just need to remember doxy. And it's

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actually easy to remember why because when you hear clamydia clamydia,

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what word sticks out? Clam right? And where do you

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find clams in a dock by the sea? Doc C cycling,

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So anytime you hear clamydia, think about finding those clams

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in a dock by the sea, and you'll remember your

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first line med doc C cycling. And if you want

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to get really fancy, remember those clams have been sitting

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out in the sun for a little too long, getting

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all nasty and they're getting swarmed with gnats. And then

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I'll help you remember your first line test Nucleic acid

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amplification or GNAT testing So for clamydia, remember your clams

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on a dock by the sea being swarmed by gnats,

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and you remember your first line med and diagnostic test,

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and that's chlamydia. Let's talk about ganoia next, So gunnoia

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infection with gram negative bacterium niceria gonorrhea, which you will

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forever remember instead as ni Siria gadoreea, set of Nicicyria gounoriea.

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Remember it as knie Syria gunoreea, as in the joint

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the knee knee Syria gonoreea. More about that in a minute.

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So in the US knee Syria gunnoreea. It's the second

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most commonly reported commuticable disease. There's not a whole lot

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to know here, and there is definitely some overlap with chlamydia.

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Let's first start with clinical manifestations. So while there are

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areas outside of the genitalia that can be infected, genital

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infections are the most common associated with this organism, and

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just like in chlamydia, a large number of patients may

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be asymptomatic, so keep that in mind. But let's talk

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about your symptomatic patients as that's likely what will be

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tested on. So in females will see service citis. This

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can manifest as vaginal paritis and or mucopurulent discharge, and

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just like in chlamydia, this can spread and develop into

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pelvic inflammatory disease, which occurs in approximately ten to twenty

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percent of females. With cervical GANNERRIEA, both males and females

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will see eurethritis, so dysyria, urinary urgency, or frequency purulent discharge,

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which is more common in males. This organism can also

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affect areas outside of the genitalia ghanacoc conjunctivitis, which mainly

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affects infants born to untreated mothers. Perihepatitis known as fits

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you Curtis syndrome and disseminated infection can occur, and this

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is the highest heeled thing to know about GONNERRIEA as

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it's always tested on so Ganococcal infection can spread from

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the initial site and up to three percent of patients.

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Disseminated infection often leads to one of two clinical syndromes,

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which is a triad of tenosinovitis, dermatitis, polyalthralgis or and

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this is the one to know, purulent authritis, which can

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involve the wrist or ankles, but most commonly the need

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This vignette always seems to pop up on exams time

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and time again. It'll be a young patient complaining of

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dysyria and knee pain, recently engaging in unprotected sexual intercourse,

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et cetera. I've seen this question so many times, so

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it's in your best interest just remember this, and that's

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why instead of niceria gonorehea again, remember it as knee

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syria gonoreea, just to help you remember the purulent authritis

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most commonly involving the knee. Don't forget it all right. Diagnosis,

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just as in chlamydia, you're going to use GNAT again,

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nucleic acid amplification testing. This will be your test of

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choice for initial diagnosis. Treatment one med to know and

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that's going to be sef triaxone. As of the time

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of this recording, sef triaxone is the standard of care

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for treatment of gonerrhea and has the lowest rate of

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ganococcal drug resistance. This may change in the future, but

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as of now, no sef triaxon, which is usually administered

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as a single intramuscular dose. With that being said, if

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you're treating gonnerrhea, what other presumptive treatment should likely be considered.

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That's right, Like we talked about before, chlamydia, chlamydia and

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gonerrihea are unfortunate friends and often come together, So doxycycling

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likely will be added to this regiment unless it's been

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excluded through testing. So that's gonoriea serviceitis eurethritis possible to

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progress to PID. Most importantly, know of the potential for

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purilent arthritis, most commonly in the knee. Remember knee siri

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gonerhea diagnose with NAT, treat with sef triaxone, and as

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coinfection with chlamydia as common, doxy will likely be added

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to your regimen. Next, let's talk about Bartonella. And while

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there are a number of Bartnella species that can infect humans,

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when we're talking about the exam, the species you need

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to know is Bartonella hens lay which is the causative

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organism for cat scratch disease. So Bartnella hens layan is

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the most common form of Bartonellosis in the United States

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and the one you'll be tested on. So Bartnella henslay

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is a gram negative bacteria that can spread between animals

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and humans, which is by definition a zoonotic disease. As

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far as transmission, this will most often be from a

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scratch or a bite from a cat infected with Bartnella

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hens lay, and that's why this is called cat scratch

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disease as cats serve as a natural reservoir for Bartnella

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hens lay. By scratch or a bite from an infected

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cat as well as exposure to cat fleas infected with

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this species can lead to transmission. In humans. Most commonly

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see this in young individuals, more than fifty percent of

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cases in children younger than eighteen years of age, so

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likely will be a child in the vignette. As far

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as clinical manifestations, a number of things can be seen fever, malaise,

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even disseminated disease affecting the liver, spleen, bone, etc. What

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you need to know for the exam is limphatinopathy. Regional

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limphatinopathy is the hallmark of this disease due to a

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granulomatose inflammatory response, and it's what you have to know.

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This will definitely be in the question so in large

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lymph nodes that will appear proximel to the site of inoculation,

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so near the bite or scratch, there'll be tender arethema

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of the overlying skin, usually appearing around two weeks after

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the bite or scratch. So remember lymphat anopathy. That's the

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highest yield thing to know for clinical manifestations. Nothing high

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yield for diagnosis, generally a clinical diagnosis that can be

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supported with zerol logic tests or biopsy treatment. Next, there's

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one meth that you need to know, and that is ezythromycin.

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Even though many patients will have resolution of symptoms without antibiotics,

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the whole point is to prevent serious complications, which as

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many as fourteen percent of patients will have diseminated disease.

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So patients with mild to moderate disease with just lymphat

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aopathy are going to get a five day course of exythromycin.

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There are alternative cipro, etc. But focus on ezythromycin as

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that's your first line. In patients with as seminated disease,

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you'll usually add or a fampin too. Axythromycin main take

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away for treatment though for your exam, I would just

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focus on azythromycin. Okay, So cat scratch disease A few

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high old things to know how to remember all of

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those high old points. Well, this is cat scratch disease.

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When you think of cat scratch disease, I want you

233
00:12:02,240 --> 00:12:04,600
to think of black cat scratch disease. So think of

234
00:12:04,600 --> 00:12:07,279
a black cat. So B l ack contains all of

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00:12:07,279 --> 00:12:09,399
the hild things you need to know. Starting with B

236
00:12:09,639 --> 00:12:12,960
for Bartnella Henslay. Cat scratch disease is an infectious disease

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00:12:13,000 --> 00:12:16,679
caused by Bartnella Hensley. Next L, which stands for lymphat aopathy.

238
00:12:16,879 --> 00:12:20,480
This disease is usually characterized by self limited regional lymphat aopathy.

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00:12:20,559 --> 00:12:23,559
Gotta remember that. Next, the A stands for xythromycin, which

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00:12:23,600 --> 00:12:25,720
is your first line med for most patients. See of

241
00:12:25,799 --> 00:12:28,279
course stands for cats, as they serve as the natural

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00:12:28,320 --> 00:12:31,720
reservoir for Bartonella hensley. I. Finally, K stands for kids,

243
00:12:31,840 --> 00:12:34,120
as this will most commonly be a disease of children

244
00:12:34,159 --> 00:12:37,159
and young adults. So again, cat scratch disease. Remember black

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00:12:37,200 --> 00:12:40,879
cat scratch disease. Bartnella hens Lay lymphat aopathy is xythromycin

246
00:12:41,000 --> 00:12:44,720
cats and kids. Next, let's talk about botulism. What's botulism? Well,

247
00:12:44,720 --> 00:12:47,639
this is a rare but potentially life threatening paralysis caused

248
00:12:47,679 --> 00:12:51,840
by a neurotoxin that's produced by Laustridium botulinum, a group

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00:12:51,879 --> 00:12:56,200
of gram positive rod shaped spore forming anaerobic bacteria. Let's

250
00:12:56,240 --> 00:12:58,759
hit the high old topics. So there's three common types

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00:12:58,799 --> 00:13:02,639
of botulism. These are infant botulism, food borne botulism, and

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00:13:02,720 --> 00:13:05,480
wound botulism. And each of these are associated with high

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00:13:05,480 --> 00:13:07,519
old sources or little things that you need to know.

254
00:13:07,679 --> 00:13:09,720
So let's talk about the three common types and these

255
00:13:09,759 --> 00:13:12,600
sources of infection in each And because there's three sources

256
00:13:12,639 --> 00:13:15,120
that do have high old associations, I have a mnemonic

257
00:13:15,279 --> 00:13:17,080
for you to remember them. So what I want you

258
00:13:17,120 --> 00:13:20,039
to remember is Baby's black bottle, Baby's black bottle, to

259
00:13:20,080 --> 00:13:22,759
help you remember the three high old associations, which we're

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00:13:22,759 --> 00:13:25,440
going to talk about now, starting with baby, which helps

261
00:13:25,440 --> 00:13:29,120
you remember infant botulism, which happens when a baby swallows

262
00:13:29,200 --> 00:13:33,120
sea bochulinum spores. Because infants have poorly developed gut flora,

263
00:13:33,320 --> 00:13:36,039
these spores can actually settle, colonize, and release talks and

264
00:13:36,120 --> 00:13:38,600
right inside the GI tract. In the US, even though

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00:13:38,600 --> 00:13:41,679
we have typically associated this with consumption of honey, most

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00:13:41,679 --> 00:13:44,960
cases actually come from everyday environmental dust and soil that

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00:13:45,039 --> 00:13:48,159
contain these spores that infants are susceptible to. So even

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00:13:48,200 --> 00:13:51,759
though honey can contain spores, it's likely not the main source,

269
00:13:51,840 --> 00:13:54,559
as even after years of warning parents to avoid honey,

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00:13:54,639 --> 00:13:57,559
the rates of infant botulism haven't gone down, which tells

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00:13:57,600 --> 00:13:59,559
us honey is likely only a minor source of this

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00:13:59,600 --> 00:14:02,879
infect In just twenty twenty five, there was an outbreak

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00:14:02,919 --> 00:14:05,720
of botulism that was actually associated with with a popular

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00:14:05,759 --> 00:14:08,279
brand of powdered formula. So for babies it's not so

275
00:14:08,360 --> 00:14:11,679
much a specific source as it is their susceptibility. Next

276
00:14:11,720 --> 00:14:13,639
is wound botulism, which I want you to remember the

277
00:14:13,679 --> 00:14:16,919
word black, as in baby's black bottle. So there's something

278
00:14:16,960 --> 00:14:20,759
known as wound botulism when sea bochulinum infects wounds, puncture wounds,

279
00:14:20,799 --> 00:14:22,960
et cetera. But the most important and the one that

280
00:14:23,000 --> 00:14:25,000
will likely be in your vignette, and the reason this

281
00:14:25,039 --> 00:14:28,039
one is labeled black is because wound botulism has often

282
00:14:28,120 --> 00:14:32,279
been associated with injection drug use, particularly with black tar heroin,

283
00:14:32,360 --> 00:14:34,720
which I have this exact question in school, So remember

284
00:14:34,799 --> 00:14:37,440
black tar heroin. It's very specific, but it does come up.

