Cram The Pance - S1E29 Pneumonia

Episode Date: July 3, 2021

Pneumonia review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so let's do pneumonia today. So this is definitely one you'll get at least a few questions on the pants. I can't imagine you won't. It's a pretty popular topic because there are so many different questions they can ask you about all the different organisms that you see in hospital acquired, community acquire. There's just a bunch of things that you need to know for pneumonia. So I did my best to really break it down and just boil it down into the things that you really need to know. And, you know, I try to simplify it as best I can because it can get a little overwhelming. So let's get started with pneumonia.

Thank you as always. guys you really I just really appreciate all the comments the people reaching out to me just letting me know that it's helping you I really do appreciate that so thank you so much for that and as always if you haven't checked out the YouTube channel please do it's cram the pants on YouTube so let's go ahead and get started with pneumonia pneumonia as you know is an infection of the lungs with consolidation or these interstitial lung infiltrate so clinically pneumonia is very simple it's a fever cough and consolidation seen on chest x-ray boom there's pneumonia so it's very simple but

it's when you get into all the different organisms, that makes it a little bit more tricky, the different types. So the first thing I want to start with is just to familiarize you with community acquired pneumonia versus hospital acquired pneumonia. So it's an important distinction to make and it's going to guide your empiric treatment because the organisms acquired walking around at the local grocery store are going to be much different than the ones in the hospital. Hospital organisms are obviously going to be more resistant. They're going to be more virulent strain. So community acquired pneumonia, that's pneumonia acquired outside of the hospital setting. That's pretty obvious. And then also you can make the distinction.

If they develop pneumonia under 48 hours of hospital admission, it's still considered community acquired due to the incubation period. So hospital acquired pneumonia is pneumonia acquired 48 hours or more after hospital admission. So if it's been 48 hours or more after. after they've been admitted to the hospital, that's considered hospital-acquired pneumonia. The organisms that you're looking for that you're worried about in hospital-acquired pneumonia is going to be pseudomonas and MRSup. Those are the most common organisms you'll see in hospital-acquired pneumonia. So that's what you really need to know for those two, just to know the difference.

There's also something known as ventilator-ventilator-associated pneumonia. It's just pneumonia acquired 48 or more hours after endotracheal inhibition. Don't worry so much about that. Just know your community acquired pneumonia and hospital acquired pneumonia and just know hospital acquired is 48 hours or more after hospital admission. That's hospital acquired. Okay. So this is the tough part, your organisms.

The organisms seen in pneumonia, they're really important. There's a good amount that you need to know about them, the way the patients are going to present with different types of organisms versus others, the treatment options. It's just an important component of pneumonia that you kind of need to know. I really try it again to only focus on the little tiny bits that you need to know about each, but there's a lot of organisms. So let's break it down first. I want to go over what your typical organisms are and then your atypical organism.

So let's go over that first. So your typical organisms in community acquired pneumonia is going to be strepnumo, hemophilis, influenza, and m. Ketterhalis, staphoreus, and klepsiello. those are the main ones. Now if you only want to remember one of those, it's definitely going to be strepneumo. It's the most common bacterial pathogen overall. And luckily, though, in the U.S., it's actually decreasing in incidence because of the pneumococcal vaccine, which targets strep pneumo. So strep pneumonia, that's the one you really need to know for your typical organisms in CAP. I'm going to start calling a CAP instead of saying community acquired pneumonia over and over. So strepneumo is the main one,

but you also have H. Influenza, M. Katerholis, uh, staph, Oriot. and Klebsiello. So those are your typical organisms. Clinically, you're going to have classic signs on clinical presentation with your typical organism. So fever, productive cough, period of sputum, pleuritic chest pain, something known as Rigerus. And if you're not familiar with this, Riger's is not just chills. Rikers, it's like this full-on violent shaking. And it's something that you very well may see in a vignette or hear about in a clinical history of a patient. So it's just violent shaking that patient's going to have in bacterial infections, like with pneumonia. And you'll see these symptoms compared with the presentation in atypical organisms is different.

We're going to go over that next. So next is your atypical organisms. So first you have mycoplasma pneumonia. So in typical organisms, you should just remember strepneumo. If you're going to remember one, in atypicals, you should just remember your mycoplasma pneumonia. That's really the most common atypical organism, and it's the one you'll always have an exam question on. It's just a really common atypical organism. So mycoplasm pneumonia, that's the one you should focus on.

