The Audio PANCE and PANRE Physician Assistant Board Review Podcast

Podcast Episode 107: This vs. That – PANCE Blueprint Comparisons You Need to Know (Part 1)

Tue, 15 Aug 2023 10:00:36 +0000

Listen to Podcast Episode 107: This vs. That – PANCE Blueprint Comparisons You Need to Know (Episode 1)

In today’s session, we will be discussing five questions related to PANCE/PANRE Blueprint topics. These questions will cover similar presentations and crucial comparisons that are important for you to know. These topics are often used by PANCE/PANRE test question writers, so it’s essential to learn how to differentiate between them. This is the first part (episode 1) of a series.

If you can’t see the audio player, click here to listen to the full episode.

Links from today’s episode:

Sign up for our new PANCE and PANRE Test-Taking Masterclass.
Check out my first blog in our “This vs. That” Blueprint series: The PANCE Blueprint Showdown: Crohn’s Disease vs. Ulcerative Colitis.
Want a question of the day that covers the Blueprint – ALL of it? Sign up for the Entire Blueprint Email Series.
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook for more daily questions.
Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars.

I hope you enjoy this free audio component of the examination portion of this site. Smarty PANCE includes over 2,000 interactive board review questions, along with flashcards, ReelDx cases, integrated Picmonics, and lessons covering every blueprint topic available to all Smarty PANCE members.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Interactive exam to complement today’s podcast

1. A 32-year-old woman presents with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points. Which of the following is the most likely diagnosis?

A) Crohn’s Disease
B) Ulcerative Colitis
C) Infectious Colitis
D) Irritable Bowel Syndrome (IBS)
E) Ischemic Colitis

Answer and topic summary

The answer is B) Ulcerative Colitis

The patient’s symptoms of chronic bloody diarrhea, weight loss, fever, and the sigmoidoscopy findings of a friable rectal mucosa with multiple bleeding points are consistent with a diagnosis of ulcerative colitis (UC), which is a form of inflammatory bowel disease (IBD). UC typically involves the rectum and may extend proximally to involve other parts of the colon.

Incorrect answers:

A) Crohn’s Disease: This is another type of IBD. However, Crohn’s usually presents with non-bloody diarrhea, abdominal pain, and may involve any part of the GI tract from mouth to anus, often with skip lesions. In this case, the bloody diarrhea and the findings on sigmoidoscopy are more indicative of ulcerative colitis.

C) Infectious Colitis: Although infectious causes can lead to similar symptoms, the duration of this patient’s symptoms (6 months) is much longer than typically seen with infectious colitis. Additionally, fever is less common in infectious colitis.

D) Irritable Bowel Syndrome (IBS): IBS is a functional GI disorder characterized by abdominal pain with a change in bowel habit. It does not cause weight loss, fever, or bloody stools.

E) Ischemic Colitis: This typically presents acutely in older patients or those with vascular risk factors. The clinical presentation often includes abrupt onset of abdominal pain and bloody diarrhea. The duration and pattern of symptoms in this patient are more consistent with IBD.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Colorectal disorders ⇒ Inflammatory bowel disease

2. A 27-year-old female presents to the emergency department with a 3-day history of a widespread painful rash. She reports having started a new medication for her seizures 1 week ago. On examination, you note erythematous macules that are coalescing into large areas of epidermal detachment. The mucous membranes of her mouth, eyes, and genital region are also affected, and the skin involvement covers more than 30% of her body surface area. A skin biopsy reveals full-thickness epidermal necrosis. Based on her presentation and the medication history, which of the following diagnoses is she most likely suffering from, and which medication most likely contributed to this condition?

A) Erythema multiforme major secondary to Levetiracetam (Keppra)
B) Toxic Epidermal Necrolysis (TEN) secondary to Carbamazepine
C) Stevens-Johnson syndrome (SJS) secondary to Metformin
D) Acute generalized exanthematous pustulosis secondary to Lisinopril
E) Stevens-Johnson syndrome (SJS) secondary to Atorvastatin

Answer and topic summary

The answer is B) Toxic Epidermal Necrolysis (TEN) secondary to Carbamazepine

The patient’s presentation with widespread epidermal necrosis, mucous membrane involvement, and skin detachment affecting more than 30% of her body surface area is suggestive of Toxic Epidermal Necrolysis (TEN). SJS and TEN are considered a spectrum of the same disease, with SJS affecting less than 10% of body surface area, SJS-TEN overlap affecting 10-30%, and TEN affecting more than 30%. The diagnosis can be confirmed by biopsy (showing necrotic epithelium) if clinical characteristics (eg, target lesions progressing to bullae, ocular and mucous membrane involvement, Nikolsky sign, desquamation in sheets) are inconclusive. Immediate discontinuation of the offending drug is paramount. Patients with TEN often require transfer to a burn unit or an intensive care unit for supportive care. Fluid and electrolyte balance, pain control, and prevention of secondary infections are critical. Immunomodulatory agents like IVIG (intravenous immunoglobulin) or cyclosporine may be considered, but their efficacy is still under debate.

Option A: Erythema multiforme major: Presents with targetoid lesions and is less severe than SJS and TEN. Levetiracetam is not strongly associated with SJS or TEN.

Option D: Acute generalized exanthematous pustulosis is an extensive formation of nonfollicular sterile pustules on erythematous background combined with fever and peripheral blood leukocytosis. This uncommon eruption is most often an allergic reaction because of drugs such as aminopenicillins and sulfonamides inter alia.

A good way to remember the body surface area affected in TEN is “T hree x T en = T hirty percent in Toxic Epidermal Necrolysis

The distinction between SJS, SJS/TEN overlap, and TEN is based on the type of lesions and the amount of the body surface area with blisters and erosions

Blisters and erosions cover between 3% and 10% of the body in SJS
11–30% in SJS/TEN overlap
over 30% in TEN

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Desquamation ⇒ Toxic epidermal necrolysis and Stevens-Johnson syndrome

3. A 32-year-old male presents to his primary care physician complaining of persistent fatigue, unintentional weight loss over the past 3 months, and a painless swelling in the left side of his neck. On examination, there is a non-tender, rubbery 3cm lymphadenopathy in the left cervical region. A subsequent excisional biopsy of the node is performed, and microscopy reveals large atypical cells with abundant cytoplasm and bilobed nuclei, reminiscent of an “owl’s eye” appearance. What is the most likely diagnosis?

A) Acute lymphoblastic leukemia (ALL)
B) Non-Hodgkin’s Lymphoma
C) Burkitt’s lymphoma
D) Hodgkin’s Lymphoma
E) Chronic lymphocytic leukemia (CLL)

Answer and topic summary

The answer is D) Hodgkin’s Lymphoma

The patient’s clinical presentation with painless cervical lymphadenopathy and constitutional symptoms, coupled with the histological finding of large cells bearing the “owl’s eye” appearance (Reed-Sternberg cells), is characteristic of Hodgkin’s Lymphoma. Hodkin’s lymphoma is the most common type of lymphoma and usually presents as a solitary cervical lymph node that has been there for > 30 days. It is commonly manifested with painless cervical adenopathy; there may be splenomegaly or enlargement of other immune tissue, fever, weight loss, fatigue, or night sweats. Upper body lymph nodes are the most common. Diagnosis is based on clinical presentation and confirmed by an excisional biopsy of an involved lymph node. Histology often reveals the pathognomonic Reed-Sternberg cells, which have bilobed nuclei. A chest radiograph should be obtained to search for mediastinal adenopathy. Treatment for Hodgkin’s Lymphoma depends on the stage of the disease and typically involves a combination of chemotherapy, most commonly the ABVD regimen (Adriamycin, Bleomycin, Vinblastine, Dacarbazine). Radiation therapy might be added, especially for localized disease.

Answer Choices Explanations:

A) Acute lymphoblastic leukemia (ALL): Affects mainly children and presents with bone marrow failure symptoms.

B) Non-Hodgkin’s Lymphoma: A group of lymphoid malignancies. Reed-Sternberg cells distinguish Hodgkin’s Lymphoma from Non-Hodgkin’s types.

C) Burkitt’s lymphoma: Fast-growing non-Hodgkin’s lymphoma linked to the Epstein-Barr virus. Exhibits a “starry sky” appearance on microscopy.

E) Chronic lymphocytic leukemia (CLL): A malignancy of mature B cells in older adults. Increased lymphocyte count and smudge cells on a peripheral blood smear.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Lymphoma (ReelDx + Lecture)

4. A 65-year-old male presents to your office complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath sounds, pursed-lip breathing, end-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation, and a small, thin-appearing heart. PFTs show a decreased FEV1 / FVC ratio.

A) Asthma
B) Chronic bronchitis
C) Emphysema
D) Pulmonary fibrosis
E) Bronchiectasis

Answer and topic summary

The answer is C. Emphysema

The patient’s presentation of shortness of breath with exertion, barrel-chested appearance, pursed-lip breathing, findings on chest X-ray (e.g., flattened diaphragm, hyperinflation, and a small heart), and pulmonary function test results all align with the diagnosis of emphysema.

Emphysema is a lung disease that causes shortness of breath. It is one of the two main conditions that make up chronic obstructive pulmonary disease (COPD). The other condition is chronic bronchitis.

In emphysema, the air sacs (alveoli) in the lungs are damaged. Over time, the inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream.

The main cause of emphysema is cigarette smoking. Other causes include air pollution and chemical fumes. A small percentage of cases are caused by a familial or genetic disorder, alpha-1-antitrypsin deficiency.

The body’s natural response to ↓ lung function is chronic hyperventilation = Pink Puffers! CO2 Retainers – the body must increase ventilation to blow off CO2
Minimal cough (compared to chronic bronchitis), quiet lungs
Minimal sputum (compared to chronic bronchitis)
Thin, underweight, and barrel chest

Answer Choices Explanations:

A) Asthma: An obstructive lung disease that is reversible and is marked by bronchoconstriction. It typically presents with episodes of wheezing triggered by factors such as allergens, exercise, or infections.

B) Chronic bronchitis: Defined by a productive cough for 3 consecutive months in 2 successive years. It’s a subtype of chronic obstructive pulmonary disease (COPD), with its main causative factor being smoking. The primary concern is mucus production, as opposed to the alveolar wall destruction seen in emphysema.

D) Pulmonary fibrosis: Represents a set of disorders causing scarring of the lung tissue, leading to a restrictive lung disease pattern. Symptoms might include a dry cough, finger clubbing, and inspiratory crackles upon examination.

E) Bronchiectasis: It is marked by the chronic dilation of bronchi or bronchioles due to repeated infections and inflammation. Patients often have a chronic cough and produce significant amounts of sputum.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Chronic obstructive pulmonary diseases ⇒ Emphysema

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, and General Surgery EOR topic lists

5. A 68-year-old woman presents to the emergency department with chest pain that started 5 hours ago. She describes the pain as a heavy pressure radiating to her left arm. It began at rest and has persisted. She has a history of hypertension and diabetes mellitus. An ECG shows ST-segment depressions in leads II, III, and aVF. Troponin I levels are elevated at 0.55 ng/mL (normal: <0.04 ng/mL). Which of the following is the most likely diagnosis?

A) Stable angina
B) Unstable angina
C) Non-ST segment elevation myocardial infarction (NSTEMI)
D) ST-segment elevation myocardial infarction (STEMI)
E) Prinzmetal angina

Answer and topic summary

The answer is C) Non-ST segment elevation myocardial infarction (NSTEMI)

This patient’s presentation with chest pain at rest, ST-segment depressions on ECG, and elevated troponin I levels are consistent with NSTEMI. NSTEMI is characterized by myocardial ischemia severe enough to result in myocyte injury and elevated cardiac biomarkers but not sufficient to cause ST-segment elevation on ECG.

NSTEMI is diagnosed clinically with supporting findings from ECG changes, especially ST-segment depressions or T-wave inversions, and elevated cardiac biomarkers (troponins or CK-MB). Elevated troponins, in particular, differentiate NSTEMI from unstable angina.

Immediate management includes antiplatelet agents (e.g., aspirin, clopidogrel), anticoagulation (e.g., heparin or enoxaparin), and nitrates for symptom relief. A coronary angiography, followed by possible revascularization (percutaneous coronary intervention or coronary artery bypass grafting), might be required based on risk assessment.

Answer Choices Explanations:

A) Stable angina: Characterized by predictable chest pain or discomfort with exertion or stress, which is relieved by rest or nitroglycerin.

B) Unstable angina: Presents as chest pain at rest, new-onset angina, or angina that is more frequent, longer in duration, or not relieved by rest/nitroglycerin. Crucially, cardiac biomarkers (e.g., troponins) remain normal, differentiating it from NSTEMI.

D) ST-segment elevation myocardial infarction (STEMI): Acute myocardial infarction characterized by ST-segment elevation on ECG. Requires immediate reperfusion therapy.

E) Prinzmetal angina: Caused by coronary artery spasm leading to transient ST-segment elevation. Pain typically occurs at rest, often in the early morning hours.

Smarty PANCE Content Blueprint Review:

PANCE Blueprint Cardiology => Coronary Heart Disease (PEARLS) => Non-ST-Segment Elevation MI (NSTEMI) ReelDx

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

Print it up and start crossing out the topics you understand, marking the ones you don’t, and making notes of key terms you should remember. The PDF version is interactive and linked directly to the individual lessons on Smarty PANCE.

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The post Podcast Episode 107: This vs. That – PANCE Blueprint Comparisons You Need to Know (Part 1) appeared first on The Audio PANCE and PANRE.

Podcast Episode 106: Ten PANCE, PANRE, and Rotation Questions + Review of Adrenal Insufficiency

Wed, 14 Jun 2023 09:00:45 +0000

Listen to Podcast Episode 106: Ten PANCE, PANRE, and Rotation Review Questions + Review of Adrenal Insufficiency

If you can’t see the audio player, click here to listen to the full episode.

Welcome to episode 106 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams.

Links from today’s episode:

Sign up for our new PANCE and PANRE Test Taking Masterclass
Sign up for the Entire Blueprint Email Series
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook
Review adrenal insufficiency and adrenal disorders
Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Interactive exam to complement today’s podcast

1. A 22-year-old female with an unknown past medical history presents to the ER with a prolonged seizure lasting more than 5 minutes per EMS. Her airway was supported, and IV access was obtained en route to the ER. Her blood glucose is 120. Her vitals are stable, and laboratory studies are relatively unremarkable. Which of the following would be an appropriate medication to give to this patient?

A. Calcium gluconate
B. Propofol infusion
C. Lorazepam
D. Clonidine
E. Narcan

Answer and topic summary

The answer is C. Lorazepam

The patient has status epilepticus, which is defined as >5 minutes of continuous seizures or > 2 discrete seizures between which there is incomplete recovery of consciousness. Most episodes of status epilepticus in adults are due to a brain lesion or a toxic/metabolic disturbance (e.g., alcohol withdrawal, hypoglycemia, etc). Immediate management of status epilepticus includes stabilizing the airway, placing pulse oximetry and cardiorespiratory monitors, establishing IV access, and getting a glucose level. The first-line pharmacological agent given is a benzodiazepine (e.g., lorazepam or diazepam). Keppra, valproate, or other anti-seizure medication can be given as well.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Seizure disorders ⇒ Status epilepticus

Also covered as part of the Internal Medicine EOR and Emergency Medicine EOR topic list

2. A 41-year-old male presents to the ER after a construction accident that left him with severe right eye pain and decreased visual acuity. On a physical exam, you notice a teardrop-shaped pupil. Which of the following is the most likely diagnosis?

A. Globe rupture
B. Acute angle-closure glaucoma
C. Retinal detachment
D. Corneal laceration
E. Metallic foreign body

Answer and topic summary

The answer is A. Globe rupture

Mechanical globe injuries occur when there is a laceration or full-thickness rupture through the cornea and/or sclera. Globe rupture (also called an open globe) follows blunt eye injury (e.g., motor vehicle crash, assault, thrown ball, etc). Globe lacerations occur after trauma from a sharp-penetrating object (e.g., knife or high-velocity projectile). PE signs include subconjunctival hemorrhage, irregularly-shaped pupil, hyphema (anterior chamber bleeding), decreased visual acuity, and limited EOM. This is an emergency and a patient should see an ophthalmologist immediately.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Traumatic disorders ⇒ Globe rupture

3. A 45-year-old male veteran presents to your clinic complaining of the following for 4 months: problems with concentration, difficulty staying asleep, persistent negative state, inability to remember events that happened while he was in Iraq, feelings of detachment from others, avoidance of other veterans, and distress when seeing violence on the TV. He denies hallucinations. He has been a veteran for 5 years. Which of the following is the most likely diagnosis?