285
00:14:37,639 --> 00:14:40,360
Last is food born botulism, which you'll remember as bottle

286
00:14:40,600 --> 00:14:43,240
because bottle helps remind you of canned or bottle foods,

287
00:14:43,240 --> 00:14:47,080
which often contain preform boculinum toxin, an exam favorite. So

288
00:14:47,159 --> 00:14:52,200
food born botulism is often seen with home canned foods, vegetables,

289
00:14:52,240 --> 00:14:55,200
and fish, and the US higher rates occur Alaska native

290
00:14:55,320 --> 00:14:58,559
populations due to the consumption of aged or fermented fish,

291
00:14:58,720 --> 00:15:01,639
while in China it's commonly to home fermented tofu and

292
00:15:01,679 --> 00:15:04,799
bean products. All right, So to tie everything together, remember

293
00:15:04,799 --> 00:15:07,720
Baby's black bottle for the types of botulism and their sources.

294
00:15:08,039 --> 00:15:11,360
Baby for infant botulism or sports colonized the gut, Black

295
00:15:11,440 --> 00:15:14,559
for wound botulism with IV drug use, particularly with black

296
00:15:14,600 --> 00:15:17,799
tar heroin, and bottle for food born botulism with improper

297
00:15:17,919 --> 00:15:22,559
bottled or canned foods. Next, clinical manifestations, so Claustrinium botulinum

298
00:15:22,600 --> 00:15:25,960
can cause muscle weakness or flacid paralysis by blocking the

299
00:15:26,000 --> 00:15:29,559
release of acetyl coline at the neuromuscular junction. This happens

300
00:15:29,600 --> 00:15:33,279
because the toxin cuts something called a snare protein, which

301
00:15:33,320 --> 00:15:36,279
are what nerve cells need to release acetyl coline into

302
00:15:36,279 --> 00:15:39,440
the synapse. So without that signal the muscle can't contract

303
00:15:39,519 --> 00:15:41,799
and we have the clinical presentation will go over next.

304
00:15:41,960 --> 00:15:45,159
So the classic presentation of botulism is acute onset of

305
00:15:45,240 --> 00:15:49,360
bilateral cranial neuropathies with symmetric descending weakness, so we can

306
00:15:49,360 --> 00:15:52,279
see things like double visions, slurred speech, and difficulty swallowing.

307
00:15:52,480 --> 00:15:54,480
If you want to focus on the five main clinical

308
00:15:54,559 --> 00:15:57,799
manifestations you'll most likely see on an exam question. Remember

309
00:15:57,840 --> 00:16:01,639
the five d's of botulism, which are dilated fixed pupils,

310
00:16:01,679 --> 00:16:06,120
diplopia which is double vision, dysphasia which is difficulty swallowing,

311
00:16:06,240 --> 00:16:11,080
dysarthria which is difficulty speaking, and descending muscle weakness or paralysis.

312
00:16:11,440 --> 00:16:13,879
So that's your clinical meniphesations. Remember the key here is

313
00:16:13,919 --> 00:16:16,919
the muscle weakness and cranial nerve dysfunction. Focus on the

314
00:16:17,000 --> 00:16:19,919
five d's diagnosis This is usually going to be made

315
00:16:20,039 --> 00:16:23,159
on clinical findings alone. This can later be confirmed by

316
00:16:23,279 --> 00:16:28,000
botulinum toxin detected in serum, stool, or wound specimens. Confirmatory

317
00:16:28,039 --> 00:16:29,960
testing can take a while to come back though, and

318
00:16:30,000 --> 00:16:32,159
generally you do not want to wait for these test

319
00:16:32,200 --> 00:16:34,559
results before moving on to treatment, which will be with

320
00:16:34,879 --> 00:16:39,240
botulinum antitoxin, which is the main therapeutic option for botulism.

321
00:16:39,360 --> 00:16:42,600
Of course, be aware of supportive treatment like nasogastric feedings

322
00:16:42,639 --> 00:16:46,559
to minimize aspiration risk indubation for patients with respiratory failure,

323
00:16:46,759 --> 00:16:50,159
but botulinum anatoxin is the main focus here. Okay, recap

324
00:16:50,200 --> 00:16:52,840
for botulism. Remember Baby's black bottle for the types of

325
00:16:52,879 --> 00:16:56,440
botulism and their sources. Baby for infant botulism where spores

326
00:16:56,440 --> 00:16:59,559
colonize the gut, Black for wound botulism with ib drug use,

327
00:16:59,600 --> 00:17:03,039
particularly black tar heroin, and bottle for food born botulism

328
00:17:03,240 --> 00:17:06,279
with improperly bottled or canned foods. Remember your five d's

329
00:17:06,319 --> 00:17:11,279
for clinical manifestations dilated, fixed pupils, diplopia, dysphasia, dysarthria, and

330
00:17:11,359 --> 00:17:14,640
descending muscle weakness. Diagnosis can be made clinically and confirmed

331
00:17:14,640 --> 00:17:18,519
with toxin detection. Later treat with anti toxin. That's botulism.

332
00:17:18,559 --> 00:17:22,680
Moving on to Campelobacter specifically campelo Bacter J. Juny, which

333
00:17:22,720 --> 00:17:26,240
is a gram negative, curved or comma shaped bacteria. Camplow

334
00:17:26,240 --> 00:17:28,720
Bacter A juni, or CJ as we'll call them, is

335
00:17:28,759 --> 00:17:31,640
a common food borne pathogen that can cause diarrhea in

336
00:17:31,680 --> 00:17:34,720
all age groups. Let's start with transmission. So CJ can

337
00:17:34,759 --> 00:17:37,599
be found in a variety of domestic and wild animals,

338
00:17:37,680 --> 00:17:40,839
and infection may be acquired through consuming these animals, usually

339
00:17:40,960 --> 00:17:44,119
raw or undercooked meat, So poultry is a common one.

340
00:17:44,440 --> 00:17:47,519
Know this one for sure. Contamination of beef, pork, or

341
00:17:47,599 --> 00:17:50,759
lamb is less common, so really focus on poultry. Milk

342
00:17:50,880 --> 00:17:55,000
is another big one, specifically, consumption of unpasteurized milk is

343
00:17:55,039 --> 00:17:59,000
a common source and definitely an exam favorite. And contaminated water.

344
00:17:59,319 --> 00:18:02,759
Nearly any natural water source can be infected. There's other

345
00:18:02,839 --> 00:18:06,279
routes person a person transmission via fecal oral route, vertical

346
00:18:06,319 --> 00:18:09,480
transmission from mom to baby. Even domestic pets like puppies

347
00:18:09,480 --> 00:18:12,599
can be a source. But poultry, unpasteurized milk. That's what

348
00:18:12,640 --> 00:18:14,400
you got to know for the exam, all right. So

349
00:18:14,440 --> 00:18:20,039
clinical manifestations as you'd expect, abdominal pain, cramping, fever, diarrhea,

350
00:18:20,079 --> 00:18:22,680
which can be watery or bloody. So bloody diarrhea can

351
00:18:22,720 --> 00:18:25,160
be seen in around fifteen percent of adults. In children,

352
00:18:25,200 --> 00:18:27,680
it's much more common, closer to fifty percent. And this

353
00:18:27,720 --> 00:18:30,960
is an important differentiating factor. Remember, because things like cholera

354
00:18:31,160 --> 00:18:34,160
was typically watery but not bloody, and that's because CJ

355
00:18:34,279 --> 00:18:38,319
invades the intestinal mucosa, causing inflammation, damaging capillaries, and allowing

356
00:18:38,319 --> 00:18:40,799
blood to leak into the stool. Another important thing to

357
00:18:40,839 --> 00:18:43,960
know is that CJ can closely mimic other conditions, most

358
00:18:44,079 --> 00:18:48,400
notably acute appendicitis, because sometimes abdominal pain may occur before

359
00:18:48,480 --> 00:18:51,359
the onset of diarrhea, which can delay recognition of an

360
00:18:51,359 --> 00:18:54,440
infectious cause. So someone that comes in with adominal pain

361
00:18:54,440 --> 00:18:57,559
that radiates to the right aliac fossa tenderness on exam

362
00:18:57,680 --> 00:19:00,119
very similar to appendicitis, which is why this is called

363
00:19:00,119 --> 00:19:02,880
pseudo appendicitis. And you can of course use ultrasound or

364
00:19:02,880 --> 00:19:05,599
CT to help differentiate the two. But remember this as

365
00:19:05,599 --> 00:19:08,400
it's sometimes tested on. It definitely was for me and

366
00:19:08,440 --> 00:19:10,200
of course good to know when you're out there practicing

367
00:19:10,240 --> 00:19:13,039
as well as far as diagnosis, so suspects CJ and

368
00:19:13,079 --> 00:19:15,799
a patient with abdominal pain and diarrhea in the context

369
00:19:15,799 --> 00:19:18,839
of risk factors for transmission somebody who is drinking milk

370
00:19:18,920 --> 00:19:21,640
straight from the utter, for instance, and then diagnosis can

371
00:19:21,640 --> 00:19:25,319
be established with stool testing, usually with stool culture. Finally,

372
00:19:25,359 --> 00:19:28,240
treatment it's pretty straightforward. For most patients, this is going

373
00:19:28,279 --> 00:19:31,160
to be supportive care, and in patients with severe divies disease,

374
00:19:31,200 --> 00:19:34,119
antibiotics can be used, typically as if the remycin is recommended,

375
00:19:34,279 --> 00:19:37,519
fluoroquino loans are an alternative. One last thing I want

376
00:19:37,559 --> 00:19:39,720
you to know for CJ is that CJ can cause

377
00:19:39,759 --> 00:19:42,240
some pretty high yield complications that are often tested on,

378
00:19:42,480 --> 00:19:44,240
and the main one to know is going to be

379
00:19:44,400 --> 00:19:47,599
geon Berat syndrome. CJ is actually the most common precipitate

380
00:19:47,680 --> 00:19:49,960
of geon Beret syndrome, so you need to know this.