There's also Legionella, chlamydia pneumonia, as well as your viruses. So you're like influence A and B, rhinovirus, adenovirus. Don't worry so much about those. So if those are your atypical organisms. So why are they called atypical? What's atypical about these organisms? So one, the main thing is the presentation. These patients that have these atypical organisms,

compared to the patients with typical organisms, they're going to have a much more indolent and less severe course. So you may have heard of walking pneumonia. Well, that's your atypical organisms. A lot of times these patients are just going to have these mild symptoms. And it turns out they have pneumonia. You never expect it. They're just going to have like this mild cough.

It may be productive. They may have a fever. They're not going to feel that terrible, though, compared to some of those symptoms I went over with the typical organisms. So that's the first thing. They may have this less severe symptoms. a more indolent course with these atypical organisms. The other thing is that with atypical organisms, you can often have these unique

extrapulmonary manifestations that are not commonly seen in typical organisms. So you may have diarrhea, like with legionella, you may have otalgia with mycoplasma, all of these extra pulmonary things that aren't commonly seen in your typical organisms. And then the third reason, not so important for the exam, but another reason they're known as atypical is do the resistance of these organisms to the beta lactam antibiotic class and the fact that they can't be visualized on gram stain. So that's the, that's the third thing. But mainly focus on their, their presentation that they're less severe in symptoms generally. And then also the fact that they have all these unique extrapulmonary symptoms. So to make it easy for a vignette, just remember if it

kind of sounds like pneumonia, but they have some weird stuff thrown in and earache, diarrhea, or it's a young patient and they don't really feel that bad, then you should, be thinking of atypical and that's it's really that simple for an exam question okay so that's your atypical versus your typical organisms now let's break down the important organisms and discuss just the stuff you need to know about each one um so just so you know as i go over these i'm going to give you the likely clinical manifestations or presentation for the organisms none of these are like 100% exclusive or specific so like chronic chronic chronic alcoholism that's commonly seen in club scella can also be seen in strep pneumo so know that

that these are commonly seen in these organisms, but it's not like 100% specific. So let's go over the ones I think you should know and the couple things that I really tried to break it down as best I can into things you just really need to know about each. So strepneumo, of course, you have to know this is your most common cause of community acquired pneumonia. That's one. And then the other thing I think you should know is that you may see on a clinical vignette, on a vignette that they describe the sputum as either rusty or blood. Tensed so strepneumo supposedly the the sputum can sometimes be blood tinge or rusty and a lot of times they'll describe it that way in a vignette I've seen that multiple times in real life I don't know how common it really is but it's definitely a popular way to describe it on a vignette

So strepneumo most common cause of community acquired pneumonia and then blood tinged or rusty sputum next one H influenza or homophilus influenza so the one the one you most like hear about in a vignette when it comes to H flu is the fact that this patient has an underlying pulmonary disorder and the one that you'll most commonly hear about is COPD. So when you see homophilus influenza, think COPD or other underlying or other underlying pulmonary disorders, asthma, bronchiactocysts, but COPD is the one you'll most commonly hear about. So Hamophilus influenza, COPD, and I say it that way because this is the way that I used to remember it. So hemophilus influenza like ham ham maufous influenza ham comes from a pig. COPD has the

word cop in it C OPD. I have I'm not like stating any opinion about cops but this is just how I remembered it. So I'm not trying to offend anybody. But I'm sure we've all heard that cops are called pigs or people have stated that. So COPD has the word cop in it. Hamophilus influenza. I just used to think of ham and a pig. So that just helped me associate the two. So COP, cop, hamophilus, pig, and then you kind of can remember the two. So as soon as you see hemophilus influenza, and they say what likely is associated with this or that you have a patient with COPD and they say what organism is most common, you see Hamophilus, you're like, okay, ham, pig, COP, and then you can hopefully

make the association. All right, so, haemophilus influenza, COPD. Next, Klebsiella. So the vignette, I always remember seeing. for Klebsiella was an alcoholic presenting with this this sputum that they described as blood-tinged, thick, they call it Krant-Jelly Sputum, and that's Klebsiella. So the three things you need to know about Klebsiella and the way that I used to remember them was Klebsiella is spelled with a K. But I used to remember Klebsiella as spelled with a C,

because for Klebsiella, it's all about the C's. So one, chronic alcoholism or chronic illness. It's most frequently seen in hospitalized patients and in those with impaired host defenses like diabetes, alcoholism, malignancy, but the one you're always going to hear about is chronic alcoholism. So that's your first seat, chronic alcoholism or chronic illness. Second C is Cranc jelly sputum. So to the increased inflammation, necrosis seen in patients with Klepsiella, and it can lead to this thick blood-tinged sputum and it's referred to as current jelly sputum. That's your second C. The third C is cavatory lesions.

