#781: The Art of the First Call

All right, welcome everyone. My name is divine. This is episode six seventy five of the divine intervention podcasts and Here today we're gonna be finishing up the series on the farm crash course, you know the drugs that matter It's been a six-part series super high-yield series Starting episode six seventy. So make sure you kind of check it out So let's jump right in so You know, and today we're gonna focus on a lot of the very critical antibiotics I've kind of talked about some already, but I think it'll be helpful to kind of focus on some very critical ones Like you don't want to walk into any US Emily exam not knowing about these ones, right? So what if they give you a question about a patient and they tell you that this patient has a history of a heart failure Right, but the and you know has been on On pharmacotherapy, you know been on combination from a therapy for a while But that this person was recently diagnosed with a lung infection and the patient was faced placed on a On an antibiotic and now this person has, you know, like two or three weeks after you know treatment The person has had to be you know cranking up the TV to hear anything at home and things like that So what antibiotic drug class was most likely to treat the person's infection? So I really hope you're saying that this person probably used that amino glycoside, right? And I'm a little glycoside, right? So, um, and we're gonna see how this links with his heart failure Presentation and things of that nature, right? So remember your amino glycosides the representative ones you missing your exams are going to be things like gentle mice in To promise in amy casein, you know amy casein is spelled M a am I K a c i n, right? So how do these drugs work? They basically bind the 30 s ribos almost subunit, right? And when they bind it so they're 30 s inhibitors, they basically cause misreading of the mRNA, right? So you essentially don't make Functional proteins. So because you don't make functional proteins, it basically destroys the bacteria, right? Their bacteria is cytol, right? That's actually pretty unusual for Most protein synthesis inhibitors most protein synthesis inhibitors are bacteria static, right? So this one is bacteria cytol so that's kind of important and the two big effects You want to know and then I'm going to circle back to what I talked about earlier on is that again number one They are nephrotoxic, right? Because they love to accumulate within the cells of the proximal tubule, right? Remember the proximal tubule is like the workhorse of the nephron does a lot of reabsorption Does a lot of active transport and things like that, right? Again, our friends at the NBM is know that all of you have memorized that. Ooh, this stuff is nephrotoxic But again, this point about Accommodation within the proximal tubule is not a point that many resources make and it's not a point that many people understand So that's something you certainly want to make sure you know for you exams They really want to make sure you know for your exams and then you also want to make sure you know that these drugs are auto toxic, right? So it can affect either hearing or it can affect vestibular function or it can affect both, right? And when it happens is usually irreversible, usually irreversible, right? And again, prognosis prognosis prognosis the USMLEs if there is a prognostic angle with something They love to take those angles these days, right? So For example, like they can say oh, which of the following elements in the patient's care most increased risk of developing this adverse effect, right? It is again dose, right? The higher the dose, the higher the risk of this nephron or auto toxicity, right? And duration of therapy, right? Those are two things you want to make sure you know your exams the two Ds dose and duration of therapy, right? So you're developing these adverse effects is Depending on how much you get and how long you're on the drug for, right? So that's why if you notice in the hospital, they monitor like the peak and trial levels of this this these drugs, right? They get very monitored very closely, right? Because again, that that's kind of like the having her two problems, right? And again, you want to make sure that you know drug interactions That's the thing the US ML is with pharmacology these days. The unusual is the go after things are drug interactions prognosis Things of that nature, right? So you want to be careful with that. Hey, you don't want to combine an amino glycoside with a lube diuretic if you can avoid it Or an amino glycoside with vancomycin if you can avoid it, right? Because again, that would pretty much juice up your Nephrotoxic and auto toxic risk, right? So like for example, this person has a history of heart failure most would have heart failure They're on water pills, right? They're on lube diuretics to help with pulmonary diva Well, go figure that can cause problems, right? Because you're basically combining two nephrotoxic and auto toxic medications together So that's something you just want to be careful about on your exams, right? So that's number one number two Is also don't forget that amino glycosides, right? They're neuromuscular blocking agents, right? So it's not a good idea if a person has a history of like a neuromuscular disorder like my senior graphics And I'm in a glycoside may not be the smartest may not be the smartest decision there all right And then the next one I'm going to talk about right so let's talk about Vancomycin, right? It's also nephrotoxic since we're talking about those. Let's kind of lump those together