381
00:19:50,240 --> 00:19:54,240
Reactive arthritis, post infectious irriable bowel syndrome are other late

382
00:19:54,319 --> 00:19:57,559
onset complications of CJ, but please focus on gion Beret

383
00:19:57,559 --> 00:20:00,559
syndrome as this will very likely be tested on. All Right,

384
00:20:00,599 --> 00:20:02,519
so there's a few high eel things to know for CJ.

385
00:20:02,839 --> 00:20:05,720
Here's a quick way to remember the important details. When

386
00:20:05,759 --> 00:20:09,200
you think of Camp low Bacter camp Elobacter, think of

387
00:20:09,240 --> 00:20:12,440
a camp, a summer camp named Camp Elobacter, with a

388
00:20:12,480 --> 00:20:15,200
camp counselor named you guess it's CJ. Now CJ, our

389
00:20:15,240 --> 00:20:18,759
trustee camp counselor at Camp Elobacter is grilling up some

390
00:20:18,839 --> 00:20:21,160
food for the campers, and on the grill we see

391
00:20:21,200 --> 00:20:24,480
a big old raw chicken. Since it's hot at camp elobacter,

392
00:20:24,799 --> 00:20:27,440
he's drinking a cold glass of milk to cool him down.

393
00:20:27,680 --> 00:20:30,079
The raw chicken and milk help us to remember the

394
00:20:30,200 --> 00:20:33,880
undercooked meat, most commonly poultry and unpasteurized milk, which are

395
00:20:33,920 --> 00:20:36,880
common methods of transmission for this pathogen. Now, a few

396
00:20:36,880 --> 00:20:39,599
other things you'll notice about CJ. He's wearing a beret,

397
00:20:39,799 --> 00:20:42,640
which helps you remember Gyon beret syndrome. In his front

398
00:20:42,640 --> 00:20:45,680
pocket there is a big oversized fake pen, like something

399
00:20:45,680 --> 00:20:48,319
from a gag store, which helps us remember the pseudo

400
00:20:48,480 --> 00:20:52,480
apenn dicitis commonly associated with his condition. And finally, poor

401
00:20:52,559 --> 00:20:55,559
CJ is wearing a diaper, which helps us remember the diarrhea,

402
00:20:55,640 --> 00:20:59,160
sometimes bloody, seen with CJ infections. So quick recap. The

403
00:20:59,240 --> 00:21:01,559
raw chicken and glass of milk points to the common

404
00:21:01,599 --> 00:21:05,000
transmission sources. The beret CJ is warring helps you to

405
00:21:05,079 --> 00:21:08,359
remember Gyon beret syndrome, the oversized fake pen in his

406
00:21:08,480 --> 00:21:12,640
pocket represents pseudo apendicitis, and the diaper helps remind you

407
00:21:12,680 --> 00:21:16,279
of the diarrhea often bloody, associated with camp Blowbackter Jay JUNI.

408
00:21:16,640 --> 00:21:20,880
That's cj X. Let's talk about diphtheria. So dip theia

409
00:21:20,960 --> 00:21:24,359
is an infectious disease caused by the gram positive Bacillis

410
00:21:24,519 --> 00:21:28,440
griny Bacterium diph THEORYA or C dip theoria, and for

411
00:21:28,480 --> 00:21:30,599
the sake of this lecture, it will now be called

412
00:21:30,680 --> 00:21:33,799
CE dip theory gray instead of CE dip theory A.

413
00:21:34,400 --> 00:21:38,440
Remember it as see dip theory gray gray gray gray gray.

414
00:21:38,559 --> 00:21:41,039
Remember that word also for the sake of the mnemonic

415
00:21:41,279 --> 00:21:44,000
gray is spelled with three a's, So dip theory gray

416
00:21:44,200 --> 00:21:47,119
g r aaa Y. Remember that it will help you

417
00:21:47,119 --> 00:21:49,240
get the exam question right and I'll explain why in

418
00:21:49,279 --> 00:21:51,680
a minute. So ceed dip theory gray. Infection can lead

419
00:21:51,759 --> 00:21:55,559
to respiratory or cutaneous disease. Some patients may also be

420
00:21:55,599 --> 00:21:58,839
asymptomatic carriers. We don't see this as often since the

421
00:21:58,880 --> 00:22:02,319
availability of vaccina, but seed dip theory gray is reappearing

422
00:22:02,359 --> 00:22:04,240
in some regions. So what do you need to know.

423
00:22:04,359 --> 00:22:07,160
Let's keep it simple, starting with the clinical manifestations. So

424
00:22:07,200 --> 00:22:10,480
with respiratory dip thory gray, you can have a sore throat, malaise,

425
00:22:10,519 --> 00:22:13,519
cervical impot andopathy. These patients can actually have some pretty

426
00:22:13,519 --> 00:22:16,160
severe swelling of the neck. They can develop what's called

427
00:22:16,240 --> 00:22:19,359
a bull neck where you have this massive swelling of

428
00:22:19,359 --> 00:22:23,119
the tonsils, uvulas, cervical lymphanodes. And finally, the most important

429
00:22:23,119 --> 00:22:24,920
finding and the one that you will not forget and

430
00:22:24,920 --> 00:22:27,000
the reason you'll always call the seed with theory gray,

431
00:22:27,359 --> 00:22:30,039
is because the hallmark finding is going to be gray

432
00:22:30,079 --> 00:22:33,480
pseudo membranes. So at least a third of patients infected

433
00:22:33,480 --> 00:22:36,599
with this organism will have these adherent gray what they

434
00:22:36,640 --> 00:22:41,000
call pseudo membranes covering the pharynx, soft palate, nasal membrane.

435
00:22:41,119 --> 00:22:43,920
These will often bleed if scraped, and the reason people

436
00:22:44,200 --> 00:22:47,519
with dip theory gray develop these is because these organisms

437
00:22:47,599 --> 00:22:50,759
attached to the pharynx or surrounding areas and it can

438
00:22:50,799 --> 00:22:54,400
release a toxin, a DT toxin, which causes inflammation and

439
00:22:54,480 --> 00:22:58,680
ultimately necrosis of the tissue. This resulting necrotic epithelium mixed

440
00:22:58,680 --> 00:23:02,119
with inflammatory cells cellular debris lead to the appearance of

441
00:23:02,160 --> 00:23:05,599
this gray, leathery adherent membrane. These pseudo membrane can also

442
00:23:05,680 --> 00:23:08,440
dislodge and wind up in the baranchial tree, leading to

443
00:23:08,519 --> 00:23:12,640
respiratory compromise. There are systemic manifestations which can involve the heart,

444
00:23:12,720 --> 00:23:15,839
nervous system, kidneys. But the main takeaway you do not

445
00:23:15,920 --> 00:23:19,279
want to forget your hallmark gray pseudo membrane. That's why

446
00:23:19,359 --> 00:23:22,119
you will always call this seed dip theory gray. All right,

447
00:23:22,200 --> 00:23:25,359
less important, but no, there is cutaneous disease which patients

448
00:23:25,359 --> 00:23:29,519
may develop these unhealing sores or shallow gray ulcers. But

449
00:23:29,599 --> 00:23:33,279
again focus on gray pseudo membranes in respiratory seed dip

450
00:23:33,359 --> 00:23:36,000
theory gray all right. So for diagnosis and a patient

451
00:23:36,039 --> 00:23:38,599
you suspect may have dip theory gray, you'll culture. In

452
00:23:38,680 --> 00:23:41,960
PCR testing, diagnosis is a little bit involved. You first

453
00:23:42,000 --> 00:23:44,400
start with a swab of the throat, naars or any

454
00:23:44,440 --> 00:23:47,480
cutaneous lesion that demonstrates signs of infection. Then you send

455
00:23:47,519 --> 00:23:51,359
them out for culture. Cultur will identify the Karni Bacterium species.

456
00:23:51,480 --> 00:23:54,160
Then we have to determine if these species identified is

457
00:23:54,319 --> 00:23:57,640
dune undone toxogenic, and the PCR testing helps with that.

458
00:23:57,720 --> 00:24:00,279
It will help detect the presence of the toxin gene,

459
00:24:00,359 --> 00:24:02,279
which is a good start, but it won't tell us

460
00:24:02,279 --> 00:24:05,559
if there is active toxin production, so we need additional

461
00:24:05,599 --> 00:24:08,799
testing like with an elix test to help establish active

462
00:24:08,839 --> 00:24:11,119
toxin production. So why do we need to do all

463
00:24:11,119 --> 00:24:13,720
of this? Why can't we just stop at identifying seedp

464
00:24:13,759 --> 00:24:15,960
theory gray on culture? Isn't that enough? Why do we

465
00:24:15,960 --> 00:24:18,440
need to know if it's a toxic strain? Well? Determining

466
00:24:18,480 --> 00:24:22,920
toxogenicity is important, one because toxogenic strains generally cause the

467
00:24:23,200 --> 00:24:26,160
more severe systemic disease we worry about. And two it

468
00:24:26,200 --> 00:24:29,640
helps direct appropriate treatment and isolation protocols, as some patients

469
00:24:29,680 --> 00:24:32,640
may only be a symptomatic carriers. The main takeaway is

470
00:24:32,680 --> 00:24:35,400
here is toxogenic strains are the issue, and for the exam,

471
00:24:35,440 --> 00:24:37,920
I would focus on just remembering your culture and PCR

472
00:24:38,000 --> 00:24:41,720
testing for diagnosis. Next, let's talk about treatment. Treatment involves

473
00:24:41,720 --> 00:24:44,480
the three a's, which is why you remembered gray spelled

474
00:24:44,480 --> 00:24:46,640
with three a's. The three a's of DIP theory GRAY

475
00:24:46,680 --> 00:24:50,519
treatment are airway antiitoxin and antibiotics. Although cultures and toxin

476
00:24:50,559 --> 00:24:53,160
testing should be obtained for diagnosis, you do not want

477
00:24:53,160 --> 00:24:56,519
to wait for confirmation before initiating a treatment. Therapy has

478
00:24:56,559 --> 00:25:00,359
started immediately based on clinical suspicion. If toxogenic DIP theoryray

479
00:25:00,400 --> 00:25:03,039
treatment is later rolled out, certain treatments can be discontinued,

480
00:25:03,119 --> 00:25:06,480
but early intervention is critical to prevent complications. So starting

481
00:25:06,480 --> 00:25:09,200
with the first A, which stands for airway, so aggressive

482
00:25:09,240 --> 00:25:12,440
airway management and patients with respiratory dip theory gray is

483
00:25:12,559 --> 00:25:16,279
very important as respiratory failure due to airway compromises a

484
00:25:16,359 --> 00:25:20,039
major complication and a cause of mortality, so intubation may

485
00:25:20,079 --> 00:25:22,240
be needed. Also keep in mind these patients will usually

486
00:25:22,279 --> 00:25:26,039
be placed on isolation precautions. Next A stands for antitoxin.