I kind of say this like plus or minus. Used to be thought that around 30 to 50% of patients with Club Ciello would have these cavitary lesions on imaging. I'd say take it with a grain of salt. This data is kind of outdated. You know, a few sources are still kind of making that association. But it's still probably going to be on an exam question. It's just a popular thing to ask. So remember, Club Cella, spell it with a C instead of a K.

And remember, chronic alcoholism, corang jelly, sputum, and cavitary lesions. Those are your three C. Next one, staphoreous. All you should know about staphoreus, post-fluous. That's it. Staphoreus, post-viral infection. Flu in particular. So, staphoreas pneumonia, that's community acquired, is usually seen in patients who are recovering from influenza.

So post-influenza pneumonia, that's really the only thing I'd say to waste your time knowing about staphoreas, post-flu. That's it. Make it nice and simple. All right. Next one, one of your atypicals. So you're mycoplasma pneumonia. So if they give you a vignette, and it sounds like atypical pneumonia or walking pneumonia, like mild symptoms, young patient, healthy otherwise, definitely be thinking mycoplasma.

Again, this is going to be your most common cause of your atypical. So mycoplasma, as soon as you see young and healthy patients living in a close proximity, this is key here because M pneumonia is spread via respiratory droplets. So you see infection arise among individuals living in close quarters. So families living in the same household, schools, healthcare facilities. And the one you should really kind of put in your head because this is the popular way that I always remember seeing in a vignettes is military barracks. That's for some reason the one they always like to mention. So military barracks are all living close together.

So young and healthy patients close proximity thinking you should be thinking mycoplasma. The other thing too is the extra pulmonary symptoms of course. So coughs or throat, rhinorrhea, cariza. ear pain. It's common to have these upper respiratory symptoms with mycoplasma infection. One that I want to point out, not because you should know it, but because that it used to be something that a lot of people heard about and thought it was associated with mycoplasma. It's kind of found out that it wasn't true, was something known as bolus mearyngitis. So this is this fluid-filled

blisters on the tympanic membrane. And when I was in school, it used to be said that this was commonly seen with mycoplasma pneumonia, but it's actually found out that a lot of the new studies are saying there's really no association between the two. So hopefully you won't get a vignette about it. Because like I said, I remember learning about it in school, but it's turned out that that wasn't really a true, you know, they're not commonly associated together. A lot of the studies have found there was no association between the two. So if you hear it, maybe the exam questions might be a little outdated, but otherwise you

should know the most up-to-date sources are saying there's no association between the two. And then the last thing is something known as cold autoimmune hemolytic anemia. So it's possible to get something known as cold autoimmune hemolytic anemia with mycoplasma infection. I don't want you to go too deep into this. Just know if you see it in a vignette, know that it can be seen with mycoplasma. It's just a type of hemolysis where the antibodies, they attack the blood group antigens. And it's only in temperatures lower than the normal body temp. So they're called cold agglutons.

So just remember cold autoimmune hemoin hemolytic anemia. It should be thinking of mycoplasma. So those are the things that I'd say focus on. Young and healthy patient living in close proximity, those extra pulmonary symptoms, and then cold autoimmune hemelitic anemia. Mycoplasma should be on your list of differentials. All right, let's move on to Legionella.

Legionella, cough and diarrhea. You can almost stop there. You see a cough and you see diarrhea. They mention like pneumonia type symptoms, and then they also mention GI like diarrhea. See these two symptoms combined in a vignette. Right away, you should be thinking of Legionella. In real life, there's a million things that can cause both.

but in the vignette, you should be looking for Legionella and the answer choices. So that's the first thing. That's probably the most important thing. Then also look in the history that they mention some sort of outbreak with contaminated water sources. So they're probably going to mention a hot tub in the vignette, a humidifier, an AC system, something that can lead to the transmission of Legionella via inhalation of aerosolized mist from water sources. That's your key in a vignette. It can also be transmitted through soil, but you're not commonly going to hear about that. It's mostly through inhalation through water sources.