Right, but remember vancomycin how does it work? It's a cell wall inhibitor, right? Vank is a cell wall inhibitor, right? So it basically binds the D-Alar D-Alar terminal of peptidog lycan, right? And then when it does that it pretty much blocks transpeptidition, right? Transpeptidition you're pretty much disrupting The formation of the that bond that holds the cell wall together, right now the big big big big side effect Right many of you probably know is red man syndrome rates like a vancomycin infusion reaction But the thing is you want to be a little more precise again I can I can pretty much almost promise you the USM is they're not gonna give you a vanque question and put red man syndrome as the answer That's insane. No, they're not gonna do that now What they're gonna do is they're gonna ask the mechanism, right? They're gonna ask the mechanism There are certain nooks again, like these pool changes if don't in recent months Honestly, it's just about getting a little more granular with some of these things that they test So let's get a little granular of the red man syndrome, right? So remember, it's not an allergy, right? One common misconception many people have and the USM is they love to test is people thinking that oh This is some kind of allergy. No, it's not. It's literally not an IG-mediated allergy No, it's basically direct Marcel de granulation direct Marcel de granulation. And what's the thing that triggers that direct de granulation from Marcel's? It's actually a rapid infusion, right? In fact, this is probably like the greatest determinant of your propensity to develop red man syndrome the speed with which the Infusion of vancomycin is given that's a USM Like question right there the speed which which the vancomycin is given, right? So how do you fix this or prevent this? Exercise the fruit of patients, right? Slow down the infusion, give anti-histamines, right? Because it's the histamine it's it's the histamines released from the muscles that causes many of these symptoms, right? So you don't have to stop the drug, right? You'll give your answer choices on your exams that involve like stopping the drug or Liberling the patient has having some kind of allergy. Don't do any of those things. No, don't stop the drug Just slow down, right? And don't label the person as being allergic to vancomycin. They're not allergic to vancomycin This is not an allergic reaction guys. This is super high yield. This is not an allergic reaction, right? And again, remember vancomycin it's nephrodotoxic, right? It's nephrodotoxic, right? Especially the nephrodotoxicity that risk is gonna climb a lot when you combine it with other nephrodotoxic drugs like Like a menoglycosis for example, right? So just something you want to keep at the back of your mind as you prepare for your for your exams, right? And again, if you love the way I teach you love the way I make integrations You're gonna absolutely love my classes, right? You're gonna absolutely love my classes, right? So in this month of October, yay new month, right? I have a bunch of classes that are for step one to three and then some courses that are specifically for step two and step three, right? So like for example, um, I have like a 20 hour class taking place the last five days of October You know, you know, from the 26 to the 30th, I guess not taking the last five days, right? But it's over Zoom, you know, we cover internal medicine, surgery, OB-GYN, neuropsych, peds, multi-systems, processes on disorders, right? And it's not a lecture, you know, it's through clinical vignettes, exam styles scenarios So you learn how to take the test, but you also learn the content, and it's me that teaches the the entire thing, right? So I integrate content across the systems, I've stripped off fluff, right? Translease very well to complex level two and three, right? I have an MBME testing and strategies class, very helpful for step one, two, step three, and for for shelf exams, right? Again, that's on the, it's going to be like on the 20th of October, right? I work through a range of questions to basically help you build approaches to, you know, avoiding traps on MBME questions, getting relevant information from a QSTEM, breaking down 50-50 scenarios, handling ethics questions, answering questions on material you don't even know very well at all, right? Again, I think you really love the class, right? And then I'll have a bio-stats and EP class, right? It's a four hour class, also for step one, two, step three, right? Again, I'm not doing plug and charge, just showing you formulas, no, I'm showing you how to think about bio-stats and EP, so you can answer pretty much any scenario through your way. And then I have a social sciences quality improvement, hospital medicine and ethics class, that's all for so for step one, two, step three. So five hour class, many people have taken you, found you to be extremely helpful, right? And then I have a last mini review, it's a three hour class, just for step two and step three, right? Rapid review of key topics, you know, tested on the step two against step three, exams, right? Especially from like, just very recent, you know, testing administrations and things like that, right? And then for step one, specifically, I have a 25 hour class, actually. That's going to be taking place from the second to the sixth of November. So if you're studying for step one or studying for step two, step three, and you have like, awful foundations, that class will be perfect, perfect, perfect, perfect for you, right? And then looking ahead to next year, I have a 50 hour step two, step three class, very