487
00:25:26,160 --> 00:25:30,640
Specifically diphtheria antitoxin or DAT is used, which is interesting

488
00:25:30,680 --> 00:25:34,599
as the diphtheria antiitoxin is in a quine derived antibody

489
00:25:34,599 --> 00:25:38,400
that's obtained from the plasma of horses imminized against diphtheria toxin,

490
00:25:38,759 --> 00:25:42,640
so this antiitoxin binds to and inactivates the toxin. Not only.

491
00:25:42,680 --> 00:25:45,119
The last A stands for antibiotics. Per up to date,

492
00:25:45,279 --> 00:25:48,880
xythromycin is now the preferred agent. Luckily another A penicillin

493
00:25:48,880 --> 00:25:51,400
and erythromycin used to be preferred and are of course

494
00:25:51,440 --> 00:25:54,319
still used, but a xythromycin is preferred for dip theory

495
00:25:54,359 --> 00:25:58,200
gray due to increased penicillin resistance and preferred over erythromycin

496
00:25:58,279 --> 00:26:00,680
due to better side effect profile. Just a few other

497
00:26:00,759 --> 00:26:03,720
side notes. You want to also identify and test close

498
00:26:03,799 --> 00:26:08,119
contacts and potentially administer prophylactic antibiotics if needed. And remember

499
00:26:08,119 --> 00:26:11,039
the ultimate goal with dip theory Gray is prevention with immunization.

500
00:26:11,359 --> 00:26:13,960
All right, So dip theory Gray. Infectious disease caused by

501
00:26:13,960 --> 00:26:17,920
the gram positive Bacillis karini bacterium theory Gray. Remember sore throat,

502
00:26:17,960 --> 00:26:20,720
cervical and fatinopathy, that big old bullneck and of course

503
00:26:20,759 --> 00:26:23,039
the star of the show Gray, pseudo membranes that can

504
00:26:23,039 --> 00:26:26,440
bleed have scraped. DIP theory Gray. Diagnose with culture and PCR.

505
00:26:26,759 --> 00:26:28,799
Treat with your three a's. That's why Gray is spelled

506
00:26:28,839 --> 00:26:32,480
with three a's. Airway antitoxin and antibiotics, especially as zythrope.

507
00:26:32,680 --> 00:26:35,519
That's dip theory Gray. Moving on to acute rheumatic fever

508
00:26:35,680 --> 00:26:39,599
or rf ARF, which is a delayed immune mediated complication

509
00:26:39,680 --> 00:26:41,880
that occurs two to four weeks after exposure to a

510
00:26:41,920 --> 00:26:44,720
specific organism. It's highly tested on you got to know it.

511
00:26:44,920 --> 00:26:48,359
So the organism in question is Group A Streptococcus or

512
00:26:48,519 --> 00:26:52,599
gas so ARF is a systemic immune mediated inflammatory condition

513
00:26:52,799 --> 00:26:55,519
that occurs two to four weeks after group A strep

514
00:26:55,599 --> 00:26:58,759
or gas infection. There's this broad immune response to the

515
00:26:58,799 --> 00:27:03,079
infectious organism that can lead to multiple organ systems being damaged,

516
00:27:03,119 --> 00:27:05,680
including the joints, skin, and heart, which brings us to

517
00:27:05,680 --> 00:27:08,400
the highest sealed part of the disease. The clinical manifestations

518
00:27:08,559 --> 00:27:11,559
which also form the framework for diagnosis. So ARF is

519
00:27:11,559 --> 00:27:15,079
diagnosed using the Jones criteria, which are divided into major

520
00:27:15,160 --> 00:27:18,680
and minor criteria. These criteria are named after doctor T.

521
00:27:18,799 --> 00:27:21,839
Duckett Jones, who first described the diagnostic rules for a

522
00:27:21,880 --> 00:27:24,640
cue romatic fever in the nineteen forties. The five major

523
00:27:24,759 --> 00:27:27,839
Jones criteria, which typically present one to five weeks after

524
00:27:27,880 --> 00:27:32,119
a gas infection, include arthritis, which is usually the earliest

525
00:27:32,119 --> 00:27:35,640
manifestation of ARF. This is sometimes described as migratory as

526
00:27:35,680 --> 00:27:37,880
it'll start in one joint then quickly jump to another,

527
00:27:38,160 --> 00:27:39,559
so the knee for a few days, then a few

528
00:27:39,599 --> 00:27:42,519
days later the elbow, wrist, ankle, et cetera carditis, so

529
00:27:42,559 --> 00:27:46,039
we can see pericarditis. Myocarditis most commonly will see involvement

530
00:27:46,079 --> 00:27:49,440
of the mitral and aortic valves, with mitrol regurgitation being

531
00:27:49,480 --> 00:27:53,200
the most common Valvular legion. Next sitaham Korea, which is

532
00:27:53,240 --> 00:27:57,079
a neurologic disorder consisting of a erratic, abrupt involuntary movements,

533
00:27:57,160 --> 00:28:00,720
muscle weakness, et cetera. Erethema marginatum. This is a pink

534
00:28:00,799 --> 00:28:03,880
or faintly red, non pruitic rash that involves the trunk

535
00:28:03,920 --> 00:28:07,480
and sometimes the limbs, usually sparing the face, often evanescent

536
00:28:07,519 --> 00:28:09,599
where it'll pop up and then disappear in a matter

537
00:28:09,599 --> 00:28:12,799
of hours. The lesion usually has a sharply demarketed outer

538
00:28:12,880 --> 00:28:17,279
border and diffuse inner margin forming a continuous ring. And finally,

539
00:28:17,519 --> 00:28:21,079
cutaneous nodules, which are these firm, painless lesions ranging from

540
00:28:21,119 --> 00:28:25,039
a few millimeters to two centimeters in size, often located

541
00:28:25,039 --> 00:28:28,559
over bony surfaces. So that's your Jones major criteria for

542
00:28:28,720 --> 00:28:30,839
our You got to know those. The demonic for Jones

543
00:28:30,960 --> 00:28:34,480
major criteria is Luckily Jones jo Nes. This is an

544
00:28:34,480 --> 00:28:36,599
old demonic that I learned in school, but I modified

545
00:28:36,599 --> 00:28:38,160
it a little bit to make it a little easier

546
00:28:38,200 --> 00:28:40,839
to remember. Starting with J that stands for joint which

547
00:28:40,839 --> 00:28:44,599
you will help you remember your migratory polyarthritis. OH stands

548
00:28:44,640 --> 00:28:46,480
for oh my heart, what you will help you remember

549
00:28:46,519 --> 00:28:51,240
carditis mutual regurgitation being a common manifestation. N stands for nodules,

550
00:28:51,279 --> 00:28:55,119
your subcutaneous nodules, the firm, painless lesions usually located over

551
00:28:55,160 --> 00:28:58,480
a bony surface. E stands for arithmo marginatum, the pink

552
00:28:58,599 --> 00:29:01,519
non pruritic rash most often on the trunk and sometimes

553
00:29:01,519 --> 00:29:03,960
the limbs. And then finally the S, which the original

554
00:29:04,039 --> 00:29:06,799
mnemonic stood for Sinnaham Korea. But I knew damn well.

555
00:29:06,799 --> 00:29:08,519
On an exam, I would not remember what the heck

556
00:29:08,559 --> 00:29:10,839
that stood for, So instead I just remembered it as shaky.

557
00:29:11,240 --> 00:29:14,079
Because even if you remember Sidnaham Korea on an exam,

558
00:29:14,119 --> 00:29:16,880
they're not going to say the patient presents with Sinnaham Korea.

559
00:29:17,039 --> 00:29:20,519
They're going to say the patient presents with uncoordinated jerking movements.

560
00:29:20,799 --> 00:29:22,759
So just remember the S as shaky, just to make

561
00:29:22,799 --> 00:29:25,720
it easier. So remember the five manifestations of r F.

562
00:29:25,960 --> 00:29:28,440
Remember Jones, J, O, N, E, S, J for joint

563
00:29:28,440 --> 00:29:31,319
for the polyothritis, O for oh my heart for carditis,

564
00:29:31,440 --> 00:29:34,440
N for nodules, E for arithemo marginatum, and S for

565
00:29:34,640 --> 00:29:38,559
shaky aka Sinaham Korea. And then we have the minor manifestations,

566
00:29:38,720 --> 00:29:41,559
which are going to be feverthralgia, which is joint pain

567
00:29:41,640 --> 00:29:45,759
usually involving several joints. Elevated acus phase reactants, so most

568
00:29:45,799 --> 00:29:48,880
patients with RF will have elevated inflammatory markers to increase

569
00:29:49,000 --> 00:29:51,960
levels of E, s R and CRP and finally abnormalodies

570
00:29:51,960 --> 00:29:56,640
on ECG specifically a prolonged PR interval, So again fever arthragia,

571
00:29:56,720 --> 00:29:59,759
elevated acute phase reactants prolonged PR, which I used to

572
00:29:59,759 --> 00:30:04,880
remember umber as fat as an faat so f for fever,

573
00:30:05,160 --> 00:30:07,920
A for our thralgia, the second A for acute phase

574
00:30:07,960 --> 00:30:11,079
reactants which are elevated and then T for two long

575
00:30:11,160 --> 00:30:14,559
PR for your prolonged PR interval. So minor criteria again

576
00:30:14,640 --> 00:30:18,920
is fat faat fever aarthralgia, acute phase reactants too long PR.