A. Acute stress disorder
B. Cyclothymic disorder
C. Brief psychotic episode
D. Derealization/depersonalization disorder
E. Post-traumatic stress disorder

Answer and topic summary

The answer is E. Post-traumatic stress disorder

Post-traumatic stress disorder is a complex disorder defined by the behavioral, somatic, cognitive, and emotional effects of trauma. The most common causes are sexual relationship violence (33%), death or traumatic event of a loved one (30%), interpersonal violence like physical assault (12%), and participation in organized violence like combat (11%). The DSM-V criteria for PTSD is:

Exposure to a traumatic event(s). And then for ≥1 month of each of these that started/worsened after a traumatic event and are associated with the traumatic event:

1) Intrusion symptoms

2) Avoidance of stimuli

3) Alterations in cognitions and mood

4) Alterations in arousal/reactivity

Treatment is SSRIs + counseling/psychotherapy. About 50% of patients will recover in 3 months with treatment.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Trauma and stressor-related disorders ⇒ Post-traumatic stress disorder

Also covered in Emergency Medicine EOR, and Family Medicine EOR Blueprint

4. Which of the following clinical findings would you likely expect in a patient with primary adrenal insufficiency?

A. Hypernatremia, hypokalemia, tired
B. Moon facies, depression, bruising
C. Polyuria, polydipsia, intense thirst
D. Fatigue, hyponatremia, hyperpigmentation
E. Hypothermia, bradycardia, goiter

Answer and topic summary

The answer is d. Fatigue, hyponatremia, hyperpigmentation

Adrenal insufficiency is defined as insufficient production of hormones by the adrenal glands. Remember, the MOST common cause of adrenal insufficiency overall is the sudden withdrawal of exogenous steroids. The most common primary cause of adrenal insufficiency is autoimmune adrenalitis (aka Addison disease, aka 21-hydroxylase antibodies against the adrenal gland). Patients will have symptoms and signs of glucocorticoid & mineralocorticoid deficiency, such as fatigue (MC), weight loss, nausea, vomiting, hyponatremia, hyperkalemia, skin hyperpigmentation (due to increased production of proopiomelanocortin prohormone), hypotension, and salt craving. Remember, secondary adrenal insufficiency does NOT lead to hyperpigmentation, only primary adrenal insufficiency (this is commonly asked in tests). Diagnosis of adrenal insufficiency is made by serum cortisol level and then a cosyntropin stimulation test. Treatment is glucocorticoids +/- mineralocorticoids.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Adrenal Disorders ⇒ Primary adrenal insufficiency

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Emergency Medicine EOR topic list

5. A 42-year-old male presents with right upper extremity numbness, dysesthesia, weakness, and arm pain with exertion. The symptoms are aggravated by activity and reaching overhead. Which of the following is the most likely diagnosis?

A. Thoracic outlet syndrome
B. Median nerve compression
C. Biceps tendon rupture
D. Carpal tunnel syndrome
E. Subclavian steal syndrome

Answer and topic summary

The answer is A. Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) refers to a constellation of signs & symptoms that occur due to compression of the neurovascular bundle in the space of the thoracic outlet. Causes include trauma, repetitive injuries, anatomical defects, and pregnancy. The clinical presentation depends on what is being compressed (i.e., nerve, vein, and/or artery), but may include the following: pain, numbness, weakness, muscle weakness, fatigue, swelling, or coldness. Often these symptoms are aggravated by activity or raising the arm overhead. Diagnostic tests include ultrasound, x-ray, CT scan, EMG, MRI, etc. Treatment options depend on what type of TOS the patient has (e.g., physical therapy for neurogenic TOS).

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Spinal Disorders ⇒ Thoracic outlet syndrome

6. A 34-year-old female is diagnosed with immune thrombocytopenic purpura. What is NOT a known cause or risk factor of ITP?

A. Hepatitis C
B. Systemic lupus erythematosus
C. HIV
D. COVID-19
E. Warfarin

Answer and topic summary

The answer is E. Warfarin

Immune thrombocytopenic purpura (ITP) is acquired thrombocytopenia caused by autoantibodies against platelet antigens. Primary ITP is specifically due to autoimmune mechanisms, whereas secondary ITP is associated with other conditions or drugs. Some examples of causes of secondary ITP include systemic lupus erythematosus (SLE), HIV infection, hepatitis C infection, COVID-19, and thyroid dysfunction. There are also many drugs that can lead to ITP, but warfarin is not known to be one of them. Clinical symptoms include petechiae, purpura, easy bleeding, bruising. Obviously, platelets will be low. Work-up for ITP should include HIV and HCV testing, TSH, ANA, coagulation studies, and peripheral blood smear. A bone marrow biopsy can be done to rule out something more pathological. Treatment includes steroids (high-dose) and IVIG. Definitive treatment is splenectomy.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Coagulation Disorders ⇒ Thrombocytopenia ⇒ Idiopathic thrombocytopenic purpura

Also covered as part of the Internal Medicine EOR topic list

7. A 72-year-old African American male presents to the clinic complaining of weight loss, fatigue, and back pain. During the physical exam, you palpate an enlarged, irregular, nodular prostate. Which of the following is the most important risk factor for the development of this most likely diagnosis?

A. Genetic factors
B. Ethnicity
C. Increasing age
D. Obesity
E. High meat diet

Answer and topic summary

The answer is C. Increasing age

Prostate cancer is the most common cancer among men (excluding skin cancer) — as about 1 in 8 men will get it. The most important risk factor for the development of prostate cancer is increasing age. Other risk factors include ethnicity, genetic factors, obesity, tobacco, and a diet high in animal fat. Clinical manifestations may include non-specific urinary symptoms (frequency, urgency, etc), hematuria, bone pain, elevated PSA, and an indurated/asymmetrical prostate with nodules on digital rectal exam. Diagnosis is made by a transrectal biopsy of the prostate.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Genitourinary ⇒ Neoplasms of the Genitourinary System ⇒ Prostate cancer

Also found in Internal Medicine EOR PAEA blueprint

8. A 52-year-old female with a history of previous abdominal surgeries presents to the ER with nausea, emesis, abdominal pain, and inability to pass gas. On physical exam, you notice abdominal distention and auscultate high-pitched tinkering sounds in the upper abdominal quadrants. Which of the following is the most likely diagnosis?

A. Mesenteric ischemia
B. Diverticulitis
C. Gastric ulcer perforation
D. Small bowel obstruction
E. Ischemic colitis

Answer and topic summary

The answer is D. Small bowel obstruction

A bowel obstruction happens when the normal flow of the GI tract is interrupted. The most common cause of small bowel obstruction is intraperitoneal adhesions (s/t previous surgeries). Other causes include hernias or neoplasms. Clinical features include nausea, vomiting, crampy abdominal pain, and obstipation (inability to pass stool). On physical exam you may note abdominal distention, tinkling high-pitch sounds on auscultation, and hyperresonance to percussion. Initial diagnostic modalities include an abdominal x-ray and CT with contrast. These patients need to be admitted for further evaluation and management. Surgery should be consulted.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Diseases of the Small Intestine ⇒ Small bowel obstruction

Also covered as part of the Family Medicine EOR, Emergency Medicine EOR, and General Surgery EOR topic list

9. Which of the following is the most common cause of acute cor pulmonale?

A. Cardiac tamponade
B. Pulmonary embolism
C. Mitral regurgitation
D. Congestive heart failure
E. Portopulmonary syndrome

Answer and topic summary

The answer is B. Pulmonary embolism

The most common cause of acute cor pulmonale is a massive pulmonary embolism (PE). Cor pulmonale is defined by RV failure/enlargement due to a pulmonary issue. The reason a PE leads to acute right heart failure is because a PE is a mechanical obstruction that increases vascular resistance in lungs and increases RV afterload. The RV can’t unload sufficiently and this results in dilation of the RV. The dilated RV impedes on the LV, leading to decreased LV output and decreased supply to the coronary arteries. It also causes RV wall tension/pressure to build and thus coronary perfusion is impeded to the right heart, further leading to ischemia. Also, the dilation of the RV can lead to tricuspid regurgitation, which further reduces blood flow. As the RV becomes ischemic, it can’t contract as well and this further decreases RV output and LV output — leading to a dangerous cycle toward shock. You can risk stratify the degree of RV compromise by getting an echocardiogram, BNP, & troponin.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Circulation ⇒ Cor pulmonale

10. A 25-year-old female with no past medical history presents with nausea, emesis, and pelvic pain. She is normotensive, afebrile, and slightly tachycardic (HR 102 bpm). On physical exam, you palpate an ovarian/pelvic mass. Beta-hCG is negative. The pelvic US is pending. Which of the following is the most likely diagnosis?

A. Ectopic pregnancy
B. Appendicitis
C. Pelvic inflammatory disorder
D. Ovarian torsion
E. Placenta abruption

Answer and topic summary

D. Ovarian torsion

Ovarian torsion refers to the rotation of the ovary, often leading to complete or partial obstruction of blood supply. The most common predisposing factor is an ovarian mass. Presenting features include pelvic pain (90%), nausea, emesis, and fever. On physical exam they may have pelvic and/or abdominal tenderness. A pelvic ultrasound is the mainstay of evaluation when ovarian torsion is suspected. You can get a beta-hCG to rule out an ectopic pregnancy. The definitive diagnosis is made by directly visualizing a rotated ovary at the time of surgical evaluation. Surgery and OB-GYN should be consulted for further management.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Reproductive System Blueprint ⇒ Ovarian Torsion

Also covered as part of the Women’s Health PAEA EOR topic lists

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

Smarty PANCE is not sponsored or endorsed by, or affiliated with, the National Commission on Certification of Physician Assistants.

The post Podcast Episode 106: Ten PANCE, PANRE, and Rotation Questions + Review of Adrenal Insufficiency appeared first on The Audio PANCE and PANRE.

Podcast Episode 105: Ten PANCE, PANRE, and Rotation Review Questions

Mon, 08 May 2023 09:00:03 +0000

Listen to Podcast Episode 105: Ten PANCE, PANRE, and Rotation Review Questions

If you can’t see the audio player, click here to listen to the full episode.

Welcome to episode 105 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams.

Links from today’s episode:

Sign up for the Entire Blueprint Email Series
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
Review systemic lupus erythematosus (SLE)
Review the diabetes diagnostic guidelines
Review gestational diabetes screening guidelines
Review basal cell carcinoma and our comparison tables of the Blueprint dermatologic neoplasms
Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Interactive exam to complement today’s podcast

1. A 68-year-old male farmer presents with a flesh-colored papule with a rolled border located on the right side of his forehead. As you examine the lesion closely, you notice something else about the lesion. Which of the following physical exam findings would make you more suspicious of malignancy?

A. Telangiectasia
B. Nikolsky sign
C. Hypopigmentation
D. Tenderness to palpation
E. Central umbilication

Answer and topic summary

The answer is A. Telangiectasia

The patient has basal cell carcinoma, which is a skin cancer with low metastatic potential. It commonly occurs on the face (70% of the time). There are different types of BCC (nodular vs. superficial vs. infiltrative). However, nodular is the most common (80%) and typical characteristics you may see include a papule with a rolled border, pearly-like look, flesh-colored, and telangiectasia. Risk factors for BCC include UV radiation, certain genes, inherited disorders, etc.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Dermatologic Neoplasms ⇒ Basal cell carcinoma

Also covered as part of the General Surgery EOR and Family Medicine EOR topic list

2. Which of the following is the most common type of elder abuse?

A. Neglect
B. Emotional abuse
C. Physical abuse
D. Sexual abuse
E. Financial exploitation

Answer and topic summary

The answer is A. Neglect

The most common type of elder abuse is neglect, which refers to the failure of a trusted person to protect an older person from harm or provide for their needs. Self-neglect is also common, which is when an older person can’t proide their own care. Some warning signs include bruising, lacerations, skin tears, spiral fractures, malnutrition, pressure ulcers, and dehydration. If you even suspect an older adult is being neglected, you should report this immediately to adult protective services (or similar agencies) and treat the medical complications immediately.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Abuse and Neglect ⇒ Child/elder abuse

3. Which of the following is the most common bacterial cause of a hordeolum?

A. Streptococcus pyogenes
B. Staphylococcus aureus
C. Clostridium perfringens
D. Propionibacterium species
E. Enterobacter aerogenes

Answer and topic summary

The answer is B. Staphylococcus aureus

A hordeolum (stye) is an abscess of the eyelid that is acute. It will usually present with pain and swelling of the eyelid. The most common pathogen indicated is Staphylococcus aureus. Risk factors include dirty eye makeup, rosacea, and seborrheic dermatitis. A way to differentiate hordeolums from chalazions is that Hordeolums are Hot (aka warm/tender).

Treatment may include warm compresses (10 min up to 5 times daily) plus massaging the eyelid to aid in drainage.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Disorders of the Eye ⇒ Lid disorders ⇒ Hordeolum

Also covered as part of the Family Medicine EOR topic list

4. A 19-year-old female presents to the clinic with fatigue, weight loss, arthralgia, and an erythematous rash in a malar distribution over the cheeks and nose (that spares the nasolabial folds). Which of the following is the most common cardiac manifestation of the patient’s likely diagnosis?

A. Third-degree AV block
B. Mitral regurgitation
C. Myocarditis
D. Pericarditis
E. Bradydysrhythmias

Answer and topic summary

The answer is D. Pericarditis

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can impact almost any organ. It’s important to be aware of how SLE clinically presents in order to get to a diagnosis and treatment.

The most common clinical features overall are fatigue (80-100%), arthralgia/arthritis (>90%), fever (>50%), and Raynaud phenomenon (~50%). You may also see the classic malar rash that spares nasolabial folds.

Cardiac complications are common (50%) in SLE, and they lead to morbidity and mortality. The most common cardiac manifestation is pericarditis. Other cardiac issues these patients may have include pericardial effusion, myocarditis (rare), and valvular dysfunction.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Rheumatologic Disorders ⇒ Systemic lupus erythematosus

Also covered as part of the Internal Medicine EOR and Family Medicine EOR topic list

5. Which of the following is the most common and important risk factor for aortic dissection?

A. Bicuspid aortic valve
B. Connective tissue disorder
C. Turner’s syndrome
D. Systemic hypertension
E. Aortic surgery

Answer and topic summary

The answer is D. Systemic hypertension

Aortic dissection is a life-threatening emergency and is defined by a tear of the inner layer of the aorta. On an exam, you may be asked about the classifications:

– Standford Classification: Stanford A is ascending aorta and Standford B is descending aorta

– DeBakey Classifications: type I is Both (ascending + descending aorta), type II is Ascending aorta, and III is Descending aorta. (Hint: It spells out BAD.)

The most important & common risk factor is systemic hypertension. Known causes of acute, severe increases in blood pressure include weight lifting, energy drinks, and cocaine. The classic presentation is “tearing and ripping chest pain with pulse deficits.” Treatment is lowering the BP via IV beta-blockers for both Type A and B and then surgery (for Type A).

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Aortic aneurysm/dissection

6. Which of the following is characterized by a rash that has a “slapped cheek” appearance at first and then progresses into a maculopapular rash on the arms and trunk in a reticular pattern?

A. Roseola infantum
B. Rubella
C. Measles
D. Erythema infectiosum
E. Kawasaki disease

Answer and topic summary

The answer is D. Erythema infectiosum

Erythema infectiosum is a condition characterized by a fever with a rash. It is caused by parvovirus B19 infection. The classic presentation is a “slapped cheek” rash on the face and an erythematous, lacy reticular rash on the trunk and extremities. Some call it the “fifth disease.” It is a common childhood viral exanthem. Diagnosis is usually clinical (serology can be done though). The disease is self-limiting and no specific therapy is warranted (most of the time).

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Viral Infectious Disease ⇒ Erythema infectiosum

Also covered as part of the Pediatric Rotation EOR topic list

7. Which of the following is the most common cause of generalized musculoskeletal pain in young adult females?

A. Multiple sclerosis
B. Rheumatoid arthritis
C. Polymyalgia rheumatica
D. Menstruation
E. Fibromyalgia

Answer and topic summary

The answer is E. Fibromyalgia

Fibromyalgia is the most common cause of generalized muscle/bone pain in young adult females. Patients with fibromyalgia also usually have fatigue, cognitive fog, sleep disturbances, morning stiffness, headaches, paresthesias, and depression. On a physical exam, you will see tenderness to palpation at multiple sites. Initial treatment includes patient education, aerobic exercise, management of concurrent issues (e.g., sleep and psychiatric), & tricyclic antidepressants (e.g., amitriptyline 10 mg).

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Rheumatologic Disorders ⇒ Fibromyalgia

Also covered as part of the Internal Medicine EOR and Family Medicine EOR topic list

8. Which of the following is the best first-line treatment for a post-menopausal woman with osteoporosis and no pathological fractures?

A. Bisphosphonates
B. Parathyroid hormone analogs
C. RANKL inhibitors
D. Selective estrogen receptor modulators
E.Calcitonin

Answer and topic summary

The answer is A. Bisphosphonates

Osteoporosis is characterized by low bone mass and skeletal fragility leading to decreased bone strength. There are no clinical symptoms of osteoporosis until a patient has an actual fracture. Vertebral fractures in particular, are the MOST common clinical manifestation of osteoporosis.

Diagnosis is made by a DEXA scan (T-score < -2.5 standard deviations) or a fragility fracture.

Lifestyle changes that can be made include exercise and cessation of smoking. The first-line pharmacological agent is oral bisphosphonates (e.g., alendronate or risedronate).

Remember bisphosphonates should be administered first thing in the AM and >30 min before the first food. Patients should stay upright for >30 minutes.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Rheumatologic Disorders ⇒ Osteoporosis

Also covered as part of the Family Medicine EOR topic list

9. A 72-year-old female with sick sinus syndrome (s/p pacemaker) presents to your clinic with fever and chills. On a physical exam, you appreciate a new murmur located at the left 5th intercostal space at the midclavicular line. You also notice petechiae on the patient’s conjunctivae. Which of the following is the most likely diagnosis?