So look for them to mention a hot tub, like I said, an AC system in like a hotel or something, and all these people got infected. That's what you're going to look for in the vignette. And then lab finding, there's a couple unique things. So you're going to see hyponatremia and then elevated hepatic transaminases, so your AST or ALT. Those are, of course, not specific. But if you see these lab findings combine it with a patient with diarrhea,

a cough, proper history, Legionella right away should be high on your list of differential. So again, Legionella, cough and diarrhea, that's your big one. And then anytime they mention any kind of contaminated water source, and then if lab findings with hyponatremia or elevated hepatic transaminases are mentioned, those are all things that can be commonly seen on Legionella. All right, so that's probably the hardest part about pneumonia, is just knowing those little key things about each organism. Diagnosis, I'm going to make it pretty brief because pneumonia diagnosis,

It's really made using like a clinical spectrum with your diagnostic findings, your clinical findings. There's no like one best test to diagnose. Of course, chest x-ray is great, but even that there's a lot of problems with. So diagnostic tests are pretty low yield for the exam. Let's just quickly go through them and kind of talk about a little bit that you'll see with each. So chest x-ray, you'll generally see low bar pneumonia with typical organisms. And then your atypical are going to be more like hazy, patchy infiltrates with atypicals. that may not come up on the exam, but just know that your atypicals again is going to be atypical.

It's going to be more of like a hazy kind of patchy infiltrate rather than that lobar pneumonia seen with typical organisms. CBC, of course, you have an infection, so it could show leukocytosis. Another one that's kind of important just because of a scoring system we're going to go over later with curb 65 is your BUN. Also your serum electrolytes you can get as well. And then you can do blood cultures and sputum gram stains and sputum cultures, but it's really only for your patients with moderate and severe pneumonia. You're not really going to be getting a sputum culture routinely in a patient you're treating in the outpatient setting.

So remember they do have a place. You can do those things, but it's not commonly used unless you have your hospitalized patients more severe. That you do your cultures, your blood cultures, your sputum and gram stain and cultures and things like that. The last test, diagnostic tests I want to go over is something, your PCR testing. You're really only going to do those in Legionilla and Mycoplasma. So you can use PCR testing in those. That's really your diagnostic tests.

Do not waste a lot of time on that because there's really not much. That's very high yield in there. So the other thing I want to go over kind of related to the diagnosis is these different severity index tools and calculators. It's really only one that I'm going to focus on. So these are calculators used in patients with pneumonia to determine how severe the infection is and how they need to be handled, whether it's going to be inpatient, outpatient ICU. The one you're going to be tested on is curb 65. So it's easy to memorize. There's really only a few things you need to know.

The more accurate test, though, just so you know this, the one that's commonly used in clinical settings is known as the pneumonia severity index or the PCI. Luckily, they're not going to ask you any questions on it because there's just way too much to memorize. It's like over 20 different components. So it's one of those things that you'll use out in, you know, when you're out on your rotations, you're going to get the app like your MDCal or go to the website and actually do it that way, but they're never going to ask you on an exam. That would just be cruel. There's just too many components.

But like I said, you can be asked about curb 65 because there's only a few things you need to know. So let's just quickly go over curb 65 so you're familiar with it because I did get a question. So you should probably just know it. It's not that hard. So curb 65 stands for confusion, urea, respiratory rate, blood pressure, and age over 65 or older. So what you do is you give one point for each thing that they're positive for, and I'll go over each individual one. And then you take your points calculated and that helps you decide whether they're going to be treated in an outpatient setting, inpatient or ICU. you. So confusion in the C in Curb 65 stands for confusion. So if they have any type of altered mental

status, that's one point. Uria, the U and Curb 65 stands for your uria or your BUN, your blood urea nitrogen, either over 7 millimoles or over 19 MGs. So that's your uria. Respiratory rate 30 or more breaths per minute. That's another point. Blood pressure, either your systolic less than 90 or your diastolic. 60 or less for diastolic. And then age 65 or older is another point. So if you get zero points, the patients, none of those things, you're going to treat them in an outpatient setting. If they get up to two points, then you want to admit them. You want to treat them, you know, in the hospital. Three or more, you should be considering ICU. So zero points, outpatient,

two points, admitted, three or more ICU. That between one and two, it's kind of one of those things that you make your clinical judgment on. Up to date kind of has more of a persistence. Like they feel like as soon as you get one point, you should probably admit them. But all of the other calculators don't really say to admit until about two points. So kind of know that in between one to two is kind of questionable, but two definitely inpatient, three ICU and then zero is going to be your outpatient. So that's curb 65. If you want to waste like a minute or two to memorize it, because you might get one question right. I don't know if it's 100% worth it. But all right, let's move on to some more higher yield things.