limited spots available, right? So if you want to sign up for that, shoot me an email, I teach all these classes through Zoom, I'm the one that teaches them is not like some TA that's teaching them, it's me, literally, that's teaching these classes, right? So let's jump to the next stroke here on our list, right? So what if they give you a question about a patient and they tell you that this patient, you know, you know, has acne and was recently placed on some kind of pharmacotherapy. but now the person has like very seen wear redness and pain on the skin and visited the beach recently. What drugs are we talking about here? Obviously we're talking about tetracycline, right? Tetracycline, especially like doxycycline. That's like the classic one they use on the exams. Although another big one is also minocycline, right? So remember, how do these drugs work, right? These are 30s inhibitors. They bind the 30s ribosomal subunit and they basically prevent aminoacyl-TRNA synthetase. I mean, aminoacyl-TRNA from binding to the ribosome, right? If aminoacyl-TRNA cannot bind to the ribosome, it can do protein synthesis, right? Now, the big thing you want to know about many of these, this drug is that, hey, they, they kill it calcium, right? They kill it calcium. So basically anywhere where you have calcium in your body, they're gonna cause problems there, right? So they bind calcium in like developing bone, calcium in your teeth, right? So they can cause like tooth discoloration, they can cause hypoplecia of the animals, right? So this is why you generally try to avoid them in pregnancy, right if you can, when kids on the reach eight, although you want to be careful, you know, Lyme disease, even if you're under age eight, doxy still first line, doxy still first line, Lyme disease, under age eight, doxy still first line, doxy still first line, right? For pregnancy, again, I will encourage you to probably go with something else like amoxicillin or sephiroxine, but doxy is okay in pregnancy for Lyme disease, especially if it's a short course. But again, I'll say in pregnancy, amoxicillin or sephiroxine is where it's at. If you don't see those, then you can go ahead and pick like doxy cycling, that's fine, right? But if you're not pregnant, doxy, doxy, doxy pretty much every time for a Lyme disease question, all right? Now, one other thing I want to know here, and that's kind of traces to what I mentioned about the patient, is the photosensitivity, right? Remember the drugs that cause photosensitivity, the numonic is sat for photo, right? So S for so photo mites, A for amylo, A for amylo-roan, not amylo glycosis, A for amylo-roan, and the T for tetracycline, right? So if they give you a question about a person having stern burns when you exams, being treated for acne, because remember we used doxy, doxycycline, aminocycline to treat acne, right? That's basically what they're going after on you exams, right? So even at normal sun exposure, these patients can get just significant stern burns, right? So they can give you a question on you exams, that's about tetracycline, and they make it a counseling question, right? Where basically it's like, hey, tell them the hey, if you're on this drug, you probably don't want to step out in the sun too much, right? Or just applying some kind of sun protection, you know, wearing like clothes that can protect you from the sun, and things like that really, really don't matter, right? And then I guess what's the other disorder where people can get stern burns, right? Lupus, lupus, lupus, lupus, lupus, they can give you a stern burn presentation in lupus. That's something that's actually pretty high out to know for your exams, right? And then don't forget your blistering skin disorders, right? Especially when you're exposed to the sun, like for fear, cutinia, tarda, right? That's just another thing you want to kind of co-locate in your mind, right? And then I guess since we're kind of talking about tissue cycling, maybe like another good drug class to talk about along those lines. Are your fluorocuenolones, right? Are fluorocuenolones, remember the way they work, right? These are gonna be drugs like like seaprofloxacin, livofloxacin and things like that, right? Livofloxacin is very good for respiratory infections, right? And one thing I will also say, like certain fluorocuenolones, like NAR floxacin, so NOR, FLO, XACIN, right? NAR floxacin or ore floxacin. Those are very good for SBP perphylaxis, right? Spontaneous bacteria, parotonitis, perphylaxis, right? But again, how do these drugs work, right? And he'll be DNA gyries and two polysomeries, four, right? And when you do that, that's gonna interfere with DNA replication in bacteria, right? Now the big, big, big side effects you wanna know with these drugs. Number one, tendon rupture, tendon, tendon, tendon rupture, right? Especially the Achilles, especially the Achilles, especially the Achilles, right? And the thing is, it's particularly common in people that over age 60. But one thing our friends at the MBM is love to do again, I'm telling you this, they know that everybody knows about the tendon rupture with fluorocuenolones. They know that all of you know that stuff. So what are the ways that they found to test the same thing, right? Again, they can make a drug interaction question from it or they can make a prognostic question from it. And that's for example, taking cortical steroids, right? A person that is taking steroids, steroids can cost tendon up with these. They can mess up your collagen, a person taking steroids and concurrently on a fluorocuenolone that is a horrible, horrible, horrendous mix. You're just kinda setting yourself up to explore that Achilles. So that's something you definitely wanna make sure you know for your exams, right? That's a very nice backhanded way they can test this tendon opathy issue with fluorocuenolones. Another thing they also love to test with fluorocuenolones is the QT prolongation, right? So again, they can give you a question about a person that's already on another QT prolonging drug. Let's say for example, they are on, you know, Ziprasi don't for example, right? An anti-psychotic or they're in a drug rehab program, right? 