A. Bacterial pneumonia
B. Pericarditis
C. Rheumatic fever
D. Infective endocarditis
E. Pleural effusion

Answer and topic summary

The answer is D. Infective endocarditis

The patient has infective endocarditis (IE), which is an infection of the endocardial surface of the heart. Risk factors include pre-existing valvular or congenital heart disease, IVDU, indwelling cardiac devices, IV catheters, or recent dental/surgical procedures. The most common symptoms include fever (90%), new murmur (85%), and petechiae (20-50%). Other textbook findings include Janeway lesions (non-tender macules on palms/soles), Osler nodes (tender nodules on pads of fingers/toes), and Roth spots (hemorrhagic lesions of the retina). The best diagnostic test is a transesophageal echocardiogram. The modified Duke criteria can be used as a diagnostic guide but must be interpreted in light of pretest probability. At least 3 sets of blood cultures should be obtained. Treatment includes IV antibiotics and removal of any infected device.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Traumatic, infectious, and inflammatory heart conditions ⇒ Acute and subacute bacterial endocarditis

Also covered as part of the Emergency Medicine EOR, Internal Medicine EOR, and Family Medicine EOR topic list

10. Which of the following is not considered diagnostic for diabetes mellitus?

A. Random plasma glucose > 200 mg/dL with symptoms of hyperglycemia
B. A1c > 6.5
C. Fasting plasma glucose > 126 mg/dL on at least two separate occasions
D. Plasma glucose > 200 mg/dL measured after a glucose tolerance test
E. All of the above are diagnostic

Answer and topic summary

The answer is E. All of the above are diagnostic

Type 2 diabetes mellitus is a very prevalent, serious disease that impacts about 9% of adults in the United States. Risk factors include family history, obesity, sedentary lifestyle, smoking, and poor diet habits. Initial symptoms include polyuria, polydipsia, polyphagia, and blurred vision. Diagnosis is made by one of the following answer choices seen on the first slide. First-line therapies include metformin and lifestyle changes (i.e., weight loss + exercise). Early combination therapy can be considered at treatment initiation to extend the time to treatment failure. It is VERY important to reach tight glycemic control as soon as possible in diabetic patients. Complications of diabetes include microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (stroke, myocardial infarction).

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Diabetes Mellitus ⇒ Diabetes Mellitus Type 2

Also covered as part of the Family Medicine EOR and Emergency Medicine EOR topic list

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

Smarty PANCE is not sponsored or endorsed by, or affiliated with, the National Commission on Certification of Physician Assistants.

The post Podcast Episode 105: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 104: Ten PANCE, PANRE, and Rotation Review Questions

Mon, 20 Mar 2023 17:04:50 +0000

Listen to Podcast Episode 104: Ten PANCE, PANRE, and Rotation Review Questions

If you can’t see the audio player, click here to listen to the full episode.

Welcome to episode 104 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams.

Links from today’s episode:

Sign up for the Entire Blueprint Email Series
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Smarty PANCE is not sponsored or endorsed by, or affiliated with, the National Commission on Certification of Physician Assistants.

Interactive exam to complement today’s podcast

When is screening for gestational diabetes done?

A. 16 weeks
B. 22 weeks
C. 24 weeks
D. 32 weeks
E. 34 weeks

Answer and topic summary

The answer is C. 24 weeks

Prenatal care is extremely important. Screening for gestational diabetes is routinely done in pregnant patients at 24 weeks of gestation (typically until 28 weeks). Pregnancy is associated with insulin resistance, mostly because of the placenta’s secretion of human placental lactogen. There are bad consequences of gestational diabetes, so it is critical it is diagnosed and treated adequately.

The initial test is a one-hour 50-gram oral glucose tolerance test (GTT). A positive test >135 mg/dL. If a patient tests positive, they need to undergo the second test, which is a three-hour 100 mg oral GTT. The cut-offs are debated, but generally, the following are positive results: fasting > 95 mg/dL, 1 hour>180 mg/dL, 2 hours>155 mg/dL, 3 hours>140 mg/dL.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Complicated Pregnancy ⇒ Gestational diabetes

Also covered as part of the Women’s Health EOR topic list

2. A 60-year-old male with a history of alcohol abuse and esophageal varices is brought to the ER with lethargy, delirium, weakness, and nausea. He is normotensive and afebrile. On physical exam, he is ill-appearing with jaundice, spider angiomas, a distended abdomen, and 3+ pretibial pitting edema. Based on his history and clinical presentation, which of the following electrolyte abnormalities would you expect to see in this patient?

A. Hyponatremia
B. Hypocalcemia
C. Hypercalcemia
D. Hyperphosphatemia
E. Hypermagnesemia

Answer and topic summary

The answer is A. Hyponatremia

The patient has hypervolemic hyponatremia secondary to cirrhosis. The causes of hypervolemic hyponatremia are cirrhosis, nephrotic syndrome, and CHF. Symptoms include nausea, headache, lethargy, and seizures. It’s important to have an approach to hyponatremia since it is the most common electrolyte abnormality in the hospital.

First, it’s important to rule out pseudohyponatremia due to proteins, glucose, or mannitol. Also, make sure it’s not a diuretic causing hyponatremia.
Next, consider the volume status – are they hypervolemic, hypovolemic, or euvolemic?
Hypovolemic causes are more obvious (emesis, hemorrhage, etc.); however, urinary sodium can help differentiate between hypovolemia and euvolemia. If uNA < 20, then this means the renin-angiotensin-aldosterone system is on and trying to maintain pressure/volume; therefore, it is likely the patient is hypovolemic.

Treatment of hyponatremia depends on the cause. It usually involves fluid restriction and possibly (and carefully) a hypertonic solution. Remember – rapid correction of hyponatremia can lead to central pontine myelinolysis.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Renal System ⇒ Fluid and Electrolyte Disorders ⇒ Hyponatremia

Also covered as part of the Internal Medicine EOR topic list

3. A 12-year-old male patient presents with a circular, expanding rash located where a tick had bitten him. He had recently been camping in the upper Midwest. He also complains of a headache and mild fever. Which of the following is a known cardiac complication of the patient’s most likely diagnosis?

A. Supraventricular tachycardia
B. Atrioventricular block
C. Wandering atrial pacemaker
D. Sinus bradycardia
E. None of the above

Answer and topic summary

The answer is B. Atrioventricular block

The patient most likely has Lyme disease, which is a tick-borne illness usually caused by Borrelia burgdorferi. It is more prevalent in the Northeast and upper Midwest. Erythema migrans, which is a circular, expanding rash that may look like a “bull’s eye” is seen about 20% of the time with Lyme disease. Clinical features in the early localized disease include fever, headaches, malaise, arthralgia, and lymphadenopathy. Treatment is doxycycline for non-pregnant adults and children. Amoxicillin is a second-line treatment. A well-known cardiac complication is an atrioventricular block.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Spirochetal Disease ⇒ Lyme disease

Also covered as part of the Internal Medicine EOR and Family Medicine EOR topic list

4. Which of the following is not a manifestation of congenital rubella syndrome?

A. Deafness
B. Cataracts
C. Heart defects
D. Microcephaly
E. Fetal growth acceleration

Answer and topic summary

The answer is E. Fetal growth acceleration

Clinical features of a congenital rubella infection (CRI) include deafness, cataracts, and cardiac disease. Patients may also have CNS abnormalities, such as microcephaly. Typically, a congenital rubella infection will lead to fetal growth restriction, not fetal growth acceleration. A classic finding that you may see on exams is petechiae and purpura — some call these “blueberry muffin lesions.” In general, CRI should be considered in patients who have a suspected rubella infection during their pregnancy. Laboratory studies on the child (before the age of one) are done to help confirm the diagnosis. There is no treatment, and supportive care/surveillance is the main way to manage a congenital rubella infection.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Viral Infectious Disease ⇒ Rubella (German Measles)

Also covered as part of the Pediatric EOR topic list

5. Which of the following is the most common cause of cardiogenic shock?

A. Right ventricle failure
B. Tachydysrhythmias
C. Myocardial infarction
D. Coronary vasospasms
E. Papillary muscle rupture

Answer and topic summary

The answer is C. Myocardial Infarction

Cardiogenic shock is a type of shock that occurs due to cardiac pump failure; essentially, it is the most severe expression of heart failure. It is defined by systemic tissue hypoperfusion secondary to poor cardiac output despite adequate intravascular volume. The most common cause of cardiogenic shock is a myocardial infarction. Other causes include atrial/ventricular tachyarrhythmias, aortic or mitral valve insufficiency, septal defects, free wall rupture, etc. Therapy options vary but may include inotropic support (e.g., dobutamine), intra-aortic balloon pump, and percutaneous ventricular assist devices.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Hypotension ⇒ Cardiogenic shock

Also covered as part of the Emergency Medicine EOR topic list

6. A 20-year-old female with asthma presents to the clinic with “white stuff” in her mouth for the past few days. On physical exam, you notice a few white plaques on the buccal mucosa and tongue. The lesions are easily scraped off with a tongue depressor. Which of the following is the best initial treatment of choice for the most likely diagnosis?

A. Fluconazole
B. Amphotericin B
C. Lidocaine solution
D. Nystatin
E. Bactrim

Answer and topic summary

The answer is D. Nystatin

The patient has oropharyngeal candidiasis, which is a local infection in patients with certain risk factors (e.g., AIDs, dentures, radiation, inhaled glucocorticoids, etc.). This patient has asthma so the likely causative culprit is her inhaled glucocorticoids. The most common cause of oropharyngeal candidiasis is C. albicans. On a physical exam, you will see white plaques in the mouth (which can be scrapped). In smokers, the lesions may look more yellow/brown.

Diagnosis is usually clinical but can be confirmed by scraping the lesion. A KOH test can be performed on the scrapings — budding yeast with pseudohyphae are seen. The treatment of choice is nystatin swish and swallow or topical clotrimazole. If a patient has a severe disease or fails topical therapy, oral fluconazole can be given.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Fungal Infections ⇒ Candidiasis

Also covered as part of the Internal Medicine EOR and Pediatric Rotation EOR topic list

7. A 51-year-old male presents to the clinic. His wife explains his symptoms: brief, involuntary movements of his limbs, depression, impaired thinking, and weight loss. Which of the following is the most likely diagnosis?

A. Parkinson disease
B. Multiple sclerosis
C. Alzheimer disease
D. Vascular dementia
E. Huntington’s disease

Answer and topic summary

The answer is E. Huntington’s disease

Huntington’s disease is an autosomal-dominant disorder characterized by progressive neurodegeneration. It is due to the expansion of the cytosine-adenine-guanine (CAG) trinucleotide in the HTT gene. The main clinical features include choreiform movements, dementia, cognitive impairment, and psychiatric problems. Patients typically present during mid-life. Diagnosis is confirmed by genetic testing. A brain MRI may reveal caudate atrophy. Treatment is generally supportive and symptomatic. There is no cure for Huntington’s disease.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Huntington Disease

Also covered as part of the Internal Medicine EOR topic list

8. A 42-year-old male with a history of diabetes presents the ER with a “bad rash” on his left thigh. He said he had previously gotten a bug bite there. He is febrile (102.2F), tachycardic (110 bpm), and hypotensive (80/50 mmHg). On physical exam, you notice a 2-inch erythematous circular lesion that is warm to the touch. Which of the following is the best next step in the management of this patient?

A. Initiate IV antibiotics and fluids
B. Surgical consult for amputation
C. Outpatient dermatology referral
D. Order venous ultrasound of the leg
E. Send home on oral antibiotics

Answer and topic summary

The answer is A. Initiate IV antibiotics and fluids

This patient has a severe case of cellulitis and sepsis. The best next step is to initiate intravenous antibiotics and fluids. A broad-spectrum antibiotic (like cefepime) plus coverage for MRSA (vancomycin) would be appropriate.

The most common cause of cellulitis is Group A beta-hemolytic Streptococcus pyogenes. What differentiates cellulitis from erysipelas is that erysipelas is more well-defined. Antibiotic options for more mild cellulitis cases include Bactrim, clindamycin, and Keflex.

It’s important to keep in mind that events don’t happen in a vacuum — the bug bite led to cellulitis, and the patient’s body responded to the cutaneous infection in a complex and dysregulated way (i.e. sepsis), eventually leading to hypotension and instability.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Dermatologic Infectious diseases ⇒ Bacterial Infections ⇒ Cellulitis

Also covered as part of the Family Medicine EOR, Emergency Medicine EOR, and General Surgery EOR topic list

9. An 8-year-old male is brought into the clinic by his mother, who is concerned about his behavior in school and at home for the past 7 months. In both settings, he lacks the ability to pay attention, does not follow directions or listen, is easily distracted, is reluctant to do tasks, and constantly loses his homework and pencils. Which of the following is a common side effect of the first-line treatment for this condition?

A. Cognitive fog
B. Appetite suppression
C. Constipation
D. Somnolence
E. Xerosis

Answer and topic summary

The answer is B. Appetite suppression

The patient has attention-deficit hyperactivity disorder (ADHD). There are two main patterns: inattentive or hyperactive-impulse (some may have a combined presentation). The DSM V has criteria for diagnosing ADHD and the various subtypes, but in general, symptoms should be seen in multiple settings, last for 6 months or more, and negatively impact social/academic activities. The first-line pharmacological treatment for ADHD, in most cases, is a stimulant (e.g., methylphenidate, dextroamphetamine, etc.). The most adverse effects of stimulants include moodiness and irritability, and appetite suppression. It’s important to monitor children’s growth and weight when they are taking a stimulant for this very reason.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Neurodevelopmental disorders ⇒ Attention-Deficit/Hyperactivity Disorder

Also covered as part of the Pediatric Rotation and Psychiatry EOR topic list

10. Which of the following patients should be screened for lung cancer, according to the USPSTF?

A. 82-year-old with 34 pack-years who quit 2 years ago
B. 51-year-old with 31 pack-years who quit 10 years ago
C. 70-year-old with 14 pack-years who quit 5 years ago
D. 40-year-old with 20 pack-years who quit 2 weeks ago

Answer and topic summary

The answer is B. 51-year-old with 31 pack-years who quit 10 years ago

The U.S. Preventive Services Task Force (USPSTF) recently changed the lung cancer screening guidelines in March 2021.

An annual low-dose chest CT scan (NOT chest x-ray) should be done for those who are 50 to 80 years old with at least a 20-pack-year history and who currently smoke or have quit within the past 15 years.

It is also important to note that these guidelines do not apply to those who have another illness that already severely limits their life expectancy.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Neoplasms ⇒ Lung cancer

Also covered as part of the Family Medicine EOR and Emergency Medicine EOR topic list

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

The post Podcast Episode 104: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 103: Ten PANRE & PANRE-LA Intervention Complex Practice Questions

Wed, 08 Mar 2023 12:00:42 +0000

Listen to Podcast Episode 103: Ten PANRE & PANRE-LA Intervention Complex Practice Question

If you can’t see the audio player, click here to listen to the full episode.

Welcome to episode 103 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten NCCPA-style board review questions for your PANRE and PANRE-LA exams.

Special from today’s episode:

Take the new PANRE & PANRE-LA (Intervention Complex) Practice Exam: Covers all the topics tested within the new PANRE (Intervention Complex) performance expectation with links to Smarty PANCE lessons.
PANRE & PANRE-LA Blueprint 8-Week Schedule and Study Planner
Read The New 2023 PANRE and PANRE-LA: Everything you Need to Know
Members can try out the newly updated PANRE-LA Smart Search Tool (you must log in to access the search bar)
Sign up for the Entire Blueprint Email Series to get daily questions for the next 478 days!
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Here is an interactive exam to complement today’s podcast

1. A 65-year-old man presents to your office with complaints of constipation for the past six months. He says that he has difficulty passing stools, which are hard and dry. He also reports occasional abdominal pain and bloating. He denies any weight loss, blood in stools, fever, or night sweats. His medical history is significant for hypertension and type 2 diabetes mellitus. His medications include metformin, lisinopril, and aspirin. He does not smoke or drink alcohol. On physical examination, his vital signs are normal. His abdomen is soft and nontender, with normal bowel sounds. There are no masses or organomegaly palpable. Which of the following is the most appropriate next step in evaluating this patient?

A) Colonoscopy
B) Barium enema
C) Thyroid function tests
D) Stool osmolarity
E) Dietary modification

Answer and topic summary

The correct answer is A) Colonoscopy

Colonoscopy is a procedure that involves inserting a flexible tube with a camera into the colon to visualize the mucosa and detect any abnormalities such as polyps, tumors, inflammation, or bleeding. It is indicated for patients with chronic constipation who are older than 50 years or have any red flag features for colorectal malignancy, such as weight loss, blood in stools, anemia, or a family history of colon cancer. This patient meets the age criterion and should undergo colonoscopy to rule out any serious causes of his constipation.

Answer explanations:

Barium enema is an imaging test that involves injecting a contrast agent (barium sulfate) into the rectum and taking X-rays of the colon. It can show structural abnormalities such as diverticula, strictures, masses, or volvulus. However, it is less sensitive and specific than colonoscopy for detecting colorectal malignancy. Therefore, it is not the preferred test for this patient.
Thyroid function tests are blood tests that measure the levels of thyroid hormones (T3, T4) and thyroid-stimulating hormone (TSH). They can help diagnose thyroid disorders such as hypothyroidism or hyperthyroidism. Hypothyroidism can cause constipation due to decreased gastrointestinal motility. However, this patient has no other signs or symptoms of hypothyroidism such as fatigue, cold intolerance, dry skin, hair loss, or bradycardia. Therefore, thyroid function tests are not necessary for this patient.
Stool osmolarity is a test that measures the concentration of solutes in stool water. It can help differentiate between osmotic diarrhea (high stool osmolarity) and secretory diarrhea (low stool osmolarity). However, this test is not useful for evaluating constipation which is defined by infrequent or difficult defecation.
Dietary modification is a nonpharmacological measure that involves increasing fiber and fluid intake to improve stool consistency and frequency. It may be effective for patients with primary constipation which has no identifiable organic cause. However, this patient has chronic constipation which requires further evaluation before initiating treatment.