So treatment. So before I start with the meds, I need to add the disclaimer that there's a lot to know with the meds for pneumonia. I tried to boil down as best I could, but don't kill yourself on meds. Know the basics. And just don't waste a lot of time beyond that because it can become a little bit overwhelming. So let's break down each individual one. So first let's start with the least severe of all. And that's going to be your community acquired pneumonia.

in an outpatient setting. How are you going to treat these patients? Well, you're going to treat them with macrolides, amoxicillin, or augmentin, or doxycycline. Now, the last option, the fourth option, is going to be a respiratory fluoroquinolone, moxythloxacin, levofloxysin, but this is something that you should only use as your last line option. You can use it, but you should try any of these other options first, just because of the adverse effect profile, the potential of promoting fluoroquinolone resistance. It's really only for patients that have contraindications to the above meds that I went over, the preferred agents or if they have comorbidities, then a lot of times we'll use respiratory fluoroquinolones. But otherwise, stick to your amoxicillindoxymecrolides

like azithromycin. You may see these drugs being used as monotherapy sometimes combined. The way that I remember that is you got community acquired pneumonia, you're effing mad. You're effing mad because you got community acquired pneumonia. So effing, the F stands for chloroquinolones, M stands for macrolides, A stands for amoxicillin or augmentin, and then D stands for doxycycline. You're effing mad, you got community acquired pneumonia. All right, next, now we have community acquired pneumonia, but now we're treating them in an inpatient setting. So first, you're effing mad that you got pneumonia, but now you have to be hospitalized. So now you have to be hospitalized. So now realize things are getting pretty effing bad. So what does that stand for? So first,

respiratory fluoroquinolones, that's your effin effing bad. So that can be used as monotherapy. So either elivofloxacin, moxifoxicin, gemfoxicin. Again, though, avoid if possible. They're tempting because they're only a once a day med and like, you know, they can be used as monotherapy. And that's why they're commonly used, but resist the temptation, unless there's a compelling reason to use it. Respiratory fluoroquinolone is kind of like your last line. unless they have all those comorbidities and everything. The other option is your B, because remember things are getting effing bad,

so your beta lactam. So, seftriaxone is the one you'll probably see most commonly used. Ampacillin-sobactam, Cepteroline, or dependent on any of those beta lactams, combined with either azithromycin, so that's from your macrolide class. You can also use chlorathromycin or doxy. So the main treatment option here for community acquired

inpatient is going to be your beta lactam so you can use septraoxone septreoline any one of those combined with either azithro and uh or doxy so you combine those two any one of those two beta lactams combine with azithro or doxy you can also use chlorithromycin instead of azithromycin but that doesn't make the mnemonic work and azithromycin is actually used more commonly the chlorotheromycin anyways and then the other option is your fallback which would be your respiratory fluroquinolones so remember community acquired inpatient now you are realizing that things are getting pretty effing bad effing f fluoroquinolones B beta lactams a is ittheromycin and D doxy so that's your treatment for that now we move on to hospital acquired

now we potentially need coverage for our hospital bugs our pseudomonis and our MRSA so with hospital acquired pneumonia the impaired treatment is going to cover those bugs of course you have to make sure that there's a risk for Mercer, you have to look at the, the organisms seen in the hospital and the resistance, et cetera. So with hospital-acquired pneumonia, you're almost always going to cover pseudomonas right away, though. Mercer's kind of, if there is a risk. So how do you cover your pseudomonas in hospital-acquired? You're going to use your antisudemonal beta-lactam. So that's piptoezo, pipersillin, tezobactam, cepapim, cepham, any one of those, any one of those antisodomonal beta lactams. And then if there is a risk for MRSA, you're going to use either

lenaesolid or vancomycin. So really, pseudomonus is going to be covered almost all the time. And then so you're going to use your pptazzo-sefbeam, septazidem. And then if there's a risk for MRSA, you tack on either linazolid or vancomycin. Now, you're only going to add your antisudemonal fluoroquinolones or amino glycosides if the patient has risk factors for gram-negative bacilli like patient with structural lung disease like bronchi ecstic cystic fibrosis or if a gram stain should positive for that or if they had IV antibiotic treatment in the last 90 days anyways this is beyond what you're going to be tested on as and it's further than you should go so if you're treating hospital acquired pneumonia assume coverage of pseudomonis with antisudemotabato beta lactams