577
00:30:19,440 --> 00:30:22,240
So how do we diagnose are f well? The diagnosis

578
00:30:22,279 --> 00:30:24,799
is made by combining the clinical findings we just reviewed

579
00:30:24,839 --> 00:30:27,880
with evidence of a preceding group a strep infection. There

580
00:30:27,920 --> 00:30:30,720
are stipulations depending on whether this is a first episode

581
00:30:30,799 --> 00:30:33,839
or a recurrent episode. Some criteria cannot be counted twice,

582
00:30:33,880 --> 00:30:36,519
like arthralgia, and the minor criteria can't be used alongside

583
00:30:36,559 --> 00:30:39,319
arthritis in the major criteria. But for example purposes, let's

584
00:30:39,400 --> 00:30:42,240
keep the simple unfocused on the basics. So diagnosis is

585
00:30:42,279 --> 00:30:45,200
made with evidence of a preceding gas infection. So this

586
00:30:45,240 --> 00:30:48,240
can be a positive rapid strep test, a positive throw culture,

587
00:30:48,359 --> 00:30:52,440
elevated or rising anti streptococcal antibody tighter, plus two major

588
00:30:52,480 --> 00:30:55,920
manifestations or one major plus two minor. So again remember

589
00:30:55,920 --> 00:30:59,200
for diagnosis, two major manifestations or one major plus two

590
00:30:59,240 --> 00:31:02,519
minor are sufficient for diagnosis of an initial episode OFF

591
00:31:02,559 --> 00:31:05,279
in a patient with evidence of preceding gas infection. What

592
00:31:05,359 --> 00:31:07,880
about treatment, It's actually pretty simple, luckily, because there's a

593
00:31:07,920 --> 00:31:09,960
whole bunch of other crap youat to remember this. The

594
00:31:10,000 --> 00:31:12,400
most important thing to know is going to be penicillin G.

595
00:31:12,880 --> 00:31:15,960
Treatment of ARF consists of eradication of the gas infection

596
00:31:16,359 --> 00:31:18,359
group aase strap. You do that with antibiotics, and the

597
00:31:18,359 --> 00:31:21,599
preferred antibiotic is penicillin G benzethene, which is a long

598
00:31:21,640 --> 00:31:25,400
acting intramuscular injection. Of course, if PENG isn't available or

599
00:31:25,440 --> 00:31:28,720
they have penicillin allergies, there are alternatives, but definitely you

600
00:31:28,720 --> 00:31:31,160
should know penicillin G for the exam. Now, there are

601
00:31:31,200 --> 00:31:34,480
other treatments depending on what other manifestations are present. URF

602
00:31:34,519 --> 00:31:37,640
associated arthritis, for instance, N SAIDs will be your first

603
00:31:37,720 --> 00:31:40,839
line to proxy and ambiprofen. So for treatment, remember penge

604
00:31:40,839 --> 00:31:43,039
and n sets to keep it nice and simple, penge

605
00:31:43,160 --> 00:31:46,359
being the highest deal component. All right, ourf acute rhumatic fever,

606
00:31:46,400 --> 00:31:48,200
it's tested on a lot. There's a decent amount of

607
00:31:48,240 --> 00:31:50,559
information to know, but you remember the high yield stuff.

608
00:31:50,559 --> 00:31:53,960
It's actually pretty easy. Instead of RF acute rheumatic fever,

609
00:31:54,039 --> 00:31:56,480
you're going to add a B and remember it as barf.

610
00:31:57,079 --> 00:31:59,960
Arf becomes barf, and you're going to remember this sentence

611
00:32:00,400 --> 00:32:04,480
Barf Jones, The fat penguin has gas. Barf Jones, the

612
00:32:04,599 --> 00:32:08,039
fat penguin has gas. That one sentence contains most of

613
00:32:08,079 --> 00:32:09,759
the high old information you need to know for a

614
00:32:09,759 --> 00:32:12,319
cute rheumatic fever. So picture this. You're at the Zoos,

615
00:32:12,400 --> 00:32:15,039
standing at the penguin exhibit, and this fat penguin names

616
00:32:15,119 --> 00:32:17,640
Jones right in front of you just keeps farting NonStop,

617
00:32:17,880 --> 00:32:19,839
so the point where it's making you want to barf.

618
00:32:20,000 --> 00:32:22,480
So when you see arf, add the bee, remember barf

619
00:32:22,640 --> 00:32:25,200
and lock in this visual. Barf Jones, the fat penguin

620
00:32:25,240 --> 00:32:28,200
has gas. Joan helps you remember the major criteria joints,

621
00:32:28,240 --> 00:32:31,480
oh my heart, nodules ur, themo marginatum, and shaky fat.

622
00:32:31,480 --> 00:32:34,720
For the minor criteria fever, arthralgia, acute phase reactants, too long,

623
00:32:34,759 --> 00:32:37,720
pr penguin, I'll give you a second and think about it.

624
00:32:37,799 --> 00:32:40,440
The first four letters are pe n G as in

625
00:32:40,559 --> 00:32:43,720
peng or penicillin G, your first line medication, and then

626
00:32:43,759 --> 00:32:46,240
finally gas, which helps you remember the infectious organism that

627
00:32:46,279 --> 00:32:48,680
caused this whole mess in the first place. Group a strip,

628
00:32:48,839 --> 00:32:52,000
so remember arf becomes barf as in barf Jones. The

629
00:32:52,039 --> 00:32:54,799
fat penguin has gas. That's a cute rhumatic fever. Let's

630
00:32:54,799 --> 00:32:57,599
talk about Rocky Mountain spotted fever next. So Rocky Mountain

631
00:32:57,599 --> 00:32:59,640
spotted fever is a tick born disease that can be

632
00:32:59,640 --> 00:33:02,039
fatal if not treated. In fact, prior to the introduction

633
00:33:02,079 --> 00:33:04,680
of antibiotics, the fatality rate was as high as eighty

634
00:33:04,720 --> 00:33:08,279
percent in some regions. More recently, with widespread antibiotic availability

635
00:33:08,319 --> 00:33:12,680
and improved disease recognition, mortality rate has dropped to approximately

636
00:33:12,720 --> 00:33:15,079
zero point one two point six percent. So who is

637
00:33:15,119 --> 00:33:18,279
responsible for this terrible disease? Well, that's an organism by

638
00:33:18,279 --> 00:33:22,000
the name of Rickettsia rickettsi, which is a gram negative

639
00:33:22,079 --> 00:33:26,599
obligate intracellular bacterium named after the pathologist Howard Rickets. And

640
00:33:26,759 --> 00:33:28,720
as difficult as the name may be to say, it's

641
00:33:28,720 --> 00:33:31,359
super easy to remember that Rocky Mountain spotted fever is

642
00:33:31,400 --> 00:33:34,519
caused by Rickettsia rockets cii. And that's because you're going

643
00:33:34,559 --> 00:33:38,000
to remember Rocky Mountain spoted fever instead as Ricky Mountain

644
00:33:38,000 --> 00:33:41,359
spotted fever. Swap Rocky for Ricky. Ricky Mountain spotted fever

645
00:33:41,400 --> 00:33:44,480
helps you remember this disease is caused by rick aka

646
00:33:44,640 --> 00:33:48,759
Rickettsia rickettsii. This is the only Ricketzial infection that has

647
00:33:48,799 --> 00:33:51,519
the name rick twice. So remember rick for Ricky Mountain

648
00:33:51,559 --> 00:33:53,559
spotted fever, all right. That brings us to our next

649
00:33:53,599 --> 00:33:56,240
important tidbit, the vector. So in nineteen oh six, Howard

650
00:33:56,319 --> 00:33:59,920
Ricketts demonstrated that Ricky Mountain spotted fever was an infectious

651
00:34:00,000 --> 00:34:02,880
disease transmitted by ticks, which prior to that people actually

652
00:34:02,920 --> 00:34:05,079
thought you got this from drinking the melted snowwater. So

653
00:34:05,200 --> 00:34:08,280
Ricky Mountain spotted fever is usually transmitted via tick bite

654
00:34:08,360 --> 00:34:11,000
and is most commonly seen in the spring and early summer,

655
00:34:11,280 --> 00:34:14,360
when outdoor activity is the highest. Transmission occurs after a

656
00:34:14,400 --> 00:34:16,960
tick has been attached for several hours, during which time

657
00:34:17,280 --> 00:34:20,280
rocketsia organisms are released from the tick's salivary glands into

658
00:34:20,320 --> 00:34:22,639
the human host. The type of tick that carries this

659
00:34:22,760 --> 00:34:25,960
varies by location. Eastern and south central US is the

660
00:34:26,239 --> 00:34:29,760
derma center of Verabilis tick derma center and DERSNY is

661
00:34:29,760 --> 00:34:31,840
the primary vector in the mountain states west of the

662
00:34:31,880 --> 00:34:35,199
Mississippi River. Probably wouldn't go too hard here with memorization,

663
00:34:35,360 --> 00:34:38,280
just remember the vector as a tick. Clinical menifestations next.

664
00:34:38,480 --> 00:34:42,440
Early symptoms of ricky mountain spotted fever are non specific fever, headache,

665
00:34:42,440 --> 00:34:46,199
as well as malaise, myalagias, abdominal pain, confusion. But the

666
00:34:46,239 --> 00:34:48,440
main clinical menaphisation I want you to remember, which is

667
00:34:48,480 --> 00:34:51,079
the hallmark of this disease and is always tested on,

668
00:34:51,599 --> 00:34:53,440
is the rash. So Ricky is going to cause a

669
00:34:53,519 --> 00:34:55,960
rash and approximately eighty eight to ninety percent of patients.

670
00:34:56,079 --> 00:34:59,079
It is uncommon at the initial clinical presentation, but it

671
00:34:59,199 --> 00:35:01,639
usually pops up the third to fifth day of illness.

672
00:35:01,800 --> 00:35:05,320
The hallmark is a blanching arithmatose rash with macules, so

673
00:35:05,559 --> 00:35:08,880
small flat spots that become particular over time, so more

674
00:35:08,920 --> 00:35:11,800
red or purple pinpoint spots. So that's great to know.

675
00:35:11,920 --> 00:35:13,800
But here's the high old part. You'll be tested on

676
00:35:14,199 --> 00:35:17,119
the appearance of the rash usually begins on the ankles

677
00:35:17,199 --> 00:35:19,920
and risks and spreads to the trunk. So remember when

678
00:35:19,960 --> 00:35:22,360
we're talking about a ricky rash, the rash begins on

679
00:35:22,400 --> 00:35:25,760
the risks and ankles and spreads what they call centripetally

680
00:35:25,840 --> 00:35:28,239
to the trunk, which just means towards the center. There

681
00:35:28,280 --> 00:35:32,079
are also complications secondary to ricky, like seizures, other neurologic

682
00:35:32,159 --> 00:35:35,800
abnormalities non cardiogenic pulmonary edema, but focus primarily on the

683
00:35:35,880 --> 00:35:39,960
rash centripetal distribution for the exam. Okay diagnosis not super

684
00:35:40,039 --> 00:35:43,840
high yield, but a presumptive clinical diagnosis of ricky is

685
00:35:43,880 --> 00:35:46,559
made based upon clinical signs and symptoms in a patient

686
00:35:46,599 --> 00:35:49,320
who are from an endemic area or visited one recently.