(Review PANRE Blueprint Topic: Constipation)

2. A 60-year-old male presents to the emergency department with chest pain and shortness of breath. ECG reveals ST segment elevation in the anterior leads. Which of the following laboratory tests is the most specific for the diagnosis of acute myocardial infarction (AMI)?

A) Troponin
B) Creatinine kinase-MB (CK-MB)
C) Myoglobin
D) C-reactive protein (CRP)
E) Brain natriuretic peptide (BNP)

Answer and topic summary

The correct answer is A) Troponin

Acute myocardial infarction (AMI) is a serious medical emergency that requires prompt diagnosis and treatment. Cardiac biomarkers such as troponin, creatinine kinase-MB (CK-MB), and myoglobin are commonly used to diagnose AMI. Among these biomarkers, troponin is the most specific for the diagnosis of AMI. Troponin is a protein found in cardiac muscle cells, and its release into the bloodstream is a specific marker of myocardial injury. Elevated troponin levels are typically seen within 3-4 hours after the onset of symptoms and can remain elevated for up to 10-14 days after an AMI.

Incorrect answer explanations:

Creatinine kinase (CK) is an enzyme found in various tissues, including skeletal and cardiac muscle. CK-MB is a specific isoform of CK found predominantly in cardiac muscle cells. Elevated levels of CK-MB can be seen in the early stages of AMI, but CK-MB is less specific for the diagnosis of AMI compared to troponin.
Myoglobin is a protein found in skeletal and cardiac muscle cells. Elevated myoglobin levels can be seen within 1-3 hours after the onset of symptoms, but myoglobin is less specific for the diagnosis of AMI compared to troponin. Elevated myoglobin levels can also be seen in other conditions that cause muscle injury, such as rhabdomyolysis.
C-reactive protein (CRP) is an acute-phase protein that is elevated in response to tissue injury, inflammation, and infection. While elevated CRP levels can be seen in patients with AMI, CRP is not specific for the diagnosis of AMI and cannot be used as a diagnostic tool on its own.
Brain natriuretic peptide (BNP) is a hormone released by the heart in response to increased pressure and volume in the cardiac chambers. Elevated BNP levels can be seen in patients with heart failure and other cardiac conditions, but BNP is not specific for the diagnosis of AMI.

(Review PANRE Blueprint Topic: Acute myocardial infarction: ST-segment elevation myocardial infarction (STEMI))

3. A 65-year-old woman with a history of atrial fibrillation, hypertension, and obesity presents to the emergency department with acute onset of severe left leg pain and swelling. She has been taking warfarin for anticoagulation but admits to missing some doses in the past week. Her blood pressure is 180/100 mmHg, pulse is 110 beats/min and irregular, and respiratory rate is 20 breaths/min. Her physical examination reveals a warm, tender, erythematous left lower extremity with prominent superficial veins and a positive Homan’s sign. Her international normalized ratio (INR) is 1.5. What is the most appropriate next step in the management of this patient?

A) Start heparin infusion and adjust warfarin dose
B) Order duplex ultrasonography of the lower extremities
C) Administer tissue plasminogen activator (tPA)
D) Perform venography of the left leg
E) Apply compression stockings and elevate the leg

Answer and topic summary

The correct answer is B) Order duplex ultrasonography of the lower extremities

Duplex ultrasonography is a non-invasive test that uses sound waves to visualize the blood flow in the veins of the legs. It can detect thrombi by measuring the diameter, compressibility, and flow characteristics of the veins. It has high sensitivity and specificity for diagnosing DVT. It is considered the first-line diagnostic test for patients with suspected DVT. If negative, it can be repeated in one week or combined with D-dimer testing to rule out DVT.

Incorrect answer explanations:

Heparin infusion and warfarin dose adjustment are indicated for patients with confirmed deep vein thrombosis (DVT) who have subtherapeutic INR levels. However, this patient has not yet been diagnosed with DVT and needs further diagnostic testing before initiating anticoagulation therapy.
tPA is a thrombolytic agent that dissolves blood clots by activating plasminogen into plasmin. Plasmin degrades fibrin, which forms the meshwork of clots. tPA may be used for patients with massive or life-threatening DVT who have contraindications to anticoagulation or who have failed anticoagulation therapy. However, it carries a high risk of bleeding complications and should not be used without confirming DVT diagnosis first.
Venography is an invasive procedure that involves injecting contrast dye into a vein and taking X-ray images to visualize any obstruction or narrowing in the venous system. It was once considered the gold standard for diagnosing DVT but has been largely replaced by duplex ultrasonography due to its higher cost, invasiveness, discomfort, and risk of allergic reactions or nephrotoxicity from contrast dye.
Compression stockings are elastic garments that apply graduated pressure on the legs to improve venous return and prevent edema formation. They may be used as an adjunctive treatment for patients with confirmed DVT, along with anticoagulation therapy. Elevation of the leg can also reduce swelling and pain by decreasing hydrostatic pressure in the veins. However, these interventions do not address the underlying cause of DVT or prevent clot propagation or embolization. They should not be used as the sole therapy for suspected or confirmed DVT without diagnostic testing or anticoagulation therapy.

(Review PANRE Blueprint Topic: Deep venous thrombosis)

4. A 7-year-old child presents with honey-colored crusting lesions on the face and extremities. The lesions started as small red papules that quickly progressed to vesicles and then ruptured, leaving behind a honey-colored crust. The child has no fever and is otherwise healthy. What is the most appropriate initial treatment for this condition?

A) Topical corticosteroids
B) Oral antihistamines
C) Oral doxycycline
D) Topical mupirocin
E) Oral acyclovir

Answer and topic summary

The correct answer is D) Topical mupirocin

The presentation of honey-colored crusting lesions on the face and extremities in a child is consistent with impetigo, a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. The most appropriate initial treatment for impetigo is topical antibiotics such as mupirocin. This is because impetigo is a localized skin infection, and topical antibiotics can effectively treat it without the need for systemic antibiotics. The topical antibiotic is applied to the affected area 2-3 times per day for 5-7 days.

Incorrect answer explanations:

Topical corticosteroids are not appropriate for impetigo as they can exacerbate the infection by suppressing the immune response and promoting bacterial growth.
Oral antihistamines are used to treat allergic reactions and are not effective in treating bacterial skin infections such as impetigo.
Oral doxycycline can be used to treat impetigo, but it is not the initial treatment of choice. Oral antibiotics are reserved for cases of extensive or severe impetigo or for patients who cannot tolerate topical antibiotics.
Oral acyclovir is an antiviral medication used to treat viral skin infections such as herpes simplex virus (HSV). It is not effective in treating bacterial skin infections such as impetigo.

(Review PANRE Blueprint Topic: Impetigo)

5. A 72-year-old woman with a history of hypertension, diabetes mellitus, and atrial fibrillation presents to the emergency department with sudden onset of left-sided weakness and slurred speech. She was last seen normal 2 hours ago by her daughter. Her vital signs are: blood pressure 180/100 mmHg, pulse 110 beats/min irregularly irregular, respiratory rate 18 breaths/min, temperature 36.5°C (97.7°F), and oxygen saturation 98% on room air. On physical examination, she has left facial droop, left hemiparesis (4/5 strength), and dysarthria. Her NIH Stroke Scale score is 8. A non-contrast head CT scan shows no evidence of hemorrhage. What is the most appropriate next step in management?

A) Administer intravenous alteplase
B) Administer intravenous heparin
C) Perform carotid endarterectomy
D) Perform mechanical thrombectomy
E) Start oral aspirin

Answer and topic summary

The correct answer is A. Administer intravenous alteplase

The patient has a clinical diagnosis of acute ischemic stroke, which is caused by occlusion of a cerebral artery by a thrombus or embolus. The most important factor in determining the treatment of acute ischemic stroke is the time from symptom onset to presentation. If the patient presents within 4.5 hours of symptom onset and has no contraindications, intravenous alteplase (a tissue plasminogen activator or tPA) should be administered as soon as possible to dissolve the clot and restore blood flow to the ischemic brain tissue. Intravenous alteplase has been shown to improve functional outcomes and reduce disability after acute ischemic stroke. The patient meets the criteria for intravenous alteplase because she presented within 4.5 hours of symptom onset, has no evidence of hemorrhage on head CT scan, and has no other contraindications such as recent surgery, active bleeding, severe hypertension (>185/110 mmHg), or use of anticoagulants. The other answer choices are incorrect because they are not indicated or effective in this scenario.

Incorrect answer explanations:

Intravenous heparin administration is not recommended for acute ischemic stroke because it does not improve outcomes and may increase the risk of bleeding complications.
Carotid endarterectomy is a surgical procedure that removes plaque from the carotid artery to prevent recurrent strokes in patients with significant carotid stenosis (>70%) who are asymptomatic or have had a transient ischemic attack (TIA) or minor stroke within the past 6 months. It is not indicated for patients with acute ischemic stroke who have not been stabilized medically.
Mechanical thrombectomy is an endovascular procedure that uses a catheter-based device to remove large vessel occlusions in patients with acute ischemic stroke who have a large penumbra (area of potentially salvageable brain tissue). It can be performed within 24 hours of symptom onset if intravenous alteplase is contraindicated or ineffective. However, it should not delay or replace intravenous alteplase if eligible.
Oral aspirin is recommended for secondary prevention of ischemic stroke after initial treatment with intravenous alteplase or mechanical thrombectomy. It can also be used as initial treatment for patients who present more than 24 hours after symptom onset or who have contraindications to intravenous alteplase. However, it should not be given within 24 hours of receiving intravenous alteplase because it may increase the risk of bleeding complications.

(Review PANRE Blueprint Topic: Stroke)

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6. A 65-year-old man with a history of hypertension and peptic ulcer disease presents to your clinic for a routine follow-up. He reports feeling well and has no complaints. His medications include lisinopril and omeprazole. His vital signs are normal. A complete blood count (CBC) shows:

Hemoglobin: 10 g/dL (normal: 13-17 g/dL)
Hematocrit: 30% (normal: 40-50%)
Mean corpuscular volume (MCV): 70 fL (normal: 80-100 fL)
Red cell distribution width (RDW): 18% (normal: 11-15%)
White blood cell count: 6 x 10^9/L (normal: 4-11 x 10^9/L)
Platelet count: 250 x 10^9/L (normal: 150-450 x 10^9/L)

What is the most likely cause of this patient’s anemia?

A) Chronic kidney disease
B) Folate deficiency
C) Gastrointestinal bleeding
D) Thalassemia trait
E) Vitamin B12 deficiency

Answer and topic summary

The answer is C. Gastrointestinal bleeding

The patient has a microcytic anemia, which is characterized by a low MCV (<80 fL). The most common cause of microcytic anemia is iron deficiency. Iron deficiency can result from inadequate dietary intake, malabsorption, increased demand, or chronic blood loss. In this patient, the most likely source of chronic blood loss is gastrointestinal bleeding due to his history of peptic ulcer disease and the use of omeprazole. Omeprazole can mask the symptoms of gastrointestinal bleeding by reducing acid secretion and healing ulcers but does not prevent recurrence or complications. The patient may also have occult blood loss that is not visible in the stool. The RDW is elevated (>15%), indicating increased variation in red blood cell size due to iron deficiency. To confirm iron deficiency, iron studies such as serum ferritin, serum iron, total iron-binding capacity (TIBC), and transferrin saturation should be ordered. The patient should also undergo endoscopy to evaluate for the source and severity of gastrointestinal bleeding and rule out malignancy. The other answer choices are incorrect because they are not causes of microcytic anemia but rather causes of normocytic or macrocytic anemia.

Incorrect answer explanations:

Chronic kidney disease can cause normocytic anemia due to reduced production of erythropoietin by the kidneys. The MCV would be normal (80-100 fL).
Folate deficiency can cause macrocytic anemia due to impaired DNA synthesis in red blood cell precursors. The MCV would be high (>100 fL).
Thalassemia trait can cause microcytic anemia due to reduced synthesis of alpha or beta globin chains that form hemoglobin. However, thalassemia trait usually has a normal or low RDW (<15%) because red blood cells are uniformly small. Thalassemia trait also has a genetic basis and is more common in people of Mediterranean, African, or Southeast Asian descent.
Vitamin B12 deficiency can also cause macrocytic anemia due to impaired DNA synthesis in red blood cell precursors as well as neurological symptoms such as peripheral neuropathy, ataxia, dementia, or psychosis. The MCV would be high (>100 fL).

(Review PANRE Blueprint Topic: Iron Deficiency Anemia)

7. A 42-year-old woman with a history of GERD presents to your clinic for follow-up. She has been taking omeprazole 20 mg daily for the past 6 months and reports significant improvement in her heartburn and regurgitation symptoms. She has also made lifestyle modifications such as avoiding spicy and fatty foods, quitting smoking, and elevating the head of her bed. She asks you if she can stop taking omeprazole or reduce the dose. What is the most appropriate next step in management?

A) Continue omeprazole 20 mg daily indefinitely
B) Discontinue omeprazole and monitor symptoms
C) Switch to famotidine 20 mg twice daily
D) Taper omeprazole to every other day for 4 weeks
E) Perform an upper endoscopy

Answer and topic summary

The correct answer is D) Taper omeprazole to every other day for 4 weeks

Explanation:

The patient has a history of GERD that has responded well to PPI therapy and lifestyle modifications. The goal of treatment is to achieve symptom relief and prevent complications such as esophagitis, stricture, Barrett’s esophagus, or adenocarcinoma. PPIs are more effective than H2 blockers or antacids for healing erosive esophagitis and maintaining remission. However, long-term use of PPIs may be associated with adverse effects such as increased risk of fractures, infections, hypomagnesemia, vitamin B12 deficiency, and chronic kidney disease. Therefore, it is reasonable to attempt a step-down approach after achieving symptom control with PPIs for at least 8 weeks. This involves tapering the dose of PPI gradually over 2-4 weeks to avoid rebound acid hypersecretion. If symptoms recur after discontinuation of PPIs, then switching to an H2 blocker or restarting PPI maintenance therapy with the lowest effective dose may be indicated.

Incorrect answer choices:

Continuing omeprazole 20 mg daily may expose the patient to unnecessary risks of long-term PPI use without attempting a trial of dose reduction or discontinuation.
Discontinuing omeprazole and monitoring symptoms may cause rebound acid hypersecretion and recurrence of GERD symptoms due to abrupt withdrawal of PPI therapy.
Immediately switching to an H2 blocker (such as famotidine) may not provide adequate symptom control for GERD, as H2 blockers are less potent than PPIs in suppressing gastric acid secretion. Slowly taper off the PPI first over 2-4 weeks (the higher the dose, the longer the taper). If symptoms return, it would be appropriate to start again with an H2 blocker. If long-term treatment is needed, H2 blockers allow better absorption of nutrients than PPIs and so potentially have fewer long-term adverse effects. If symptoms are still difficult to control, consider adding the PPI back at the lowest effective dose.
Perform an upper endoscopy: This option is not indicated for patients with uncomplicated GERD who have responded well to medical therapy. Endoscopy is reserved for patients who have alarm features such as dysphagia, odynophagia, weight loss, anemia,

(Review PANRE Blueprint Topic: GERD)

8. Which of the following is an appropriate step-down therapy for a patient with well-controlled asthma on medium-dose inhaled corticosteroids (ICS) and long-acting beta agonists (LABA)?

A) Discontinue LABA and continue medium-dose ICS
B) Discontinue ICS and continue LABA
C) Reduce ICS dose by 50% and continue LABA
D) Reduce both ICS and LABA doses by 50%
E) Switch to low-dose ICS/formoterol as needed

Answer and topic summary

The answer is E. Switch to low-dose ICS/formoterol as needed

This patient has well-controlled asthma on medium-dose ICS and LABA, which corresponds to step 4 of the asthma treatment algorithm. Step-down therapy can be considered for patients with at least 3 months of continuous good control of asthma. The goal of step-down therapy is to reduce medication use to the lowest effective dose while maintaining asthma control. According to the Global Initiative for Asthma (GINA), one option for stepping down from step 4 is to switch to low-dose ICS/formoterol as needed. This regimen involves using a combination inhaler containing low-dose ICS (budesonide) and formoterol (a fast-acting LABA) both as maintenance therapy and as reliever therapy instead of a short-acting beta agonist (SABA). This strategy has been shown to reduce exacerbations, improve symptom control, and decrease steroid exposure compared with conventional maintenance therapy with higher doses of ICS/LABA plus SABA as needed.

(Review PANRE Blueprint Topic: Asthma)

9. A 35-year-old woman presents to her primary care provider with complaints of chronic worry and nervousness for the past 8 months. She says she worries about everything, such as her health, her family, her work, and her finances. She has difficulty sleeping, concentrating, and relaxing. She also experiences muscle tension, headaches, and palpitations. She denies any history of trauma, substance abuse, or other psychiatric disorders. She has no medical problems and takes no medications. Her vital signs are normal and her physical examination is unremarkable. Which of the following is the most likely diagnosis?