pptazzo etc and then if they mention MRSA add on your linaezelid or vanco try not to overcomplicated it's it's complicated as it is i'm sorry i try to make that easy it's just not but i tried my best all right so remember let's really quickly go through it again so you have community acquired outpatient you're effing mad fluoroquinolones but try not to and then mad stands for your macrolyzed like your xithromycin moxaclymcicin and then doxy remember you're trying to combine a moxacoscelin or augen with either macrolite and doxy and then or doxy and then of course your fluoroquinolones can be used as monotherapy, but last line because of all the problems with those. Now, community acquired inpatient. Now you're no longer effing mad. You're just realizing things

are getting effing bad. So respiratory fluoroquinolones can be used as monotherapy or bad stands beta lactam, so your septriaxone, ampicillan, septarolin, plus either azithromycin or doxy. And then, of course, hospital acquired, you're treating pseudomonas or MRSA. Sudomonas can be with your antisudomonal beta lactams, pptazos cephypim, and then MRSA with lenae or vanco. All right, so I guess, you know, try your best.

Hopefully you won't get any questions on that because it's just a lot. All right, now I just want to go over a few more miscellaneous topics if you're still with me at this point. Just a few things that I think are pretty easy to remember and there's not a lot to know. So let's just try to go through those

and then we'll wrap it up. So one thing, miscellaneous topic, aspiration pneumonia. You're just going to see this in chronically ill patients, patients with reduced consciousness, like patients that are on sedatives, antipsychotics, alcohol, drug use. Basically, patients that have whatever the reason is, they aspirate their stomach contents into the lungs. They can't protect their airway, and it leads to this infection or pneumonia in the lungs. It's most commonly caused by anaerobes.

And the key to the vignette is going to be a foul-smelling sputum. It's the sputum that has this putrid odor, and this finding is, consistent with an anaerobic infection, which they, like I just said, it's most commonly caused by treatment, ampicillin-sulbactam, if they're hospitalized because you give that IV, or augmentin, which is amoxicillin clavulonate. It's good for your outpatient setting since it can be given PO. So again, aspiration pneumonia, it's a patient. It can't really protect their airway. They're going to vomit. They're going to aspirate the content into their lungs. It's most commonly caused by anorobes. Vignette's going to be a foul-smelling sputum. Treatment is going to be with

ampacillin-sulbactam or amoxicillin clavulonate. you're augmented. All right. So the last two, they're really kind of infectious disease more than their pulmonary, but they can easily be lumped into a clinical medicine exam on pulmonology. And they're easy. There's only only a couple of things to know about them. So, and I'll give you a couple of pneumonics to memorize the important things. Let's just go from really quick. So first, histoplasmosis, it's a fungal infection caused by breathing in spores of a fungus, often found in bird and bat droppings that can lead to pneumonia. All I want you to, to know about histoplasmosis is the word bird. So it can be caused, like I said, by bird and bat

droppings. So just remember bird, and you remember basically all you really need to know about it. So bird stands for, the bee stands for bird or bat droppings, bee, bird, bee, bat droppings. The I stands for etroconazole. Itchreconazole is going to be your first line treatment for outpatient and patients with mild or moderate disease. So that's your eye in bird. R stands for river valley. And that's, That's because the Mississippi and Ohio River valleys is where you're most commonly going to see this and probably what the list in a vignette. And that's because the soil in this area is rich in bird and bat droppings. So you may have also heard about this illness sometimes in people that explore caves.

And again, same thing due to the bat droppings. But that's the main thing. Mississippi, Ohio River Valley is one of the highest rates of histoplasmosis is seen there. And then the D stands for defining illness for AIDS. is an AIDS-defining illness. If you're not familiar with what that is, certain diseases, the patient has HIV and gets one of these diseases like histoplasmosis, they're now considered to have AIDS, and that's why they're called AIDS-defining illnesses.