687
00:35:49,599 --> 00:35:52,159
So fever, rash, tick bite in the right location, treat it.

688
00:35:52,440 --> 00:35:55,119
Don't wait for serologic testing to come back. Why don't

689
00:35:55,119 --> 00:35:56,920
you want to wait for serologic testing to come back

690
00:35:56,960 --> 00:36:00,000
before you give them antibiotics? Well, first, because early serology

691
00:36:00,159 --> 00:36:02,119
is obtained in the first few days are often falsely

692
00:36:02,159 --> 00:36:05,920
negative and second infulmentate cases of Ricky death can occur

693
00:36:06,039 --> 00:36:08,239
in as early as five days. So treat based on

694
00:36:08,280 --> 00:36:12,519
clinical suspicion and confirm retrospectively through serologic testing, which will

695
00:36:12,559 --> 00:36:16,280
be obtained through indirect immunofluorescent testing or in some cases

696
00:36:16,320 --> 00:36:19,480
PCR testing, which can be used to make a definitive diagnosis.

697
00:36:19,639 --> 00:36:21,559
And then finally, there are some lab findings that can

698
00:36:21,559 --> 00:36:26,519
be obtained to help support the diagnosis. Things like thrombocytopenia, hyponatremia,

699
00:36:26,559 --> 00:36:29,440
and elevation and serum aminotransferrace levels can all be seen

700
00:36:29,480 --> 00:36:32,400
with a Ricky infection. Finally, we have treatment which is

701
00:36:32,519 --> 00:36:34,400
very easy. You really just need to know one met

702
00:36:34,440 --> 00:36:37,480
and that's going to be doxy cycling. Doxy is your

703
00:36:37,519 --> 00:36:40,480
treatment of choice in both adults and children, even in

704
00:36:40,559 --> 00:36:43,920
pregnant women. The only alternative, which is chlorinmphenicol, has been

705
00:36:43,920 --> 00:36:46,599
associated with a higher risk of death, so it's really

706
00:36:46,639 --> 00:36:48,920
doxy all the way. Nothing more to know here except

707
00:36:48,960 --> 00:36:51,360
for the fact that you treat asap, do not wagh

708
00:36:51,360 --> 00:36:53,880
for serologic testing. As we talked about before, Okay, so

709
00:36:53,920 --> 00:36:56,159
you will never forget that Rocky Mountain spot of fever

710
00:36:56,280 --> 00:36:59,559
is caused from the organism ricketsia ricketsia, because again you'll

711
00:36:59,599 --> 00:37:02,360
remember it as Ricky Mountain spotted fever, super easy. But

712
00:37:02,400 --> 00:37:04,559
there's other highield stuff to know, and for that I

713
00:37:04,599 --> 00:37:06,760
have to tell you a little rhyme about Ricky or Rick.

714
00:37:07,000 --> 00:37:08,960
So here's the rhyme that contains all of the juicy

715
00:37:08,960 --> 00:37:11,440
details for the exam. Rick got bit by a tick

716
00:37:11,519 --> 00:37:13,639
because he stood on the docks and forgot to wear

717
00:37:13,679 --> 00:37:16,840
gloves and socks. Rick got bit by a tick because

718
00:37:16,880 --> 00:37:19,039
he stood on the docks and forgot to wear gloves

719
00:37:19,039 --> 00:37:22,400
and socks. So Rick, that's your cue for rickettsia, ricketsi.

720
00:37:22,400 --> 00:37:24,119
I got bit by a tick, which we know is

721
00:37:24,119 --> 00:37:26,559
the vector for this disease. Stood on the docks, which

722
00:37:26,559 --> 00:37:28,800
helps you remember doc cy cycling is the first line

723
00:37:28,840 --> 00:37:31,239
med and forgot to wear gloves and socks. Gloves and

724
00:37:31,239 --> 00:37:34,079
socks help you remember where the rash originates, super important,

725
00:37:34,159 --> 00:37:37,320
the ankles and wrist then spreads centripetally. So Rick got

726
00:37:37,320 --> 00:37:39,039
bit by a tick because he stood on the docks

727
00:37:39,079 --> 00:37:40,960
and forgot to wear gloves and socks. It's got your

728
00:37:41,000 --> 00:37:44,000
infectious organism vector, first line med and most tested on

729
00:37:44,000 --> 00:37:46,760
clinical manifestation. If you can remember that little ryme, you'll

730
00:37:46,800 --> 00:37:48,880
likely get the exam question right. All right, So that's

731
00:37:48,960 --> 00:37:52,119
Rocky aka Ricky Mountain spotted fever. We're almost there. Last

732
00:37:52,159 --> 00:37:54,159
one is going to be tetanus, so tetanus, which is

733
00:37:54,199 --> 00:37:57,719
derived from the Greek word tetanose, which literally means tension

734
00:37:57,800 --> 00:38:00,559
tight or to stretch, which makes sense when you're familiar

735
00:38:00,559 --> 00:38:02,800
with the manifestations of the disease, which will go over shortly.

736
00:38:03,159 --> 00:38:06,679
So Deatonnis is caused by the toxin producing bacteria Claustridium

737
00:38:06,760 --> 00:38:11,119
tetani which is an anaerobic gram positive spore forming bacilline

738
00:38:11,199 --> 00:38:14,559
which typically live in soil and surprisingly even present in

739
00:38:14,599 --> 00:38:17,599
the gut of mammals. So these guys don't like oxygen.

740
00:38:17,800 --> 00:38:20,840
They are anaerobes, so when they get exposed to beautiful

741
00:38:20,880 --> 00:38:24,199
fresh oxygen or an unfavorable environment, they get stressed and

742
00:38:24,239 --> 00:38:27,119
shed these little spores almost like safe little transport vehicles

743
00:38:27,159 --> 00:38:29,280
for them to hang out in until a new anaerobic

744
00:38:29,360 --> 00:38:32,360
environment presents itself for them to sprout back into Clostridia.

745
00:38:32,559 --> 00:38:35,679
So let's go over the predisposing factors. So the first

746
00:38:35,719 --> 00:38:37,840
is going to be lack of immunity, which, of course

747
00:38:37,920 --> 00:38:40,360
we know that we do have tetanus vaccines available to

748
00:38:40,360 --> 00:38:43,440
prevent this disease, and most patients who develop tetanus are

749
00:38:43,519 --> 00:38:48,159
either incompletely immunized and or receive inadequate prophylaxis following a wound.

750
00:38:48,519 --> 00:38:51,239
Next is going to be inoculation of spores. So those

751
00:38:51,239 --> 00:38:53,320
little spores we talked about before, they got to get

752
00:38:53,320 --> 00:38:55,639
into the body somehow, and this typically happens through some

753
00:38:55,679 --> 00:39:00,960
sort of penetrating trauma, splinters, gunshots, lacerations, burns, compound fractures.

754
00:39:01,159 --> 00:39:03,119
There needs to be an entry point for those spores.

755
00:39:03,360 --> 00:39:06,119
There are even some cases of neonatal tetanus which result

756
00:39:06,159 --> 00:39:09,960
from home deliveries with unsanitary cutting of the umbilical cord. Okay,

757
00:39:10,039 --> 00:39:12,960
And then we have the final key predisposing factor, and

758
00:39:13,000 --> 00:39:16,760
that's devitalized tissue. So a schemic or necrotic tissue as

759
00:39:16,760 --> 00:39:19,679
we see in many infections, is an important predisposing factor

760
00:39:19,880 --> 00:39:23,119
for developing tetanus. And why is that? Why can't tetani

761
00:39:23,320 --> 00:39:26,199
grow in healthy tissue? While it's what we talked about before.

762
00:39:26,280 --> 00:39:29,239
Tetani is an anaerobic bacteria. It thrives in the absence

763
00:39:29,280 --> 00:39:31,679
of oxygen. So when it enters the body through those

764
00:39:31,719 --> 00:39:34,360
dormant spores, what key element can wake them up and

765
00:39:34,360 --> 00:39:37,599
allow them to sprout? An environment void of oxygen, where

766
00:39:37,639 --> 00:39:39,719
can we find that in the body. A necrotic or

767
00:39:39,719 --> 00:39:42,119
a schemic tissue which has little to no blood flow.

768
00:39:42,400 --> 00:39:45,199
So this low oxygen environment allows tetni to thrive and

769
00:39:45,280 --> 00:39:47,719
germinate and do the terrible things we'll talk about next.

770
00:39:47,960 --> 00:39:50,320
So you need a combination of these three factors. Lack

771
00:39:50,320 --> 00:39:53,159
of immunity, a tetanus prone injury like a puncture wound,

772
00:39:53,199 --> 00:39:56,000
and then a schemic or necrotic tissue. All right, clinical

773
00:39:56,039 --> 00:39:59,960
manifestations next. So there are different types of tetanus. Localized

774
00:40:00,039 --> 00:40:02,239
tetanus which is only localized to a specific part of

775
00:40:02,239 --> 00:40:05,400
the body. Cephalic tetanus is a form of localized tetanus

776
00:40:05,440 --> 00:40:08,559
that involves only the cranial nerves, natal tetanus, and then

777
00:40:08,760 --> 00:40:11,039
generalized tetanus, which is the most common, and that's what

778
00:40:11,119 --> 00:40:14,000
we'll focus on. So generalized tetanus, you will have spastic

779
00:40:14,079 --> 00:40:16,800
muscle contractions. Now, really quickly, I want to just talk

780
00:40:16,840 --> 00:40:21,320
about why this disease causes these severe muscle contractions, so

781
00:40:21,480 --> 00:40:25,719
Claustridium tetana can produce a horrible toxin called tetanospasmen. This

782
00:40:25,880 --> 00:40:29,559
toxin blocks inhibitory neural transmitters like gaba and glysine, which

783
00:40:29,599 --> 00:40:32,440
normally tell muscles to relax, and without the inhibition, alpha

784
00:40:32,440 --> 00:40:37,159
modor neurons fire continuously causing severe, rigid, sustained muscle contractions.

785
00:40:37,320 --> 00:40:39,480
So we'll see things like tristmas, which is present in

786
00:40:39,519 --> 00:40:42,760
more than eighty percent of cases, involving these strong, painful

787
00:40:42,760 --> 00:40:45,719
spasms of the meceder muscles and an inability to open

788
00:40:45,760 --> 00:40:48,039
the mouth. That's why sometimes referred to as lock jaw

789
00:40:48,679 --> 00:40:52,679
opis thoughtness, which is the spasm of the spinal extensors

790
00:40:52,840 --> 00:40:56,039
leading to the severe arching of the back. Rhesis sardenticus,

791
00:40:56,079 --> 00:40:58,719
which is also known as a sardonic smile, which is

792
00:40:58,760 --> 00:41:02,440
caused by persistent face muscle spasms causing this exaggerated or

793
00:41:02,480 --> 00:41:05,639
abnormal grin. We can also see autonomic overactivity, so these

794
00:41:05,639 --> 00:41:09,880
patients can present with excessive sweating, fever, tachycardia, cardiac arrhythmias.