A) Panic disorder
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Generalized anxiety disorder
E) Adjustment disorder

Answer and topic summary

The correct answer is D) Generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by persistent, excessive, and unrealistic worry about everyday things that lasts for at least 6 months. The worry causes significant distress or impairment in social, occupational, or other areas of functioning. The anxiety is not attributable to any specific triggers or stressors. The diagnosis of GAD requires at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

Panic disorder is characterized by recurrent unexpected panic attacks that cause fear of having another attack or avoidance of situations that might trigger an attack. Panic attacks are sudden episodes of intense fear or discomfort that peak within minutes and are accompanied by at least 4 physical or cognitive symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control or dying. The patient does not report having panic attacks.
Obsessive-compulsive disorder (OCD) is characterized by recurrent obsessions (intrusive thoughts or images that cause anxiety) and/or compulsions (repetitive behaviors or mental acts that aim to reduce anxiety). The patient does not report having obsessions or compulsions.
Post-traumatic stress disorder (PTSD) is characterized by exposure to a traumatic event that involved actual or threatened death, serious injury, or sexual violence, and subsequent re-experiencing, avoidance, negative alterations in cognition and mood, and increased arousal related to the event. The patient denies any history of trauma.
Adjustment disorder is characterized by emotional or behavioral symptoms that develop within 3 months of an identifiable psychosocial stressor and cause significant impairment in social, occupational, or other areas of functioning. The symptoms usually resolve within 6 months after the termination of the stressor unless it has chronic consequences. The patient’s anxiety is not related to any specific stressors and has lasted longer than 6 months.

(Review PANRE Blueprint Topic: Generalized Anxiety Disorder)

10. A 65-year-old man with a history of type 2 diabetes mellitus presents to the emergency department with altered mental status, polyuria, and polydipsia. He has been feeling unwell for the past week with a urinary tract infection that he has been self-treating with cranberry juice. His vital signs are: blood pressure 180/100 mmHg, heart rate 110 beats per minute, respiratory rate 24 breaths per minute, temperature 37.8°C (100°F), and oxygen saturation 95% on room air. His physical examination reveals dry mucous membranes, poor skin turgor, and decreased level of consciousness. His laboratory tests show:

Serum glucose: 900 mg/dL
Serum sodium: 150 mEq/L
Serum potassium: 4.0 mEq/L
Serum bicarbonate: 18 mEq/L
Serum osmolality: 350 mOsm/kg
Urine ketones: negative

Which of the following is the most appropriate initial treatment?

A) Intravenous insulin infusion
B) Intravenous normal saline infusion
C) Intravenous sodium bicarbonate infusion
D) Intravenous potassium chloride infusion
E) Subcutaneous insulin glargine injection

Answer and topic summary

The correct answer is B) Intravenous normal saline infusion

This patient has hyperosmolar hyperglycemic syndrome (HHS), which is a complication of diabetes mellitus characterized by severe hyperglycemia (>600 mg/dL), hyperosmolality (>320 mOsm/kg), and dehydration in the absence of ketoacidosis. HHS is often triggered by an acute stressor such as infection, medication noncompliance, or excessive carbohydrate intake. The mainstay of treatment for HHS is fluid replacement with isotonic saline to correct dehydration, lower serum glucose and osmolality, and improve renal function. Insulin therapy can be initiated after adequate fluid resuscitation, usually at a low dose (0.05-0.1 units/kg/hour). Electrolyte abnormalities such as hypokalemia or acidosis should be corrected as needed.

Incorrect answer explanations:

Insulin infusion is not the first-line treatment for HHS, as it can worsen dehydration, hypokalemia, and cerebral edema if given before adequate fluid replacement. Insulin should be started after fluid resuscitation at a low dose to avoid rapid drops in serum glucose and osmolality.
Sodium bicarbonate infusion is not indicated for HHS unless there is severe acidosis (pH <7.0). The patient’s serum bicarbonate level is mildly low (18 mEq/L), but not enough to warrant bicarbonate therapy. Moreover, sodium bicarbonate can increase serum osmolality and worsen cerebral edema.
Intravenous potassium chloride infusion is unnecessary for HHS unless there is hypokalemia (<3.5 mEq/L). The patient’s serum potassium level is normal (4.0 mEq/L), so potassium supplementation is not required. However, potassium levels should be monitored closely during fluid and insulin therapy, as they may drop rapidly due to intracellular shifts.
Insulin glargine injection is a long-acting insulin that provides basal coverage for up to 24 hours. It is not suitable for treating acute hyperglycemia in HHS, as it has a slow onset of action and cannot be titrated easily according to blood glucose levels. Moreover, subcutaneous insulin administration may be unreliable in patients with poor perfusion due to dehydration.

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Podcast Episode 102: Ten PANCE, PANRE, and Rotation Review Questions

Thu, 09 Feb 2023 23:40:51 +0000

Listen to Podcast Episode 102: Ten PANCE, PANRE, and Rotation Review Questions

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Welcome to episode 102 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams.

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Interactive exam to complement today’s podcast

1. Which of the following is NOT true about a non-ST elevation myocardial infarction?

A. Non-enteric-coated, chewable aspirin 325 mg should be given
B. Troponins are elevated
C. It happens due to a partially occluded epicardial coronary artery
D. Patients need a 12-lead EKG
E. You will always see ST depressions

Answer and topic summary

The answer is E. You will always see ST depressions

A non-ST elevation myocardial infarction (NSTEMI) is defined by the absence of persistent ST-elevation with elevated cardiac biomarkers (e.g., troponin I or T, CKMB, etc). It happens due to a partially occluded epicardial coronary artery (leading to subendocardial ischemia). NSTEMI typically presents as pressure-type chest pain.

Patients with a suspected NSTEMI should receive a 12-lead EKG within 10 minutes of arrival. ST depression, transient ST-elevation, and/or T-wave inversions may be seen on EKG, but they are NOT required for the diagnosis of NSTEMI. The most important medication to give is non-enteric-coated chewable aspirin 325 mg. Other meds include sublingual nitroglycerin, oxygen as needed, beta-blockers (assuming no C/I), high-intensity statin, ACE inhibitors (if CKD, DM, or EF < 40%), P2Y12 inhibitor (e.g., clopidogrel), anticoagulation, and possibly PCI with stenting or CABG.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Coronary Heart Disease ⇒ Acute myocardial infarction ⇒ Non-ST-Segment Elevation MI (NSTEMI)

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, Emergency Medicine EOR topic list

2. A 22-year-old G1P0 female at 28 weeks gestation with a history of diabetes presents to the clinic with fever, chills, and dysuria. Vitals show tachycardia (115 bpm), tachypnea (22 bpm), and hypotension (90/58 mmHg). Physical exam reveals suprapubic tenderness. Labs reveal leukocytosis, hyponatremia, and hyperglycemia. Urine dipstick is positive for nitrites, blood, glucose, and ketones. Which of the following is the next best step?

A. Send home with oral antibiotics and analgesics
B. Reassurance and oral rehydration solution
C. Admit to hospital for antibiotics, fluids, & insulin
D. Order outpatient CT scan of the abdomen
E. Refer to an outpatient nephrologist for workup

Answer and topic summary

The answer is C. Admit to hospital for antibiotics, fluids, & insulin

The patient most likely has pyelonephritis, which is an infection of the upper urinary tract and kidneys. It is one of the most common causes of sepsis in pregnancy. The pyelonephritis is also precipitating diabetic ketoacidosis in this diabetic patient.

Clinical features of pyelonephritis include fever, flank pain, N/V, and possible CVA tenderness. Pregnant patients are at high risk for obstetric and medical complications from the infection. It is recommended that pregnant women with acute pyelonephritis should be admitted for IV antibiotics (typically at least until the woman is febrile for 1-2 days and symptomatically improved). Antibiotic options include cefepime, piperacillin-tazobactam, and meropenem. This patient will also need insulin and fluids.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Genitourinary ⇒ Infectious Disorders ⇒ Pyelonephritis

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Emergency Medicine EOR topic list

3. Which of the following is the most common benign neoplasm of the liver?

A. Hepatocellular carcinoma
B. Hepatic hemangioma
C. Liver angiosarcoma
D. Hepatocellular adenoma
E. Hepatoblastoma

Answer and topic summary

The answer is B. Hepatic hemangioma

Hepatic hemangiomas are the most common benign liver lesions. The typical patient is a 30 to a 50-year-old woman. Exposure to estrogen may increase the size of hepatic hemangiomas. Patients are typically asymptomatic; however, if they do have symptoms they may have RUQ abdominal pain. An ultrasound will show a homogeneous, hyperechoic mass. If lesions are < 5 cm, you usually don’t need to do anything. If > 5 cm, monitoring is needed Q6-12 months via MRI.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastrointestinal System Neoplasms ⇒ Liver neoplasms

4. A 12-year-old male presents with a sore throat, fever, dysphagia, and a muffled voice. On physical exam, the uvula is deviated. Which of the following is the most likely diagnosis?

A. Pharyngitis only
B. Retropharyngeal abscess
C. Peritonsillar abscess
D. Oral candidiasis
E. Foreign body

Answer and topic summary

The answer is C. Peritonsillar abscess

A peritonsillar abscess is a collection of pus near the tonsils. The most common causes are Streptococcus pyogenes (group A), Streptococcus anginosus, & Staphylococcus aureus. Clinical features include muffled voice, sore throat, fever, drooling, neck pain, fatigue, and decreased PO intake. On physical exam, the uvula may be deviated. Diagnostic tests that can be done include ultrasound or CT with contrast (depends). Treatment is antibiotics, drainage, and supportive care.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Oropharyngeal disorders ⇒ Infectious and inflammatory disorders ⇒ Peritonsillar abscess

Also covered as part of the Pediatric EOR, Family Medicine EOR, and Emergency Medicine EOR topic list

5. Which of the following is the most common cause of acute epiglottitis?

A. Staphylococcus aureus
B. Haemophilus influenzae
C. Streptococcus pneumoniae
D. Streptococcus pyogenes
E. Neisseria meningitidis

Answer and topic summary

The answer is B. Haemophilus influenzae

Acute epiglottitis is an inflammatory condition of the epiglottis (usually due to a bacterial infection). In severe situations, it is life-threatening. The most common cause overall is said to be Haemophilus influenzae; however, in adults, Streptococcal species now tend to be more common. The management of this disease should focus on giving antibiotics and steroids. Airway management and securing an airway is the most important part of treatment.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Acute epiglottitis

Also covered as part of the Pediatric EOR and Emergency Medicine EOR topic list

6. A 32-year-old female presents with pain around the nail fold on the index finger of her right hand. She is afebrile. On physical exam, you appreciate erythema and swelling of the proximal nail fold. The area is not fluctuant. Which of the following is the best treatment option?

A. Topical antibiotics and warm water soaks
B. Intravenous antibiotics
C. Oral antibiotics and incision and drainage
D. Surgical consult for removal
E. None of the above

Answer and topic summary

The answer is A. Topical antibiotics and warm water soaks

The patient has acute paronychia, which is a very common condition and essentially is just inflammation of the nail folds. The most common bacterial causes are Staph aureus and Strep pyogenes. Risk factors include manicures, nail biting, and picking at nails. Clinical features include sudden onset of painful erythema and swelling. Sometimes an abscess will be present. In this patient’s case, there was no fluctuance and so topical antibiotics and warm water soaks would be appropriate.

If the patient had an abscess, oral antibiotics and incision/drainage (with number 11 surgical blade) would be reasonable.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Bacterial Disease ⇒ Methicillin-resistant Staphylococcus aureus infection

7. A 60-year-old male presents with fatigue and weight loss. His physical exam is remarkable for gingival hyperplasia and splenomegaly. Labs reveal pancytopenia. A bone marrow biopsy reveals Auer rods. What is the likely diagnosis?

A. Acute myeloid leukemia
B. Acute lymphocytic leukemia
C. Chronic myeloid leukemia
D. Chronic lymphocytic leukemia
E. Non-Hodgkin’s lymphoma

Answer and topic summary

The answer is A. Acute myeloid leukemia

The patient has acute myeloid leukemia (AML), which is a group of cancers that involve the myeloid precursor cells. It is characterized by clonal proliferation (excessive growth) of abnormal myeloid precursor cells. Risk factors include smoking and chemotherapy/radiation.

Clinical features include fatigue, pallor, weakness, bone pain, gingival bleeding, and organomegaly. Lab findings are variable but may include pancytopenia (decrease in RBCs, WBCs, and platelets), electrolyte derangements, and/or hypoxemia. Workup should include a peripheral blood smear and bone marrow biopsy. The bone marrow biopsy will classically show Auer rods and >20% blasts.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Acute and chronic myelogenous leukemia

Also covered as part of the Family Medicine EOR topic list

8. A 42-year-old female presents for an annual physical exam with some complaints of fatigue and dyspnea. On physical exam, you appreciate a fixed S2 split. Which of the following is the most likely diagnosis?

A. Ventricular septal defect
B. Mitral regurgitation
C. Aortic stenosis
D. Atrial septal defect
E. Patent ductus arteriosus

Answer and topic summary

The answer is D. Atrial septal defect

Atrial septal defect is the most common congenital heart lesion in adults. People often don’t have symptoms until adulthood. The most common type is ostium secundum. Symptoms include fatigue and dyspnea. A classic physical exam finding on a test would be a systolic ejection crescendo-decrescendo flow murmur @ LUSB with FIXED S2, loud S1. Echocardiography is the initial imaging modality of choice. Keep in mind that a complication of ASD is that the left to right shunt can cause volume and pressure overload of the right heart and pulmonary circulation, leading to pulmonary hypertension.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Congenital Heart Disease ⇒ Atrial septal defect

Also covered as part of the Pediatric EOR topic list

9. Which of the following is not a test for acute appendicitis?

A. Murphy sign
B. Rovsing sign
C. Obturator sign
D. Psoas sign
E. McBurney sign

Answer and topic summary

The answer is A. Murphy sign

Appendicitis is one of the most common indications for emergent abdominal surgery. The most common physical exam finding is RLQ tenderness. There are some tests that may help with the diagnosis — keep in mind though that these tests/signs are NOT sensitive.

Rovsing sign: pain in the RLQ with palpation of the LLQ (indicative of peritoneal irritation)
McBurney sign: tenderness about 2 inches from the ASIS (on a straight line from ASIS to the umbilicus)
Psoas sign: RLQ pain with passive right hip extension
Obturator sign: flexion of the right hip and knee, followed by internal rotation of the right hip elicits RLQ pain

Murphy’s sign is positive in acute cholecystitis, not appendicitis. A positive test is RUQ pain on inspiration.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Diseases of the Small Intestine ⇒ Appendicitis

Also covered as part of the Emergency Medicine EOR, Family Medicine EOR, Pediatric EOR, and General Surgery EOR topic list

10. A 31-year-old female presents with pain and numbness in her anterior tibial region. On physical exam, the area is pale, cold, and pulseless. Which of the following is the best definitive treatment for this likely diagnosis?

A. Antiplatelets
B. Amputation
C. Physical therapy
D. Fasciotomy
E. IV heparin drip

Answer and topic summary

The answer is D. Fasciotomy

The patient has acute compartment syndrome, which is when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure. It can result in ischemia. The most common location is the calf. Many cases of acute compartment syndrome in the lower extremity are associated with fractures, burn injuries, crush injuries, or soft tissue infections. The “5 P’s” can help you remember the symptoms – pain, pallor, paresthesia, pulselessness, paralysis. Extremity fasciotomy is the treatment for acute compartment syndrome.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Compartment Syndrome

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

The post Podcast Episode 102: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 101: Ten PANCE, PANRE, and Rotation Review Questions

Wed, 02 Nov 2022 04:26:35 +0000

Welcome to episode 101 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, and rotation exams.

Special from today’s episode:

Join the Smarty PANCE Member’s Community then sign up for a study group to get updates about upcoming webinars.
Check out our updated End of Curriculum (EOC) Exam Course
Sign up for the Entire Blueprint Email Series
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

I hope you enjoy this free audio component of the examination portion of the Smarty PANCE website. The full board review website includes over 2,000 interactive board review questions, flashcards, and blueprint lessons available to all members of Smarty PANCE.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Listen to Podcast Episode 101: Ten PANCE, PANRE, and Rotation Review Questions

If you can’t see the audio player, click here to listen to the full episode.

Interactive exam to complement today’s podcast

1. A 75-year-female smoker with a history of atrial fibrillation and hypertension presents to the ER complaining of a 2-hour history of right-sided weakness and aphasia that has now resolved. Her physical exam and vital signs are completely unremarkable. CT head is unremarkable. Which of the following is the most likely diagnosis?

A. Subarachnoid hemorrhage
B. Transient ischemic attack
C. Cerebral venous sinus thrombosis
D. Multiple sclerosis
E. Complicated migraine

Answer and topic summary

The answer is B. Transient ischemic attack

The patient had a transient ischemic attack (TIA), which is characterized by transient neurological symptoms without objective evidence of acute infarction. Symptoms vary, but patients may have hemiparesis, hemiplegia, aphasia, or vision loss. Risk factors include alcohol, hypertension, smoking, diabetes, illicit drug use, and atrial fibrillation.

Urgent evaluation is needed in patients with symptoms of TIA (e.g., coagulation studies, TTE, EKG, CT or MRI head, imaging of the cervicocephalic vasculature via carotid US, CTA, or MRA). Treatment for high-risk patients includes dual antiplatelet therapy (ASA + clopidogrel) for 21 days and risk factor management (statin, exercise, etc). Remember the risk of an actual stroke is high after a TIA.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Vascular Disorder ⇒ Transient ischemic attack

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, and Emergency Medicine EOR topic list

2. A 26-year-old female presents with a history of miscarriages and recurrent pulmonary embolism. She is diagnosed with antiphospholipid syndrome. Which of the following is the mainstay of treatment for this condition?