They're diseases you're not really going to see in a healthy, immunocompetent individual. So histoplasmosis is one of those AIDS-defining illnesses. You see it. They had HIV. Well, now they have AIDS because it's usually only going to occur if the CD-4 count is less than or equal to 150. So remember histoplasmosis, bird. B stands for bird or back.

dropping i stands for retroconazole r stands for river valley the mississippi ohio river valley and then d stands for defining illness for aids all right last one pneumocystis pneumonia also known as PCP so pcp pneumocystis pneumonia so this is a yeast-like fungal infection and it's most commonly caused by pneumocystis gerovici i or girovechii however you want to pronounce it It's just a fungal infection that leads to pneumonia. There's really only four things you need to know about it. One, it's another AIDS-defining illness. This case, it's going to be a CD4 less than or equal to 200 that you'll generally see this.

The second thing is you may see an increased LDH on labs. So that's your serum lactate dehydrogenase. So LDH levels are elevated in around 90% of patients with PCP who are infected with HIV. So increased LDH. Third one, this is probably the one you'll see in a vignette. It's these bilateral interstitial infiltrates that you'll see on chest x-ray in a patient with PCP. It's also described as a batwing pattern. It's just how the infiltrates kind of line up on the sides of the lungs.

And then finally, treatment, this is really important to treatment of both prophylaxis are both with Bactrum. So Bactrum, of course, is trimethyphtoprins, sulfomethazol. that's how you're going to treat and prophylax in a patient with PCP. And you prophylax in an HIV patient with a CD4 count less than or equal to 200. That's when you start giving them backtrum. So the way, because probably the most important thing is the backroom for the vignette, because it's probably what you'll get asked. The way that I used to remember that backtrum is the treatment of choice for PCP or pneumocystis

pneumonia is because you, your PCP, your posterior, is coarse and prickly, PCP, posterior coarse prickly. You need your back trimmed, back trim. So that's how I used to remember it. So PCP, PCP, Psep, Namonia, posterior is coarse and prickly, PCP. You need your back trimmed, back trim. I don't know. Hopefully that's helpful for you.

It's a really nice visual. All right, so that's it. That was tough. So hopefully you guys are still with me. Those meds are really just a killer. So let's do five quick questions, and then we will be done. So question one, what is that? is the most common cause of community acquired pneumonia?

It's an easy one. That one's going to be strepneumonia. So streptococcus pneumonia is the most common cause of community acquired pneumonia. Two, homeless patient presents to the ER with a productive cough, foul-smelling sputum, and amidst the blacking out last night due to excessive alcohol use. Which antibiotic classes should be considered in this patient for the likely diagnosis? So looking at that vignette, it's a classic presentation, aspiration pneumonia, his foul-smelling sputum.

He had reduced consciousness due to the alcohol, the blackout he had, so he likely vomited and aspirated. So you're going to use either amoxicillin clavulonate, your augmentin, or ampacillin-sulbactin. Three, what organisms should be considered when prescribing empiric antibiotic treatment and a patient with hospital-acquired pneumonia? What organisms should be considered when prescribing empiric antibiotic treatment in a patient with hospital-acquired pneumonia? It's going to be pseudomonas and MRSA.

So not in every patient, of course, but those are the ones you're going to be. be most concerned about in hospital acquired pneumonia. 4. 17-year-old male presents to the office today with pharyngitis, nonproductive cough, and an earache. On chest x-ray, Apache infiltrate is visualized. What is the likely organism causing this patient's symptoms? So this one you should know.

That's going to be mycoplasma pneumonia. Remember, that's your atypical organism, your quote unquote walking pneumonia, young, healthy patient, those extrapulmonary symptoms, that is going to be likely mycoplasma and pneumonia. causing those symptoms. And then question five, what antibiotics are commonly used in the treatment of community acquired pneumonia in an outpatient setting? So which antibiotics are commonly used in the treatment of community acquired pneumonia in an outpatient setting? Remember, you are effing mad. You got community acquired pneumonia, but you're an outpatient yet, so you're not realizing things are effing bad yet. So effing mad, that's going to be fluoroquinolans. Remember,

only in patients with comorbidities or risk factors. And then mad. macrolides like azithromycin, moxicillin, and doxycycline. Remember, you're generally using a moxicillin combined with either a macrolide or doxy, and then fluoroquinolones, if need be, can be used as monotherapy. All right, guys, that was pneumonia. Hopefully, again, like I always say, I really hope that's helping you, and hopefully that was helpful. Please leave me a comment.

If it's helping, please check on my YouTube page if you haven't yet. I would really appreciate that. And thank you so much, as always, for listening and for, you know, leaving me these really nice great comments so good luck on your pants your panery your eos and good luck in pa school