795
00:41:10,000 --> 00:41:13,760
For the exam certainly focus on the intense spastic muscle contractions. Okay,

796
00:41:13,800 --> 00:41:16,960
So for diagnosis, tetanus is going to be diagnosed clinically.

797
00:41:17,039 --> 00:41:20,400
Antibody tests for tetanus exists, but they're not reliable at

798
00:41:20,440 --> 00:41:23,159
low tighters and impatients who received antiitoxin. So again, this

799
00:41:23,239 --> 00:41:25,599
is a clinical diagnosis and you should suspect this in

800
00:41:25,639 --> 00:41:28,800
a patient with intense muscle spasms, especially after a tetanus

801
00:41:28,840 --> 00:41:32,400
prone injury, someone who's been inadequately immunized. So a treatment

802
00:41:32,440 --> 00:41:36,880
is multifaceted, including airway management, wound agreement. Adequate wound to

803
00:41:36,880 --> 00:41:39,679
agreement is actually really important because tetani can persist in

804
00:41:39,719 --> 00:41:43,440
wounds even after these patients are started on antibiotic therapy. Antibiotics,

805
00:41:43,440 --> 00:41:47,199
which in most cases will be metronitasol penicyllerg is an alternative,

806
00:41:47,840 --> 00:41:51,119
and then tetanus immune globulin, which is an antiitoxin that

807
00:41:51,239 --> 00:41:55,480
binds to and can neutralize any remaining circulating unbound tetnos spasmin,

808
00:41:55,800 --> 00:41:59,960
that horrible toxin we talked about before, And benzodiazepines like diazepam,

809
00:42:00,079 --> 00:42:02,239
which are usually the first line madule used to help

810
00:42:02,280 --> 00:42:05,440
control the muscle spasms. And ultimately the goal is prevention

811
00:42:05,559 --> 00:42:10,400
with immunization with your tetanus vaccine. Once the patient is stabilized,

812
00:42:10,440 --> 00:42:13,159
they should receive active immunization with a full series of

813
00:42:13,159 --> 00:42:17,400
tetanus and diphtheria toxoid containing vaccines, as having tetanus unfortunately

814
00:42:17,480 --> 00:42:19,760
does not provide immunity. All right, we did it. That

815
00:42:19,880 --> 00:42:22,800
was your bacterial disease review. Let's do five quick questions

816
00:42:22,800 --> 00:42:25,719
to see what you've retained. Starting with question one, A

817
00:42:25,760 --> 00:42:28,719
twenty eight year old unvaccinated male presents to the emergency

818
00:42:28,719 --> 00:42:31,559
department with a three day history of sore throat, low

819
00:42:31,599 --> 00:42:34,199
grade fever thirty eight degrees celsius one hundred point four

820
00:42:34,239 --> 00:42:37,639
degrees fahrenheit, and difficulty swallowing. An examination, you note a

821
00:42:37,719 --> 00:42:41,760
gray adherent membrane covering both tonsils and the posterior FHARINGX.

822
00:42:42,000 --> 00:42:44,320
When you attempt to remove a small portion for culture,

823
00:42:44,400 --> 00:42:48,119
it bleeds. The patient has prominent cervical and fatinopathy with

824
00:42:48,239 --> 00:42:52,400
visible neck swelling. What is the most appropriate immediate management

825
00:42:52,440 --> 00:42:58,559
for the suspected diagnosis? A Administer diphtheria antitoxin, intravenous antibiotic

826
00:42:58,599 --> 00:43:03,000
and provide airway management b obtained throughat culture. Then start

827
00:43:03,039 --> 00:43:08,840
antibiotics while awaiting results. C reassure and provide symptomatic treatment

828
00:43:08,960 --> 00:43:13,440
only d initiates supportive care and observe for twenty four

829
00:43:13,480 --> 00:43:17,760
to forty eight hours before starting antimicrobial therapy or E

830
00:43:17,920 --> 00:43:20,480
arranged for ton select me to remove the pseudo membrane,

831
00:43:25,760 --> 00:43:29,559
So that is going to be a administer DIP theory, antitoxin, intravenous,

832
00:43:29,599 --> 00:43:32,280
antibiotic and airway management. So even if you have no

833
00:43:32,360 --> 00:43:34,440
idea what disease is being referenced in the vignette, you

834
00:43:34,519 --> 00:43:37,599
may recognize de gray adherent membrane being mentioned, which would

835
00:43:37,599 --> 00:43:40,639
trigger you to remember DIP theory gray spelled with three a's,

836
00:43:40,840 --> 00:43:43,039
and DIP theory gray should certainly be suspected in this

837
00:43:43,119 --> 00:43:45,639
patient with the presence of a gray pseudo membrane that

838
00:43:45,679 --> 00:43:50,000
bleeds with scraping, unvaccinated, low grade fever, prominent cervical infatinopathy,

839
00:43:50,400 --> 00:43:52,679
and what empiric treatment should be started in patients with

840
00:43:52,719 --> 00:43:55,599
suspected respiratory DIP theory Gray well the three a's, which

841
00:43:55,639 --> 00:43:57,280
is why gray is spelled with three a's to help

842
00:43:57,320 --> 00:44:01,519
you remember anti toxin, antibiotic, airway metam so for respiratory

843
00:44:01,519 --> 00:44:04,800
DIP theory gray urgent empiric treatment with diphtheria antitoxin and

844
00:44:04,800 --> 00:44:08,400
antibiotics should be administered right away, even before confirmatory diagnostic

845
00:44:08,480 --> 00:44:11,039
tests come back. And of course aggressive airway management is

846
00:44:11,079 --> 00:44:13,639
important due to the risk of obstruction. So answer a

847
00:44:13,840 --> 00:44:17,760
administer dip theory anti toxin, intravenous antibiotic and airway management

848
00:44:17,800 --> 00:44:20,599
is the correct answer for this patient. Question two. A

849
00:44:20,639 --> 00:44:23,079
thirty two year old woman presents the emergency department with

850
00:44:23,159 --> 00:44:26,119
profuse watery diarrhea and abdominal cramping for the past forty

851
00:44:26,119 --> 00:44:29,519
eight hours. She reports passing copious amounts of pale, watery

852
00:44:29,519 --> 00:44:32,480
diarrhea that is non bloody and has a milky, cloudy

853
00:44:32,480 --> 00:44:36,519
appearance with small white flecks. She reports severe thirst, lightheadedness

854
00:44:36,639 --> 00:44:39,519
when standing, and is not urinated in over twelve hours.

855
00:44:39,760 --> 00:44:42,119
She returned yesterday from a medical mission trip to a

856
00:44:42,159 --> 00:44:45,239
remote region of South America, where she had limited access

857
00:44:45,239 --> 00:44:47,719
to clean drinking water and eight raw oysters at a

858
00:44:47,719 --> 00:44:51,119
local market. She has no significant past medical history. Vital

859
00:44:51,119 --> 00:44:55,199
science revealed tachycardian hypotensionation is a febrie. On examination. She

860
00:44:55,239 --> 00:44:59,039
appears ill and lethargic, with sunken eyes, markedly dry mucous membranes,

861
00:44:59,159 --> 00:45:01,480
and skin tentting. The that persists for over two seconds.

862
00:45:01,679 --> 00:45:04,559
Her abdomen is soft with mild diffuse tenderness and hyperactive

863
00:45:04,639 --> 00:45:07,519
bowel sounds. What is the most appropriate initial treatment for

864
00:45:07,599 --> 00:45:11,960
this patient A oral rehydration solution with glucose and electrolytes,

865
00:45:12,519 --> 00:45:18,400
b intravenous isotonic fluids, c intravenous broad spectrum antibiotics only

866
00:45:19,039 --> 00:45:27,239
or D bowel rest and observation. So that is going

867
00:45:27,280 --> 00:45:30,679
to be answered b intravenous isotonic fluids due to the

868
00:45:30,719 --> 00:45:34,760
combination of profuse, non bloody rice water stools, absence of fever,

869
00:45:34,960 --> 00:45:39,400
rapid severe dehydration, consumption of likely contaminated water, and rast shellfish.

870
00:45:39,840 --> 00:45:42,400
Even though we can't definitively say this, cholera should be

871
00:45:42,440 --> 00:45:44,760
high on your list of differentials. And with choloro we

872
00:45:44,800 --> 00:45:46,280
know to put a two between the H and the

873
00:45:46,320 --> 00:45:48,360
O to make H two O because the hygy old

874
00:45:48,360 --> 00:45:50,719
stuff involves H two oh. Including the treatment, we know,

875
00:45:50,760 --> 00:45:53,519
the initial and most important form of treatment before antibiotics

876
00:45:53,639 --> 00:45:56,079
or anything else is fluids. In mild cases, this can

877
00:45:56,119 --> 00:45:59,400
be with oral rehydration solution, but in moderate or severe cases,

878
00:45:59,400 --> 00:46:02,599
which is clearly evident in this patient, urgent administration of

879
00:46:02,639 --> 00:46:05,719
IV fluids is the cornerstone of treatment for reduction immortality.

880
00:46:06,119 --> 00:46:09,119
Answer A oral rehydration solution would only be recommended in

881
00:46:09,159 --> 00:46:12,440
mild cases, which this is not c Antibiotics are appropriate

882
00:46:12,480 --> 00:46:15,679
as an adjunct, but rehydration is the absolute priority and

883
00:46:15,760 --> 00:46:19,679
must precede antibiotic administration and d bowel rests in observation

884
00:46:19,719 --> 00:46:23,000
would be dangerous and potentially fatal. Spatial has severe dehydration,

885
00:46:23,119 --> 00:46:27,559
requiring immediate aggressive fluid resuscitation with intravenous isotonic fluids, making

886
00:46:27,599 --> 00:46:31,559
answer be the correct answer. Question three. A nineteen year

887
00:46:31,559 --> 00:46:33,960
old male presents the emergency department with a three day

888
00:46:34,000 --> 00:46:37,079
history of fever, headache. Myologist M malays two days ago

889
00:46:37,159 --> 00:46:39,840
he developed a rash on his wrists and ankles. He

890
00:46:39,880 --> 00:46:42,880
denies nause vomiting or abdominal pain. One week ago, he

891
00:46:42,920 --> 00:46:45,239
spent four days deer hunting in the wooded areas of

892
00:46:45,239 --> 00:46:48,639
North Carolina. Herport's checking himself for ticks each evening and

893
00:46:48,719 --> 00:46:50,880
recalls finding what he thought might be a small tick

894
00:46:50,920 --> 00:46:53,119
on his lower leg, although he is uncertain whether it

895
00:46:53,159 --> 00:46:55,679
was a tick or just debris. He has no significant

896
00:46:55,679 --> 00:46:58,679
past medical history and takes no medications on examination. He

897
00:46:58,719 --> 00:47:02,639
appears ill but not talk phytoscience. Temperature thirty eight point

898
00:47:02,639 --> 00:47:05,519
eight degrees celsius one oh one point eight degrees fahrenheit,

899
00:47:05,679 --> 00:47:07,840
heart rate one o two beats per minute, blood pressure

900
00:47:07,840 --> 00:47:10,960
one hundred and eighteen over seventy two. He's alert and oriented.