A. Dual antiplatelet therapy (DAPT)
B. Aspirin and heparin
C. Dabigatran
D. Warfarin
E. Heparin

Answer and topic summary

The answer is D. Warfarin

Antiphospholipid syndrome (APS) is an autoimmune disease defined by venous thromboembolism, arterial thrombosis, and obstetric morbidity in the presence of circulating antiphospholipid antibodies (aPLs). It is the most common form of acquired thrombophilia.

aPLs include lupus anticoagulant, anticardiolipin, anti-b2-glycoprotein I antibodies. Clinical features include DVTs (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), PEs (9%), and fetal loss (8%). The mainstay of treatment is warfarin. Other anticoagulants have been found to be less effective than warfarin so far.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Coagulation Disorders ⇒ Hypercoagulable states

Also covered as part of the Internal Medicine EOR and Emergency Medicine EOR topic list

3. Which of the following is the most common cause of acute bronchitis in the United States?

A. Virus
B. Bacteria
C. Fungus
D. Allergies
E. Tuberculosis

Answer and topic summary

The answer is A. Virus

Acute bronchitis is characterized by a cough due to inflammation of the large airways and trachea with no evidence of pneumonia. Acute bronchitis often follows an upper respiratory infection. The most common cause of acute bronchitis is viral. Symptoms include cough (10-20 days), headache, shortness of breath, and wheezing. The presence of fever should make you consider pneumonia or influenza.

Diagnosis is clinical. A chest radiograph should be given if it is hard to clinically distinguish between pneumonia and bronchitis. Treatment is mainly supportive care (rest, hydration) and symptomatic management (antitussives for cough, bronchodilators for wheezing, etc). Antibiotics should NOT be given for acute bronchitis.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Acute bronchitis

Also covered as part of the Emergency Medicine EOR topic list

4. A 27-year-old male presents to the clinic with shortness of breath, chest pain, and fatigue. His physical exam is remarkable for a crescendo-decrescendo systolic murmur heard at the apex. An echocardiogram reveals asymmetric septal hypertrophy and left ventricular hypertrophy. Which of the following is the best initial treatment option?

A. Procainamide
B. Hydrochlorothiazide
C. Beta-blockers
D. Aspirin
E. ACE inhibitor

Answer and topic summary

The answer is C. Beta-blockers

The patient has hypertrophic cardiomyopathy (HCM), which is a genetic disease of the heart muscle due to mutations in the sarcomere genes. It often presents with fatigue, dyspnea, chest pain, or syncope. The murmur on the physical exam is due to LV obstruction; it will be a harsh crescendo-decrescendo systolic murmur heard at the apex and LLSB. It’s important to keep in mind that the murmur intensity will decrease with more venous return (squatting) and increase with less venous return (Valsalva).

Diagnostic tests include an EKG, echocardiogram, and exercise stress testing. Treatment is indicated for symptomatic patients and includes a negative inotropic agent (i.e., nondihydropyridine CCBs or beta-blockers) and diuretics as needed for volume overload. If patients are refractory to medications, septal myectomy and percutaneous septal ablation can be performed.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Cardiomyopathy ⇒ Hypertrophic Cardiomyopathy

Also covered as part of the Pediatric Rotation EOR topic list

5. A 22-year-old female presents to the ER with crampy lower abdominal pain and vaginal bleeding for the past 2 hours. She missed her last menstrual cycle. The physical exam is remarkable for an open cervical os. No products of conception are observed. Which of the following is the most likely diagnosis?

A. Threatened abortion
B. Incomplete abortion
C. Missed abortion
D. Septic abortion
E. Inevitable abortion

Answer and topic summary

The answer is E. Inevitable abortion

The patient most likely has a spontaneous abortion, which is a nonviable intrauterine pregnancy up to 20 weeks gestation. The most common cause of miscarriages in the first trimester is chromosomal abnormalities. There are many different types of spontaneous abortions.

The patient specifically has an inevitable abortion, which typically presents with vaginal bleeding, crampy abdominal pain, and an open external cervical os without expulsion of products of conception. The fetus is not viable.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Complicated Pregnancy ⇒ Abortion

Also covered as part of the Women’s Health EOR topic list

6. Which of the following is not a risk factor for Methicillin-resistant Staphylococcus aureus (MRSA)?

A. Previous antibiotic use
B. Injection drug use
C. Indwelling hemodialysis catheter
D. Presence in long-term facility
E. All of the above are risk factors

Answer and topic summary

The answer is E. All of the above are risk factors

Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a certain type of S. aureus that is resistant to several antibiotics. Risk factors include previous antibiotic use, injection drug use, indwelling hemodialysis catheter, living in a long-term care facility, HIV infection, and recent hospitalization.

The most common site for MRSA infections to occur is the skin/soft tissue. Oral antibiotics that cover MRSA include Bactrim, doxycycline, and clindamycin. For severe MRSA infections, IV vancomycin is preferred.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Bacterial Disease ⇒ Methicillin-resistant Staphylococcus aureus infection

A. Acute myeloid leukemia
B. Acute lymphocytic leukemia
C. Chronic myeloid leukemia
D. Chronic lymphocytic leukemia
E. Non-Hodgkin’s lymphoma

Answer and topic summary

The answer is A. Acute myeloid leukemia

Clinical features include fatigue, pallor, weakness, bone pain, gingival bleeding, and organomegaly. Lab findings are variable but may include pancytopenia (decrease in RBCs, WBCs, and platelets), electrolyte derangements, and/or hypoxemia. The workup should include a peripheral blood smear and bone marrow biopsy. The bone marrow biopsy will classically show Auer rods and >20% blasts.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Acute and chronic myelogenous leukemia

Also covered as part of the Internal Medicine EOR, Emergency Medicine EOR, Family Medicine EOR, and Pediatric EOR topic list

8. Giant Cell Arteritis: The Daily PANCE Blueprint

A 55-year-old female presents with right-sided headaches, jaw pain upon chewing, and mild dizziness for the past few months. On physical exam, the right temporal artery is tender to palpation. Labs reveal an elevated ESR and CRP. What is the definitive diagnosis for this condition?

A. CT head
B. Temporal artery biopsy
C. PET scan
D. Ultrasound
E. IgA antibody level

Answer and topic summary

The answer is B. Temporal artery biopsy

The patient has temporal arteritis, which is a vasculitis of large and medium vessels. Clinical features often include fever, fatigue, weight loss, headache, jaw claudication, and transient vision loss. The typical clinical vignette is an older female presenting with a headache and jaw claudication. On physical exam, you may appreciate a temporal artery that is thickened, tender, or erythematous.

ESR and CRP are sensitive, but not specific for the diagnosis. The definitive diagnosis of temporal arteritis is a temporal artery biopsy. Treatment is high-dose steroids. It’s important that temporal arteritis is treated because it can lead to blindness, thrombotic events, and other complications.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Giant cell arteritis

Also covered as part of the Internal Medicine EOR topic list

9. Which of the following is one of the most common initial clinical symptoms in multiple sclerosis?

A. Vertigo
B. Extreme weakness
C. Depression
D. Arthralgias
E. Optic neuritis

Answer and topic summary

The answer is E. Optic neuritis

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. There are many types of MS patterns. Clinical features suggestive of MS include sensory loss in limbs or one side of the face, gait/balance issues, heat sensitivity (Uhthoff), fatigue, and Lhermitte sign. The most common presenting symptom is optic neuritis.

MRI of the brain (+/- spinal cord) is the diagnostic test of choice. The McDonald diagnostic criteria can be used to help make the diagnosis of MS. Treatment of MS includes disease-modifying pharmacotherapy, such as glatiramer acetate (Copaxone), dimethyl fumarate, natalizumab (Tysabri), interferons, and many more. Acute exacerbations of MS are managed with short-term, high-dose glucocorticoids.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Neuromuscular disorders ⇒ Multiple sclerosis

Also covered as part of the Internal Medicine EOR topic list

10. A 52-year-old male presents to the clinic complaining of “sharp burning” in his lower chest after eating a large meal. The pain goes away when he raises the head of the bed. Which of the following is the best pharmacological agent for this likely diagnosis?

A. Esomeprazole
B. Nitroglycerin
C. Aspirin
D. Codeine
E. Sucralfate

Answer and topic summary

The answer is A. Esomeprazole

The patient has gastrointestinal reflux disease (GERD), which is a common condition characterized by stomach acid flowing up into the esophagus. Classic symptoms include heartburn (burning sensation around the sternum) after eating, water brash, regurgitation, and dysphagia.

The diagnosis is usually clinical; however, if the patient has alarming symptoms (e.g., weight loss, anemia, etc), it is appropriate to get an upper endoscopy. The gold standard is an ambulatory 24-hour pH monitoring system. Initial management includes weight loss, elevating the head of the bed, and eliminating triggers (spicy foods, chocolate, etc). Most recommend starting with histamine 2 receptor antagonist therapy first (e.g., ranitidine) and then transitioning to proton pump inhibitors (e.g., esomeprazole).

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Esophageal Disorders ⇒ Gastroesophageal reflux disease

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Pediatric EOR topic list

This podcast is available on every device!

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

The post Podcast Episode 101: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 100: Atrial Fibrillation for the PANCE and PANRE

Tue, 20 Sep 2022 18:15:06 +0000

Welcome to episode one hundred of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me today as we cover atrial fibrillation for the PANCE, PANRE, and EOR exams.

Special from today’s episode:

Join the Smarty PANCE Member’s Community then sign up for the Sunday Funday Study Group. Once you have signed up, you can access the Webinar replay of this episode here
Check out our updated End of Curriculum (EOC) Exam Course (now with orthopedics!)
Sign up for the Entire Blueprint email series
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

Below you will find the audio of today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of Smarty PANCE.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.
You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page.

Listen to Podcast Episode 100: Atrial Fibrillation for the PANCE and PANRE

If you can’t see the audio player, click here to listen to the full episode.

The post Podcast Episode 100: Atrial Fibrillation for the PANCE and PANRE appeared first on The Audio PANCE and PANRE.

Podcast Episode 99: Ten PANCE, PANRE, and Rotation Review Questions

Thu, 21 Jul 2022 14:08:30 +0000

Welcome to episode 99 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me as I cover ten PANCE, PANRE, and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Join the Smarty PANCE Member’s Community
Check out our all-new End of Curriculum (EOC) Exam Course (still in development)
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

Below you will find an interactive exam to complement today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take the Practice Exam

If you can’t see the audio player, click here to listen to the full episode.

Podcast Episode 99: Ten PANCE/PANRE and EOR Topic Blueprint Questions

1. A 42-year-old male on lithium presents with polyuria, nocturia, and polydipsia. Laboratory findings are remarkable for slightly elevated sodium. Which of the following is the most likely diagnosis?

A. Neurogenic diabetes insipidus
B. Nephrogenic diabetes insipidus
C. Type 2 diabetes mellitus
D. SIADH
E. Adrenal insufficiency

Click here to see the answer

The answer is B. Nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus (DI) is a condition where the kidneys are resistant to the effects of ADH. Nephrogenic DI can occur secondary to lithium toxicity or chronic lithium use, pregnancy, inherited disorders, and electrolyte issues. Clinical features include polyuria, nocturia, and polydipsia. Serum sodium is either normal or high.

In this patient, lithium has entered the collecting duct, accumulated, and interfered with ADH’s capacity to increase water permeability. Treatment options for this patient include amiloride or thiazide diuretics. In general, whether or not lithium is discontinued depends on many factors.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Pituitary Disorders ⇒ Diabetes insipidus

Also covered as part of the Internal Medicine EOR and Emergency Medicine PAEA EOR topic list

2. A 50-year-old female presents with poor appetite, low energy, poor concentration, and feelings of hopelessness on most days for the past 3 years. She denies suicidal ideation. She has never had a past manic or hypomanic episode. Which of the following is the best treatment option?

A. Haloperidol
B. Fluoxetine
C. Lorazepam
D. Amitriptyline
E. Risperidone

Click here to see the answer

The answer is B. Fluoxetine

This patient has dysthymia, or persistent depressive disorder. The DSM V criteria follow:

Depressed mood ≥ 2 years on most days
At least 2 of the following: appetite changes, sleep changes, low energy, low self-esteem, poor concentration, hopelessness
Not without symptoms > 2 months at a time
No mania or hypomania episodes, ever

Like other psychiatric disorders, symptoms can’t be attributable to drugs, and the symptoms must cause distress/impairment. 1st line treatment is selective serotonin reuptake inhibitors and psychotherapy.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Depressive disorders ⇒ Persistent depressive disorder (dysthymia)

Also covered as part of the Psychiatry EOR, Emergency Medicine EOR, and Pediatric PAEA EOR topic list

3. An 85-year-old male with a history of chronic kidney disease presents to the ER with muscle cramps. Laboratory studies reveal potassium of 7.8 mEq/L. EKG reveals peaked T waves. Which of the following is the best initial med to give?

A. Insulin
B. Albuterol
C. Furosemide
D. Sodium bicarbonate
E. Calcium gluconate

Click here to see the answer

The answer is E. Calcium gluconate

Hyperkalemia is caused by many things: iatrogenic (ACEI/ARBs), cellular destruction (hemolysis, tumor lysis syndrome, burns), renal failure, adrenal insufficiency, etc. Symptoms are nonspecific and include muscle weakness, N/V, decreased DTRs, etc. Classically on EKG, you may see peaked T waves (there are many other findings though…such as QRS widening, PR interval prolongation, sine-wave, etc). Management for severe hyperkalemia includes calcium gluconate (stabilizes the resting membrane potential of the myocardial membrane), shifting potassium intracellularly (via beta-agonists, sodium bicarbonate, insulin), and removing potassium (via diuretics, kayexalate, or hemodialysis).

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Renal System ⇒ Fluid and Electrolyte Disorders ⇒ Hyperkalemia/hypokalemia

Also covered as part of the Emergency Medicine EOR and General Surgery PAEA EOR topic list

4. A 28-year-old male with sickle cell disease presents to the ER with chest pain, dyspnea, and a cough for the past day. Vitals are remarkable for SpO2 91% and T 102.2F. A CXR reveals bilateral pulmonary infiltrates. On physical exam the patient is alert, speaking in full sentences, and breathing without accessory muscle use. Which of the following is the most appropriate management option for this patient?

A. Surgical consultation, antibiotics, plasmapheresis, IVIG
B. Pain control, hydration, blood transfusions, oxygen, antibiotics, VTE prophylaxis
C. Immediate endotracheal intubation, aggressive intravenous fluids, antibiotics, blood transfusions
D. Blood transfusions and oxygen only
E. Empiric antibiotics and oxygen only

Click here to see the answer

The answer is B. Pain control, hydration, blood transfusions, oxygen, antibiotics, VTE prophylaxis

The patient has acute chest syndrome (ACS), which is defined as a new radiodensity on CXR with fever and/or pulmonary symptoms. It occurs due to vaso-occlusion in the pulmonary microvasculature, subsequently leading to deoxygenation of hemoglobin and sickling of RBCs. ACS is the main cause of death in patients with sickle cell disease (SCD). About 1 in 2 patients with SCD get ACS.

Patients may present with chest pain, extremity pain, and shortness of breath. Causes of ACS include fat emboli, infection, asthma, oversedation, and post-op issues. Treatment typically includes fluids, oxygen, pain control, blood transfusions, antibiotics, and VTE prophylaxis.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Hemoglobinopathies ⇒ Sickle cell anemia

Also covered as part of the Internal Medicine EOR and Emergency Medicine PAEA EOR topic list

5. Which of the following is the most common cause of bacterial sialadenitis?

A. Bacteroides
B. Staphylococcus aureus
C. Streptococcus pneumoniae
D. Escherichia coli
E. Streptococcus viridans

Click here to see the answer

The answer is B. Staphylococcus aureus

Bacterial sialadenitis is defined by inflammation of a salivary gland due to a bacterial infection. It is most commonly caused by Staphylococcus aureus. Usually, bacterial sialadenitis happens in the setting of a salivary gland stone (reduced salivary flow leads to bacteria building up in the mouth). Other risk factors include bad oral hygiene and old age. The most common gland affected is the parotid gland.

Clinical features include acute onset of fever, chills, and swelling/tenderness of the affected gland (possible to see purulent drainage). The treatment is broad-spectrum antibiotics: IV ampicillin-sulbactam. Surgical drainage is needed if an abscess develo

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Salivary disorders ⇒ Sialadenitis

Also covered as part of the Family Medicine PAEA EOR topic list

6. A 52-year-old female presents to the clinic complaining of chronic bone pain, constipation, and fatigue. Her last lab results reveal a decline in the glomerular filtration rate. Which of the following is the most likely diagnosis?

A. Acute myelogenous leukemia
B. Bronchogenic carcinoma
C. Multiple myeloma
D. Polymyalgia rheumatica
E. Colorectal cancer

Click here to see the answer

The answer is C. Multiple myeloma

The patient has multiple myeloma, which is a clonal proliferation of abnormal plasma cells. It can present with “BREAK” symptoms: Bone pain, Recurrent infections, Elevated calcium, Anemia, and Kidney failure. A serum and urine protein electrophoresis will reveal a monoclonal spike. Other diagnostic studies include a CT or MRI (reveals lytic bone lesions), peripheral blood smear (normocytic anemia in rouleaux formation), and urinalysis (Bence Jones proteins aka free light chains).

The definitive diagnosis is a bone marrow biopsy. Treatment is high-dose chemotherapy with autologous hematopoietic cell transplantation.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Multiple myeloma

Also covered as part of the Internal Medicine PAEA EOR topic list

7. A 56-year-old post-menopausal G0P0 female presents to the clinic complaining of abnormal uterine bleeding and weight loss for the past 5 months. Physical exam is unremarkable. Which of the following is not a risk factor for this patient’s likely diagnosis?