'Cause remember, people in drug rehab, they tend to get all these nasty infections, right? Endocratitis, yeah, yeah, yeah, yeah, yeah, yeah, right? So if they are already on methadone from their drug rehab, which already prolongs the QT interval, and you toss a fluorocuenolone on top of it, that can really cause a big time QT prolongation, it can lead to to sad the point, it can cause a bunch of problems, right? And again, remember, generally, fluorocuenolones, you wanna avoid them in pregnant women and kids, right? Because again, they have issues on developing a cartilage, right? So just something you wanna keep at the back of your mind for, for example, now the next drug I'm gonna talk about, right? It's a drug that you almost never see prescribed in the US, right? It's basically a drug of historic interest, but the fact that something is of historic interest doesn't mean that the US families they don't care about it, right? Like, for example, there are certain things that on the exams that you're like, wait, nobody does this stuff, you know, the shielding test and what not for B12 deficiency, but there are things that they're just certain mechanisms there that the US families like to a pulse on, so it's something you certainly wanna make sure you know for you exams, right? So like, chloromphenicol is the drug I wanna talk about here, right? Basically how those chloromphenicol work, right? Chloromphenicol binds the 50s subunit, right? And then the hippies peptidal transfer easy, shuts down peptidal transfer easy, right? Again, mostly a historical drug, right? But again, two serious toxicities, you wanna make sure you know for you exams, right? It can cause a plastic anemia, right? It can cause a plastic anemia. And that is dose independent. You could have taken a very tiny dose of chloromphenicol on your landing trouble, right? Or, so it's not dependent on the dose. Remember that dose dependence I talked about that with like the amino glycosides, right? So this is different, this one is dose independent. It is dose independent, right? Develop this plastic anemia can present as an utropinic fever on your exams, right? And also don't forget gray baby syndrome, right? Especially in neonates, right? Because again, remember, the way the body excrates or deals with chloromphenicol is that it, you know, it goes through metabolism in the liver, right? You glucoronidates the drug, right? When you add a glucoronidite, glucoronid, you know, group to the drug, right? That's how the body metabolizes a chloromphenicol, right? So the issue there is if you're a neonate, right? You don't have enough of this enzyme, right? You cannot adequately glucoronidate this drug, right? Because again, you just don't have enough of the enzyme, right? Many liver enzymes are in very short supply for a neonate, very short supply for a neonate, right? You, as you grow older, you begin to make more and more of these enzymes as your liver develops more, right? So basically for these kids, because they cannot properly process chloromphenicol, the drug essentially accumulates within them, right? They get cardiovascular collapse, they have this ashen gray discoloration of the skin, right? So again, generally, we don't give for a venecol, but these side effects you certainly want to make sure you know those for your exams, right? And then what if they give you a question on your exams about a person that is an IV drug user, but the person also has a history of depression, right? And you know, that is well controlled with pharmacotherapy. And then you're told that this person, you know, came into the hospital, you know, with two week history of shortness or breath, fevers, and they tell you that you hear a murmur, right? And that murmur, you hear the left sternal border, right? And the person was placed on pharmacotherapy. And then you're not told that this person starts having an ultra mental status, having an increase in deep tendon reflexes, what's the story here, right? What's your fending agent here? I'd hope you're thinking about lenizolid, you're thinking about what lenizolid, right? So how does this all time? Well, this person is an IV drug user, right? And the person has a history of depression, right? So if you have depression and it's well controlled, chances are pretty good that you're probably on something like an SSRI or an SNRI, some kind of serotoninousic agent, right? And then this person presented with endocratitis, IV drug user, probably stuff we're discussing the problem, right? So it's not far fetched to think that, hey, you probably want to put this person on a mercer treating drug, like lenizolid, lenizolid actually covers mercer very well. But lenizolid is a monamine oxidase inhibitor, right? So if you combine it with another serotoninousic agent, that can cause nasty, nasty, nasty serotonin syndrome, right? So just that's the link there, IV drug user, right? And IV drug user may have like some mental health challenges for which they're on a serotoninousic drug. Or they may be taking an ecstasy, right? Ecstasy