901
00:47:11,119 --> 00:47:14,239
A faint arithmatose macular rash consisting of two to four

902
00:47:14,239 --> 00:47:17,320
millimeters blanching pink macules is present on both wrists and

903
00:47:17,400 --> 00:47:21,840
ankles Bilaterally, the remainder of the skin is clear. Cardiovascular, pulmonary,

904
00:47:21,920 --> 00:47:25,199
and abdominal examinations are normal. Laboratory studies reveal platelets at

905
00:47:25,199 --> 00:47:27,639
one hundred and forty thousand, normal range being one hundred

906
00:47:27,679 --> 00:47:30,199
and fifty to four hundred thousand, and sodium one hundred

907
00:47:30,199 --> 00:47:32,239
and thirty one normal range being one hundred and thirty

908
00:47:32,239 --> 00:47:34,159
five to one hundred and forty five. Which of the

909
00:47:34,199 --> 00:47:37,039
vowing organisms is most likely the cause of this patient's

910
00:47:37,039 --> 00:47:43,039
presentation A Burellia berg de Ferry b Grini, Bacterium, Diphtheria,

911
00:47:43,960 --> 00:47:51,440
c Ricketsia ricketsii, or D. Campilowbackter jay juni. So the

912
00:47:51,480 --> 00:47:54,400
correct answer is c Ricketzia ricketsii. All right, So the

913
00:47:54,480 --> 00:47:58,119
question is asking for the most likely most likely causative organism,

914
00:47:58,360 --> 00:48:00,840
and our answer is c ricrick. But first let's start

915
00:48:00,880 --> 00:48:04,079
with while the other answer choices are incorrect, A Burellia

916
00:48:04,159 --> 00:48:06,760
bergdo ferry, which we did not go over today, but

917
00:48:06,960 --> 00:48:09,840
is an important differential as it is another tick borne

918
00:48:09,880 --> 00:48:12,920
disease and the causative organism in lime disease. And while

919
00:48:12,960 --> 00:48:16,480
the early presentation can be quite similar with the fatigue, myalgia, fever,

920
00:48:16,480 --> 00:48:20,039
et cetera, the cutaneous findings are usually different lime disease,

921
00:48:20,079 --> 00:48:22,280
and around eighty percent of patients will present with what's

922
00:48:22,320 --> 00:48:26,800
known as erythema migrants. This expanding araythematose lesion that begins

923
00:48:26,840 --> 00:48:31,000
at the tick bite site. Lesion is usually a single arithmatose,

924
00:48:31,159 --> 00:48:34,760
non painful, round or oval patch that expands slowly, and

925
00:48:34,840 --> 00:48:37,440
in some cases central clearing may occur, causing this bulls

926
00:48:37,440 --> 00:48:40,800
eye appearance. Unlike our patient who has multiple small blanching

927
00:48:40,840 --> 00:48:44,320
macules on distal extremities bilaterally not an expanding lesion at

928
00:48:44,360 --> 00:48:47,679
a bite site. B Crinibacterium, diphtheria or dip theory gray,

929
00:48:47,760 --> 00:48:50,119
as we know, will likely have a gray pseudo membrane

930
00:48:50,119 --> 00:48:53,159
mentioned in the pharynx sore throat, low grade fever, cervical

931
00:48:53,159 --> 00:48:56,599
and patanopathy with a bullneck appearance, cam Blowbacter jay junior

932
00:48:56,599 --> 00:48:59,639
answer D remember cg at camp Elobacter with the diarrhea,

933
00:48:59,679 --> 00:49:04,159
domino pain, cramping, mention of consuming undercooked poultry, drinking raw milk,

934
00:49:04,320 --> 00:49:06,239
none of which are mentioned here. So in this patient

935
00:49:06,280 --> 00:49:10,119
with fever, headache, characteristic macular blanching rash beginning on the

936
00:49:10,199 --> 00:49:13,639
wrists and ankles following take exposure in an endemic area,

937
00:49:13,760 --> 00:49:17,199
as well as the thrombocytopenia and hyponatremia on labs, we

938
00:49:17,280 --> 00:49:19,159
know in this case the most likely pathogen would be

939
00:49:19,280 --> 00:49:22,599
Rickettsia ricketsii or rick rick which we know by remembering

940
00:49:22,880 --> 00:49:25,840
Rocky Mountain spoty fever instead as Ricky Mountain spoty fever.

941
00:49:26,559 --> 00:49:29,800
Question four, Which of the following treatments should be started

942
00:49:29,840 --> 00:49:33,559
immediately in the patient mentioned above in the absence of contraindications.

943
00:49:34,000 --> 00:49:41,719
A trimethiprim, sulfomethoxizol, B doxy cycling, cmoxiscillin, d azithromycin, or

944
00:49:41,760 --> 00:49:48,559
E chlorinmphenicol. So that's going to be answered. B doxy cycling,

945
00:49:49,079 --> 00:49:51,079
So you have to know this for Rocky Mountain spotted

946
00:49:51,079 --> 00:49:53,559
fever for adults and children, doxy is going to be

947
00:49:53,559 --> 00:49:56,239
your first line med. The only alternative listed here would

948
00:49:56,239 --> 00:49:59,159
be chlorinmphenicol, although it's less effective and would really only

949
00:49:59,159 --> 00:50:01,840
be recommended if it has a history of a very

950
00:50:01,880 --> 00:50:04,760
severe adverse reaction to doxy. So remember the de monic

951
00:50:04,840 --> 00:50:06,800
rick got bit by a tick because he stood on

952
00:50:06,840 --> 00:50:09,719
the docks aka doxy cycling, and forgot to wear gloves

953
00:50:09,760 --> 00:50:11,800
and socks, And then I'll help you remember your answer here.

954
00:50:12,079 --> 00:50:14,639
Last question, Question five, a ten year old girl presents

955
00:50:14,679 --> 00:50:16,960
the emergency department with a four day history of fever,

956
00:50:17,119 --> 00:50:19,639
joint pain, and rash. She had a sore throat three

957
00:50:19,679 --> 00:50:22,519
weeks ago that resolved without treatment. Over the past four days,

958
00:50:22,559 --> 00:50:25,000
she has experienced pain that began in her left knee,

959
00:50:25,159 --> 00:50:27,880
then moved to a right ankle, and now affects both risks.

960
00:50:28,159 --> 00:50:30,440
She also reports a non itchy rash on her trunk

961
00:50:30,480 --> 00:50:33,760
that appears and then disappears on examination. Our temperature is

962
00:50:33,800 --> 00:50:36,079
thirty nine point one degree celsius one hundred and two

963
00:50:36,079 --> 00:50:38,639
point four fahrenheit, heart rate one hundred and fifteen beats

964
00:50:38,639 --> 00:50:40,880
per minute, and blood pressure one hundred and over sixty.

965
00:50:41,239 --> 00:50:43,800
Both risks are swollen, warm, and tender to pal patient.

966
00:50:44,039 --> 00:50:47,519
A faint pink rash with sharply demarketed outer borders is

967
00:50:47,559 --> 00:50:50,400
noted on the trunk and limbs, sparing the face. Cardac

968
00:50:50,440 --> 00:50:53,480
examination reveals a grade two out of six high pitched

969
00:50:53,559 --> 00:50:58,000
apical holosysolic murmur rating to the axilla. Laboratory studies show

970
00:50:58,039 --> 00:51:03,719
elevated inflammatory markers ESO, RNCRP and elevated anti streptolicin O tiers.

971
00:51:04,000 --> 00:51:08,159
Echocardiography demonstrates mitro regurgitation. Which of the following findings in

972
00:51:08,159 --> 00:51:12,000
this patient are classified as minor criteria under the twenty

973
00:51:12,079 --> 00:51:18,280
fifteen revised Jones criteria? Select all that apply A carditis, B,

974
00:51:18,559 --> 00:51:24,239
elevated acute phase reactants, c rithema, marginatum, D fever or

975
00:51:24,280 --> 00:51:31,280
E subcutaneous nodules, so that is going to be answered,

976
00:51:31,320 --> 00:51:34,920
B elevated acute phase reactance and D fever. So this

977
00:51:35,000 --> 00:51:38,199
patient's presentation is most consistent with acute rheumatic fever or

978
00:51:38,320 --> 00:51:41,559
r F supported by recent untreated group A strap infection

979
00:51:41,679 --> 00:51:44,480
and the presence of multiple Jones criteria, And the question

980
00:51:44,519 --> 00:51:46,880
is specifically asking which of the following findings in this

981
00:51:46,920 --> 00:51:49,920
patient are classified as minor criteria and if you remember

982
00:51:49,920 --> 00:51:52,639
the mnemonic answering this is easy. Remember Jones the fat

983
00:51:52,679 --> 00:51:56,400
penguin nomonic Jones being the major criteria and fat faat

984
00:51:57,000 --> 00:52:01,400
standing for minor criteria. Faat we know stans for fever, arthralgis,

985
00:52:01,599 --> 00:52:04,320
acute phase reactants, and too long pr which we can

986
00:52:04,360 --> 00:52:07,679
see answer B Elevated acute phase reactants and D fever

987
00:52:07,960 --> 00:52:10,440
fall under minor criteria, with the remainder of the answer

988
00:52:10,480 --> 00:52:14,679
choices carditis era athemum marginatum and subcutaneous nodules being classified

989
00:52:14,719 --> 00:52:17,119
as major criteria under the Joones demonic. All right, So

990
00:52:17,159 --> 00:52:19,519
that was your bacterial diseases. I hope that was helpful.

991
00:52:19,559 --> 00:52:21,199
Thank you so much for watching, and thank you so

992
00:52:21,280 --> 00:52:22,039
much for the support