A. Nulliparity
B. Tamoxifen
C. Chronic anovulation
D. Obesity
E. Late menarche

Click here to see the answer

The answer is E. Late menarche

The patient has endometrial cancer, the most commonly encountered gynecologic cancer. The cardinal symptom is abnormal uterine bleeding. Other clinical features include pelvic pain, pelvic masses, and weight loss.

Risk factors include conditions or medications that lead to chronically increased estrogen levels, such as nulliparity, tamoxifen, anovulation, and obesity. Early menarche and late menopause would be risk factors, not late menarche.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Neoplasms of the breast and reproductive tract ⇒ Endometrial cancer

Also covered as part of the Women’s Health PAEA EOR topic list

8. Which of the following are the two most common etiologies of peptic ulcer disease?

A. H. pylori and NSAIDs
B. Spicy foods and acute stress
C. Chemical ingestion and GERD
D. Smoking and alcohol use
E. Chronic stress and radiation

Click here to see the answer

The answer is A. H. pylori and NSAIDs

Peptic ulcer disease (PUD) is a common GI disease defined by a defect in the mucosal lining of the stomach or duodenum. The two most common causes are H. pylori and NSAIDs. Other more rare culprits include Zollinger-Ellison Syndrome, cancer, stress, and radiation. Surprisingly, patients are asymptomatic about 70% of the time. Common symptoms are epigastric abdominal pain, dyspepsia, and bloating. Overall, an upper endoscopy is the best diagnostic test. A biopsy should be done for ulcers with malignant features on all gastric ulcers.

The preferred treatment is PPIs. If H. pylori is the cause, an antibiotic regimen is warranted (e.g., amoxicillin, clarithromycin, and a PPI).

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastric Disorders ⇒ Peptic ulcer disease

Also covered as part of the Internal Medicine EOR, Emergency Medicine EOR, Family Medicine EOR, and General Surgery EOR topic list

9. A 72-year-old male smoker with a history of cancer presents to the clinic for an annual physical. Vitals are unremarkable. On physical exam, you notice erythema along the course of a superficial vein on his left leg. The area is mildly tender to palpation. The left leg is also larger than the other leg. Which of the following is the next best step?

A. Treat with NSAIDs and warm compresses
B. Order a duplex ultrasound
C. Initial anticoagulation immediately
D. Admit to the hospital
E. Reassurance and send home

Click here to see the answer

The answer is B. Order a duplex ultrasound

The patient has superficial thrombophlebitis, which is inflammation involving a superficial vein along with the presence of a superficial clot. Risk factors include varicose veins, estrogen, prior DVT, cancer, and hypercoagulable states. Clinical features include tenderness, induration, pain, and erythematous skin over a superficial vein.

In many cases, duplex ultrasound is needed to rule out a concurrent DVT (studies show that up to 25-50% of patients with superficial thrombophlebitis have a concurrent DVT). Treatment includes NSAIDs, warm/cold compresses, extremity elevation, and compression therapy. The decision to initiate anticoagulation for superficial thrombophlebitis depends on many factors.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Phlebitis/thrombophlebitis

10. A 63-year-old male with a history of hepatitis C presents with a pruritic rash located on the flexor surfaces of his wrist. On physical exam, you observe purplish papules with flat-tops. Which of the following is the most likely diagnosis?

A. Atopic dermatitis
B. Psoriasis
C. Lichen planus
D. Pemphigus vulgaris
E. Scabies

Click here to see the answer

The answer is C. Lichen planus

Lichen planus is a skin disorder characterized by a rash associated with the 5 Ps: polygonal, pruritic, papules, plaques, and purple. It commonly affects the wrists and ankles. Lichen planus can also cause the classic Wickham’s striae, which are white-lacelike lines (usually in the oral mucosa). A risk factor is hepatitis C.

A skin biopsy can help confirm the diagnosis. Treatment includes high potency topical corticosteroids. If a patient has an extensive form of lichen planus, then phototherapy, acitretin, or systemic steroids may help.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Papulosquamous Disorders ⇒ Lichen planus

Also covered as part of the Family Medicine EOR and Pediatric EOR topic list

Looking for all the podcast episodes?

This FREE podcast series is limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

I will be releasing new episodes every few weeks. Smarty PANCE is now discounted, so sign up now before it’s too late!

Additional resources and links from the show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This Podcast is available on iOS and Android

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

Smarty PANCE is not sponsored or endorsed by, or affiliated with, the NCCPA or the Physician Assistant Education Association (PAEA). All trademarks are the property of their respective owners.

The post Podcast Episode 99: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 98: Ten PANCE, PANRE, and Rotation Review Questions

Tue, 24 May 2022 15:07:00 +0000

Welcome to episode 98 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me as I cover ten PANCE, PANRE, and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Join the Smarty PANCE Member’s Community
Check out our all-new End of Curriculum (EOC) Exam Course (still in development)
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

Below you will find an interactive exam to complement today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take the Practice Exam

If you can’t see the audio player, click here to listen to the full episode.

Podcast Episode 98: Ten PANCE/PANRE and EOR Topic Blueprint Questions

1. An 81-year-old female presents to the ER with acute onset of low back pain. She complains of bowel dysfunction and loss of sensation over her inner thighs. Physical exam reveals decreased lower extremity reflexes. Which of the following is the best diagnostic test for the likely diagnosis?

A. Lumbar radiographs
B. MRI of the lumbosacral spine
C. CSF fluid analysis
D. Scoliosis studies
E. None of the above

Click here to see the answer

The answer is B. MRI of the lumbosacral spine

Cauda equina syndrome is a surgical emergency caused by severe stenosis in the lumbar spine (often due to acute disc herniation).

Clinical manifestations include bowel/bladder dysfunction, decreased lower extremity reflexes, sciatica, saddle anesthesia (loss of sensation over the perineum, buttock, medial aspect of thighs), and decreased anal sphincter tone. Symptoms can develop acutely or chronically.

An emergent MRI of the lumbosacral spine is the preferred diagnostic test. Surgery is the preferred treatment.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Spinal Disorders ⇒ Cauda equina syndrome

Also covered as part of the Emergency Medicine PAEA EOR topic list

2. Which of the following is the most common cause of Cushing syndrome?

A. Iatrogenic
B. Bronchogenic carcinoma
C. Pituitary adenoma
D. Adrenal adenoma
E. Obesity

Click here to see the answer

The answer is A. Iatrogenic

Cushing syndrome is a condition defined by too much cortisol. The most common cause of Cushing syndrome is exogenous steroid therapy (i.e., medical providers prescribing steroids). Other causes include a pituitary ACTH-secreting adenoma, adrenal tumors, and ectopic ACTH production from neoplasms. Classic clinical features include buffalo hump, moon-facies, purple striae, easy bruising, weight gain, depression, and weakness.

Laboratory tests will be remarkable for elevated cortisol. Late night-salivary cortisol or 24-hour urinary free cortisol is typically the initial screening test. A low-dose dexamethasone test can be done. Referral to an endocrinologist is usually done at this point (or even prior).

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Adrenal Disorders ⇒ Cushing’s syndrome

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, and Emergency Medicine PAEA EOR topic list

3. A 73-year-old female presents with facial flushing, wheezing, and watery diarrhea for a few months. Her symptoms are worsened by certain foods. Which of the following is the best initial diagnostic study to order for the suspected diagnosis?

A. 5-HIAA in urine
B. Serum ACE levels
C. Chest radiograph
D. Upper endoscopy
E. Bronchoscopy

Click here to see the answer

The answer is A. 5-HIAA in urine

Carcinoid tumors are uncommon tumors that originate from neuroendocrine cells and secrete serotonin. The most common site is the appendix, but they can also be found in the lungs, kidney, etc.

Carcinoid syndromes develop 10% of the time; clinical features include flushing, sweating, wheezing, and watery diarrhea. These symptoms are due to the release of serotonin and can be precipitated by foods high in tyramine or ethanol.

The best initial diagnostic study is a 24-hour measurement of urinary excretion of 5-HIAA (Note: 5-HIAA is a degradation product from 5HT). Surgical resection is the definitive treatment of choice.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Neoplasms ⇒ Carcinoid tumors

Also covered as part of the Internal Medicine PAEA EOR topic list

4. Which of the following is the most common cause of Mallory-Weiss Syndrome?

A. Iatrogenic
B. Vomiting
C. Abdominal trauma
D. Hiatal hernia
E. Corrosive ingestion

Click here to see the answer

The answer is B. Vomiting

Mallory-Weiss Syndrome (MWS) is defined by a mucosal tear at or below the gastroesophageal junction. MWS is one of the most common causes of an upper GI bleed. It is most commonly due to forceful vomiting. It is classically associated with alcoholism (binge drinking), but really anything that can cause vomiting can lead to a tear. Other causes include iatrogenic, trauma, hiatal hernia, and corrosive ingestion. Diagnosis is made via upper endoscopy. Intervention is rarely necessary, but if needed, the patient can undergo surgery or embolization. Do not confuse this with Boerhaave syndrome, which is an actual perforation of the esophagus!

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Esophageal Disorders ⇒ Mallory Weiss tear

Also covered as part of the Internal Medicine EOR and Emergency Medicine PAEA EOR topic list

5. A 51-year-old male presents to the clinic complaining of “band-like pressure” around his head. He has been more stressed lately. Which of the following is the most likely diagnosis?

A. Cluster headache
B. Migraine with aura
C. Sinus headache
D. Tension headache
E. Medication overuse headache

Click here to see the answer

The answer is D. Tension headache

A tension-type headache (TTH) is the most common headache. It usually presents with steady, aching, “band-like” pain that circles the entire head. There may also be tightness in the posterior neck muscles. Precipitants include anxiety, depression, and stress.

You should treat any underlying depression and/or anxiety. NSAIDs and acetaminophen are the first-line abortive treatment options for mild-moderate TTHs. For long-term prophylactic treatment, amitriptyline is preferred.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Headaches ⇒ Tension headache

Also covered as part of the Internal Medicine PAEA EOR topic list

6. Which of the following physical exam findings would you expect in a patient with mitral regurgitation?

A. Holosystolic blowing murmur best heard at the apex with radiation to the axilla
B. Diastolic blowing murmur at the left upper sternal border
C. Systolic ejection crescendo-decrescendo murmur at upper right sternal border
D. Mid-systolic harsh murmur best heard at the left upper sternal border
E. None of the above

Click here to see the answer

The answer is A. Holosystolic blowing murmur best heard at the apex with radiation to the axilla

Mitral regurgitation (MR) is characterized by a blowing, holosystolic murmur at the apex with radiation to the axilla. It can be acute or chronic. Acute causes include endocarditis and papillary muscle rupture; chronic causes include mitral valve prolapse (MVP), rheumatic fever, cardiomyopathy. The most common cause of MR is MVP.

Remember, regurgitation murmurs will often have blowing sounds, while stenotic murmurs are harsh and rumbling. Diagnosis should be made with an echocardiogram. Treatment (repair vs. replace vs. medical therapy) depends on many factors.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Valvular Disorders ⇒ Mitral regurgitation

Also covered as part of the Emergency Medicine EOR topic list

7. Which of the following is not an expected clinical manifestation of polyarteritis nodosa?

A. Kidney failure
B. Livedo reticularis
C. pANCA positive
D. Pulmonary fibrosis
E. Hypertension

Click here to see the answer

The answer is D. Pulmonary fibrosis

Polyarteritis nodosa is a systemic vasculitis of medium-sized vessels (specifically involving the nervous system and GI tract) that leads to thrombi and microaneurysms. It is associated with hepatitis B, HIV, and drug reactions. Clinical features include fever, hypertension, livedo reticularis, abdominal pain, and arthralgias. Remember patients may be positive for pANCA, but are ANCA negative.

A definitive diagnosis is made via biopsy of involved tissue (or mesenteric angiography). What sets polyarteritis nodosa apart from other vasculitides is that it spares the lungs. Treatment includes high-dose steroids. The prognosis is not really good.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Rheumatologic Disorders ⇒ Polymyalgia rheumatica

Also covered as part of the Internal Medicine PAEA EOR topic list

8. An 8-year-old female presents to the clinic with her dad. She is complaining of left ear pain and pruritus for the past few days. The physical exam is remarkable for drainage and pain on tragal pressure. The tympanic membrane can’t be visualized. Which of the following is the best treatment option?

A. Oral amoxicillin
B. Neomycin/polymyxin B/hydrocortisone drops
C. Oral cefepime
D. Oral steroids
E. Ciprofloxacin/dexamethasone drops

Click here to see the answer

The answer is E. Ciprofloxacin/dexamethasone drops

The patient has otitis externa (aka swimmer’s ear), which is inflammation of the external auditory canal. The most common bacterial cause is Pseudomonas aeruginosa (~40%). Risk factors include water exposure, trauma, ear devices, and dermatologic conditions. Clinical features include ear pain, pruritus, auricular discharge, pain/tenderness when pressure is applied to the tragus, and hearing loss.

Treatment is topical ear antibiotic/steroid drops. Medication options include neomycin/polymyxin B /hydrocortisone and ciprofloxacin/dexamethasone. **Remember that aminoglycosides are ototoxic and should be avoided when the tympanic membrane can’t be visualized!**

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Ear Disorders ⇒ External ear ⇒ Otitis externa

Also covered as part of the Pediatric EOR, Family Medicine EOR, and Emergency Medicine PAEA EOR topic list

9. Which of the following correctly depicts the typical clinical features of Parkinson’s disease?

A. Pill-rolling tremor, bradykinesia, rigidity, masked facies
B. Loss of declarative episodic memory, apraxia, olfactory dysfunction
C. Visual hallucinations, REM sleep behavior disorder, gait issues
D. Hyperorality, apathy, socially inappropriate behavior
E. None of the above

Click here to see the answer

The answer is A. Pill-rolling tremor, bradykinesia, rigidity, masked facies

Parkinson’s disease is a neurodegenerative disease. Its 3 cardinal features are tremor (“pill-rolling” at rest), bradykinesia, and rigidity. Tremor is the presenting feature in most patients. Other clinical features include hypomimia (masked facies), speech impairment, mood disorders (depression or anxiety), dysphagia, shuffling gait, stooped posture, sleep issues, cognitive dysfunction, and autonomic dysfunction.

It is mainly a clinical diagnosis. When patients respond to dopaminergic drugs, this supports the diagnosis. The mainstay of treatment is levodopa or dopamine agonists (pramipexole, ropinirole). For mild disease, monoamine oxidase type B inhibitors or amantadine can be given.

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Parkinson’s disease

Also covered as part of the Internal Medicine EOR and Family Medicine PAEA EOR topic list

10. A 72-year-old male presents with an abnormal change in bowel habits and fatigue. The physical exam is remarkable for pale conjunctiva and a palpable abdominal mass. His hemoglobin is 10 mg/dL. Which of the following is likely to be elevated?

A. Alpha-fetoprotein
B. CEA
C. CA-125
D. CA 19-9
E. AAT1

Click here to see the answer

The answer is B. CEA

The patient has colorectal cancer (CRC), which is the third most common cause of cancer death in the U.S. The USPSTF suggests screening at age 45 for individuals with an average risk. Patients may present with alarming “red flag” symptoms, a bowel obstruction, or CRC may just be found via routine screening. The most common symptom is a change in bowel habits (~70%). Other symptoms include rectal bleeding, iron deficiency anemia, and pain.

Initial diagnostic tests include colonoscopy, CBC, fecal occult blood testing, and tumor markers like carcinoembryonic antigen (CEA). CEA is more often used for surveillance and not screening though (since its sensitivity for CRC is only 46%).

Click here to view the Smarty PANCE lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastrointestinal System Neoplasms ⇒ Colon cancer

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, General Surgery PAEA EOR topic list

Looking for all the podcast episodes?

This FREE podcast series is limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

I will be releasing new episodes every few weeks. Smarty PANCE is now discounted, so sign up now before it’s too late!

Additional resources and links from the show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This Podcast is available on iOS and Android

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

Smarty PANCE is not sponsored or endorsed by, or affiliated with, the NCCPA or the Physician Assistant Education Association (PAEA). All trademarks are the property of their respective owners.

The post Podcast Episode 98: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 97: Murmurs Made Incredibly Easy – Ten PANCE Murmur Questions

Wed, 27 Apr 2022 11:00:00 +0000

Welcome to episode 97 of the Audio PANCE and PANRE PA board review podcast.

Today is a bonus episode rounding out this fabulous five-part podcast series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode, we continue our discussion of cardiac murmurs with ten PANCE and PANRE murmur questions.

We’ll cover the ins and outs of all the NCCPA content blueprint valvular disorders and learn how to identify and differentiate them from one another.

If you haven’t already, make sure to listen to our previous podcast episodes where we covered tricuspid stenosis, aortic valve murmurs, mitral valve murmurs, pulmonic valve murmurs, and HOCM and MVP.

Podcast Episode 97: Murmurs Made Incredibly Easy – 10 PANCE and PANRE Murmur Questions

Below is a transcription of this podcast episode edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to this latest episode and access even more resources below.

[00:00:00] Welcome back, everybody. This is Joe Gilboy. I work with Stephen Pasquini over there at Smarty PANCE. And today is the most dreaded podcast of all because you know what I’m going to do. That’s right. I’m going to ask cardiac murmur questions.

And I know it’s the most dreaded thing in the world. Let’s do this together because what I want to try to do here is make sense of it all. So, let’s just kind of recap some basic rules before we start going down this thing. You know, the previous lectures, what have I been barking about? What’s Joe been saying? First – inspiration, right? Expiration left.

[00:00:40] Inspiration, right? Expiration left. So, with inspiration, the right-sided murmurs sound louder. So that’s the tricuspid and the pulmonic valve regardless of if it’s stenosis or regurgitation. Expiration – left. What am I saying? Everything on the left side sounds louder with expiration, whether it’s aortic or mitral – your call.