is something that, you know, party drug, but remember, it's also a serotoninousic agent, so if something wanna keep at the back of your mind, for example, right? So lenizolid, it binds the 50s subgenies of 50s inhibitor, right? But again, don't forget, weak monamine oxidase inhibitor, right? So big drug interaction, I wanna know there, right? So if you combine it with an SSRI, one SNRI, or St. John's Ward, right? Or like lithium, for example, lithium, remember, it causes you to release more serotonin at synapses, and it also causes serotonin receptors to be more sensitive to serotonin, right? You combine those things, and you can precipitate serotonin syndrome, right? And then another kind of weird side effect you wanna make sure you know about lenizolid, is that it can cause thrombocytopenia, it can lower your platelet count, right? right, especially when you take it for a long period of time. Again, they can create a prognostic question from these, they can say, hey, you know, which of the following historic factors in this patient most strongly increase the risk of developing this adverse reaction, right? Again, it's prolong duration of therapy. And think about it, when people are being treated for MRSA, like for endocratitis, for example, they usually have to be on therapy for like six weeks. That's a very, very long time. So, the longer you take the nasolate for, right, one trim with a CVC becomes really important if you're going to be on extended therapy. And then the final drug I'm going to talk about here is metronidazole, or a metronidazole. Remember, you can use your treatment in different things, right? GRDR, intamibahistolytica, trichomoniasis, right? Anerobs, protozoans, right? Gagnerella vaginalis, subbacteravaginosis, right? And basically, right, like how does it work? Basically, like when it gets into a cell of a bacteria or protozoan, it gets reduced. And as it gets reduced, you develop a lot of reactive metabolites. And those reactive metabolites, they damage DNA, they damage DNA, right? So, it's very good against anerobs, very good against protozoans. But it's super high to know this for you, exams, that it does not work against aerobes. It does not work against aerobes. Why? Because aerobes, they don't have the enzymes to activate this metronidazole. They literally don't have the enzymes. They literally don't have the enzymes, right? Now, contrast this with your amino glycosides that work very well against aerobes, but they don't work against anerobs, right? Because you need oxygen for an amino glycoside to work, to get into the cell, right? So, make sure you can make that distinction, right? Amino glycosides work for aerobes, but not anerobs. Metronidazole works for anerobs, but not anerobs, right? Not anerobs, right? So again, metronidazole aerobes, they don't have the enzymes to activate metronidazole, right? And then under big scientific metronidazole, it's also known as the disulfirm reaction, right? With alcohol, right? You know, flourishing, nausea, tachycardia, you know, from taking alcohol with metronidazole. That's why they warn you that hey, don't take metronidazole and alcohol, right? Because you can get this disulfirm like a reaction, right? And what's the mechanism behind that reaction? Again, the USMD is mechanisms, mechanisms, mechanisms, right? It's from the inhibition of aldehyde dehydrogenase, right? From the inhibition of aldehyde dehydrogenase, right? So, you know, you need to tell patients that hey, while taking metronidazole, avoid alcohol during treatment for at least a few days afterwards, right? Because that metronidazole still be in your system for a while, for a few days, right? For a few days. And also, one kind of strange thing that you probably will not find in any resource, but it's actually pretty high yield to know for you exams, is that metronidazole, if you take it for a long period of time, that can actually increase your risk of developing a peripheral neuropathy, right? It can cause one to develop a reversible peripheral neuropathy. So notice today I've kind of talked about some two weird side effects you may not find in many resources, but I'm actually very high yield to know for you exams. That's lane nasolate with thrombocytopenia, metronidazole with peripheral neuropathy, metronidazole peripheral neuropathy. Alright, so I'm going to go ahead and stop here. Again, please subscribe to my YouTube channel, Divine Intervention USMD podcast and videos. This podcast on Apple Google and Spotify. And I offer these review classes that again tons of people have taken and found to be helpful. Like clear, I've had people take the class within the last like two, three weeks, scores are back. They did extremely well on the exams. I really try to keep these courses updated. I also offer one on one tutoring for all the USMD complex exams, ABIM exams, shelf exams, medical exams. And then, you know, I help with your applications, mock interviews and things of that nature. I truly just literally just did a mock interview. Again, I do a ton of those. Have a lot of experience with the process. And then have another website called DivineInterventionLifeLessence.com. Every week, you know, many of you don't procrast Follower, I post like one or two podcasts from a vehicle perspective, I address a life lesson. There's actually an Apple podcast that's here with that called The Divine Intervention Life Lessons Podcast. So thank you for joining me today. I really appreciate you listening to me. Thank you for all the support. I'll see you go really in episode 676. So have a wonderful day. God bless you on the wife right now. Thank you.