[00:01:01] It can be stenotic or regurgitation, it doesn’t matter, but it’ll sound louder. What is squatting? Squatting is a party. So, what are you doing? You’re bringing it all the blood flow back home. And so, if I bring all the blood flow back home, just from a laminar flow physics point of view, I bring more blood flow back home to the heart, more blood flow over a valve specifically with a diseased disease valve, it sounds louder.

[00:01:29] So, right off the bat, squatting will do what? It’s going to make all my murmurs sound louder. That’s the whole point to decrease venous return. In other words, take blood flow away from the heart. What do I do? Well, those are going to be Valsalva and standing. So, what am I doing when I do Valsalva and standing?

[00:01:56] Taking blood flow away from the heart. So, what’s going to happen to all my murmurs when I stand and perform Valsalva? It takes blood flow away from the heart. Exactly. And then hand grip. What did handgrip do? So, in school, what’d you learn about hand grip? Well, it increases afterload, right? So, what they’re really saying to you is this, and this is how I want you to visualize it.

[00:02:18] When I do hand grip, what I’m really doing is this. You’re right. I’m increasing the afterload. But you must stop and think this one out for a second, folks. What’s really in the heart? Which valve must fight afterload?

[00:02:39] Say you increase the peripheral vascular resistance for whatever reason. So, you increase the afterload, who fights it? And your answer will be… oh, wait for a second, Joe, that’s the aortic valve in the left ventricle. Exactly. So, when I perform handgrip, who am I really challenging? Oh, I’m challenging the aortic valve and everything behind it.

[00:03:00] Exactly. So that’s the point I need inside your head? Then remember our last podcast was about our low-volume lovers. Who were our low-volume lovers? Who were the special needs murmurs that really like low volume? They’re like, hey, I like low volume, not high volume. I like low volume. Who was that?

[00:03:19] That was HOCM and mitral valve prolapse. What did they both like? They both like low volume. So, they’re the opposite of all my regular murmurs. They go in the opposite direction. All right, everybody got that? I am not going to give you a list of answers. So, what I’m going to do is I want you to listen to what I’m going to say. I’m going to say the test question twice.

[00:03:47] And then I want you to pause the podcast. Just put it on pause and think about your answer before I explain it. All right. Is everybody with me? Because that’s the best thing to do. All right, here we go.

Murmur Question #1:

[00:04:11] You have a 76-year-old gentleman that presents to your emergency room and comes in complaining of shortness of breath and chest pain on physical exam. You notice an upper sternal murmur that sounds louder with squatting and goes away with hand grip—one more time. Upper sternal border, sounds louder with squatting, and goes away with hand grip. Who am I?

[00:04:45] So upper sternal border. This will be my aortic and pulmonic area. Well, it goes away with handgrip. So, who’s that going to be? So, what happens with hand grip? I increase my afterload. Which valve fights the afterload? The aortic valve. It’s not pulmonic because the pulmonic valve is not fighting the afterload; it is fighting the lung. So, this has to be aortic stenosis, which makes sense for the syncope and the shortness of breath. So aortic stenosis is going to do what? Well, squatting, that’s a party. Of course, it will sound louder. We could actually throw expiration in here as well, couldn’t we? We sure could, but it’s the handgrip. That differentiates it, doesn’t it? Because the handgrip made the murmur go away. And what did the handgrip do? I keep telling you I want you to view handgrip like sitting on your aortic valve, and you can barely open up squeak, squeak, squeak, squeak.

[00:05:47] You can barely open up. Now imagine sitting on that valve. Can it open up now? And you’re like, no, it goes away. Exactly. And that’s the point I’m trying to make. The answer is aortic stenosis.

Podcast Episode 91: Cardiac Murmurs Made Incredibly Easy (Part 1 of 5) – Aortic Stenosis and Regurgitation

Murmur Question # 2

[00:06:21] I have a 45-year-old gentleman who comes in with shortness of breath and chest pain. The murmur sounds louder with inspiration. It’s located at the upper sternal border. And I am also noticing that the patient has right ventricular hypertrophy and right bundle branch block on EKG. Who am I?

[00:06:44] Upper sternal border. Well, who are we talking about? The aortic valve or the pulmonic valve. Inspiration → right and expiration → left. So, this murmur sounds louder with inspiration, so I know that this is on the right side. Then it’s got to be the pulmonic valve. And now they’re telling me I’ve got right ventricular hypertrophy and right bundle branch block. Then blood must be backing up into the right ventricle.

[00:07:10] In other words, something must be backing up, which means the valve must be stenotic. Oh, I see your point. It’s stenotic, and the right ventricle is going to hypertrophy. Remember if you take right ventricular hypertrophy and let it go unopposed. You stretch, and you stretch, and you stretch, and you stretch, and you dilate, and you stretch, and you dilate and stretch that wall.

[00:07:28] What are you going to get? The wires are going to get busted. That’s right bundle branch block. For those of you thinking outside the box, and you’re telling me, Joe, if I dilate my left ventricle and just stretch it and stretch and a bust, the wires, I get left bundle branch? Exactly. No, that’s exactly what you’re going to get. So the answer to the question is pulmonic stenosis.

Podcast Episode 93: Murmurs Made Incredibly Easy (Part 3 of 5) – Pulmonary Valve Stenosis and Regurgitation

Murmur Question # 3

[00:07:45] You have a young 32-year-old female who recently immigrated to the United States from Indonesia and is currently working and has now been complaining of increasing shortness of breath at work. On exam, you hear a murmur at the left sternal border. It sounds louder with expiration and appears to be diastolic in nature. Who am I?

[00:08:38] So again, left sternal border. So that’s just about everybody but the pulmonic valve. The murmur sounds louder with expiration, so you know it will be on the left (louder with inspiration → right and louder with expiration → left). So, based on these parameters, I know I’m dealing with either the aortic valve or the mitral valve, and I am a diastolic murmur. So now you have to stop and think. So, this seems to be in the neighborhood of the mitral area, and it’s a diastolic murmur.

[00:09:00] So it can’t be mitral regurgitation. It has mitral stenosis, and that’s the correct answer. And then, of course, as I always say, you’ll see the test questions, do this all the time. They’ll talk about people who immigrated to the United States. And what they’re really saying to you is this. So, this lady most likely has some form of rheumatic fever.

[00:09:16] Maybe she had strep when she was a younger child and just wasn’t diagnosed. So, what they’re really sharing with you is this. As soon as I see the word immigrant, what they are really saying is this: Listen, this person is at high risk for TB. All right. That’s the one thing that we kind of worry about.

[00:09:29] The second thing is that their care is not as structured as ours. In other words, they slipped through the cracks. Could this patient have had a previous strep throat and had rheumatic fever, which led her to the mitral stenosis? Of course, she could.

[00:09:44] And that was the whole point to it. But again, it is expiration → left, left sternal border. Just about everybody is at the LSB, so that doesn’t really help. But it was on the left side. So, I know this is either going to be aortic or mitral. And then you told me it was diastolic, so this will fit mitral stenosis.

[00:10:06] So, just trying to get you to look at these murmurs differently. That’s all just more from a laminar flow physics point of view.

Murmur Question #4

[00:10:15] Next question. I have a 67-year-old female who comes in with an upper sternal border murmur. This murmur increases in intensity when she is squatting, and with handgrip, it decreases intensity with Valsalva and standing.

[00:10:41] One more time. This murmur increases in intensity with squatting and handgrip and decreases in intensity with Valsalva and standing. Who am I?

[00:10:54] So let’s think about this upper sternal border. So, what are we talking about? Pulmonic or aortic. They didn’t tell me what side right or left did they? However, they told me that this murmur increases in intensity with squatting – that’s everybody. So that’s not helping me, but they said it increases in intensity with hand grip. Stop. No stop right here.

[00:11:06] Handgrip, who’s that challenging? Pulmonic or aortic? Oh, that’s aortic, Joe. I see your point. That makes so much sense. It’s not pulmonic. So, this is going to be either aortic stenosis or aortic regurgitation.

[00:11:28] Well, let me think about this. You’re telling me that this murmur sounds louder with handgrip, and wait a second, it’s not shutting it off. It’s making it worse. This means that the valve is wide open. Oh, then this must be aortic regurgitation, and that’s the correct answer. And of course, you know, my low volume maneuvers – Valsalva and standing, of course, will make it go away. The answer is aortic regurgitation.

[00:11:51] So does everybody see this? I’m just trying to get you ready for the PANCE. But does every see how we’re looking at this now? This is what I keep hammering away at, approach this not from a memorization point of view but a laminar flow physics point. Stop memorizing!

[00:12:07] Start trying to make sense of this because once you make sense of this, it will flow so much easier for you. Ignore those things you memorized in PA school, those little four squares, the graphs, etc.. I’ve seen it all in my 30 years of teaching. You can’t teach me one more trick. And I laugh when I’m sitting here in my studio saying this to you because I know students better than students know students. And I get it, but I’m just trying to teach you what will help you the most on the boards.

Murmur Question #5

[00:12:36] Next question. I have a patient who is a 72-year-old gentleman with hypertension, diabetes, and coronary artery disease, who also smokes. He comes in complaining of increasing shortness of breath and bilateral leg swelling. He’s got a murmur noted on physical exam in the upper sternal border. The murmur sounds louder with inspiration. Squatting makes it sound louder. Standing and Valsalva make it go away. And this murmur appears to be diastolic in nature. Who am I?

[00:13:31] Upper sternal border (pulmonic and aortic area) and louder with inspiration. So, I’m on the right (inspiration → right and expiration → left). This has got to be pulmonic. So, it’s going to be pulmonic stenosis or pulmonic regurgitation. He’s a smoker. So, he’s got some pulmonary hypertension. I get it. And this is a diastolic murmur. So, what pulmonary valve disorder is diastolic?

[00:13:51] You’re going to go, oh, this has got to be pulmonic regurgitation. Exactly and wait a second. Oh, that makes so much sense. All that pulmonary hypertension, with COPD and stuff like that. Oh, that makes so much sense. And then he’s going to have to fight it. And, of course, everything is going to back up into the right ventricle and then go to his legs. The answer is pulmonic regurgitation.

Podcast Episode 93: Murmurs Made Incredibly Easy (Part 3 of 5) – Pulmonary Valve Stenosis and Regurgitation

Murmur Question #6

[00:14:27] Next question. I have a 37-year-old female with a previous history of mitral valve prolapse.

[00:14:33] However, recently, she’s been coming in with increasing shortness of breath and was diagnosed with atrial fib. Physical exam shows a murmur that increases with squatting and sounds louder with handgrip. And this murmur increases in intensity in the left lateral decubitus position. This murmur also decreases in intensity with Valsalva and standing. Who am I?

[00:15:10] One more time. The murmur increases intensity with squatting. Also, hand grip, also left lateral decubitus position, and decreases in intensity with Valsalva and standing. Who am I?

[00:15:31] All right. So, let’s think about this, she had a previous history of mitral valve prolapse. I got it. But now she’s got increasing shortness of breath and a fib – oh something went wrong.

[00:15:41] Do people with mitral valve prolapse get a fib? No, not at all. And so now this murmur is going to increase in intensity with squatting so that’s not helping me, but the hand grip, it increases with hand grip. So, wait a second. Let me think about this. So, there I am handgrip sitting on the aortic valve, which means the left ventricle has got to fill up with more blood and the left ventricle is going to contract with more blood.

[00:16:07] And then that mitral valve that should stay closed is actually blowing right on through. And if I put them in that left lateral decubitus position, that’s bringing the mitral valve to the surface. So let me think about this for a second, Joe. Hold on here. So, you’re telling me that the left lateral decubitus position brings the mitral valve to the right?

[00:16:31] So whether it be mitral stenosis or mitral regurgitation, that’s the maneuver, it’ll bring it closest to the chest. So, you hear it better. And we could argue expiration in this question, but this clue wasn’t given to me here. And does everybody see the most common cause for mitral regurgitation is actually mitral valve prolapse that goes untreated?

[00:16:48] And that’s how we get it. And then, of course, they start irritating the left atria, which is how they get the AFib. But now, does everybody understand how the handgrip made it worse? Again let’s think about it. Your hand gripping. What are you doing? Increasing the pressure behind the aortic valve.

[00:17:05] What’s the left ventricle going to do? Remember the Frank-Starling thing? What did Frank say? When you increase afterload, you’re going to increase preload. What’s the left ventricle going to do? Fill up with more blood. And there’s that mitral regurgitation valve – come and go as you please. Now that left ventricle goes to contract, what’s it going to do?

[00:17:20] Oh, it will push more blood flow against my regurgitant mitral valve. Exactly. And that’s the correct answer – mitral regurgitation.

Podcast Episode 92: Murmurs Made Incredibly Easy (Part 2 of 5) – Mitral Stenosis and Regurgitation

Murmur Question #7

[00:17:31] Next question. I have this 67-year-old gentleman who comes in complaining of right-sided heart failure. He’s also got some right atrial enlargement, and he also has bilateral lower extremity edema. During the exam you note a mid-diastolic murmur at the left lower sternal border that increases in intensity with inspiration, sounds louder with squatting, and goes away with standing and Valsalva. Who am I?

[00:18:09] Again, mid-diastolic murmur, left lower sternal border, increasing with intensity with squatting and inspiration, goes away with Valsalva and standing. Who am I?

[00:18:30] Let’s think about it. So, what did we get in the question? Well, we got the word inspiration. So, what do we know? Oh, that’s on the right. And then we said left sternal border.

[00:18:39] So who’s that? Everybody. But it’s not the pulmonic valve or the aortic valve. So, who are we talking about if it’s on the right and not the pulmonic valve? The tricuspid valve. And then you told me that it was mid-diastolic. So, wait a second. The tricuspid valve, what’s the diastolic murmur associated with the tricuspid valve? Is this regurgitation or stenosis? Oh, this is stenosis. The answer is tricuspid stenosis.

Podcast Episode 94: Murmurs Made Incredibly Easy (Part 4 of 5) – Tricuspid Stenosis

[00:18:59] What are your low volume maneuvers? Standing and Valsalva. Usually, with these maneuvers, all of the murmurs will go away. The low volume lovers are murmurs that sound louder with low volume. That’s HOCM and mitral valve prolapse.

Murmur Question #8

[00:19:13] Next question. I have a murmur that is holosystolic in nature that is located on the left midsternal border and sounds louder with squatting and inspiration. This murmur also goes away with Valsalva and standing. Who am I?

[00:19:40] One more time. I am a holosystolic blowing murmur. I’m located at the left midsternal border. I sound louder with inspiration and squatting, and I go away with standing and Valsalva. Who am I? So holosystolic means, it’s probably most likely some type of regurgitation and now you’re telling me that it’s on the left midsternal border that’s everybody. But the key piece of information you gave me is inspiration, which means this is right. Which means it’s going to be the tricuspid valve. Now you’re telling me it’s holosystolic, so that can’t be tricuspid stenosis because that is diastolic. So, this is going to be tricuspid regurgitation. The answer is tricuspid regurgitation.

[00:20:29] Then there’s that thing about the Carvallo’s sign. The increased murmur intensity with inspiration. And then sometimes we see that pulsatile liver. Because everything’s backing up on the right side, so, all that blood flow is going to the liver, and it’s causing it to kind of shake in a way. Sometimes we call it pulsatile.

So again, is everybody starting to understand this?

Inspiration → right and expiration → left
Squatting is not going to help you much
And now you have to ask, where’s the location of this murmur? And remember, when they say left, lower sternal border, they’re saying, hey, this is everybody but the pulmonic and the aortic valve, which are located in the upper sternal border.

They’re not going to be nice to you and say, oh, it’s right or left because that gives you too much information.

So again, we’re just going to pull back, and we’re going to use Joe’s basic rules.

Murmur Question #9

[00:21:17] Next question. You have a healthy 24-year-old female sitting on your exam table who comes in with mild lightheaded and dizziness with very little exertion. On physical exam, you notice that she has a murmur when she performs standing and Valsalva; however, this murmur also goes away with squatting. The rest of her physical exams is essentially unremarkable.

[00:21:57] And when you have her perform handgrip, the murmur disappears. Who am I?

[00:22:05] Remember this murmur sounded louder with standing and Valsalva. It went away with squatting, and it went away with handgrip. So, wait a second. You’re going; it went away with squatting? Isn’t squatting a party, Joe, doesn’t that make everybody sound louder?

[00:22:22] It does. Wait a second. I’m back to my special needs murmurs, the ones that like low volume. So, this is either HOCM or mitral valve prolapse. Exactly! So, let me take this one step further. So, you’re telling me if I squat, what do I do again? I’m pushing all the blood flow back home. So, you’re taking the left ventricle and filling it with blood.

[00:22:47] So if I have HOCM, then all that blood will do what? It’s going to push the walls apart. But wait a second, the murmur is going to go away. That makes sense. Wait a second. It went away with hand grip as well? So let me think about this again. Hold on. Handgrip. What’d you do? Oh, that’s right, I increased my afterload. Joe said basically you’re just sitting here on the aorta. What did Frank say? You increase afterload; you increase preload. So, what’s the left ventricle going to do to fight that afterload? Fill it with more blood. And what are the walls going to do? Push apart. That’s HOCM.

You see what you have to remember is that HOCM is not a valve problem. Say to yourself, HOCM is not a valve problem. And if you didn’t get it the first two times, let’s say it a third time, HOCM is not a valve problem. It’s a wall problem. The left ventricle walls are hitting. And so now, does everybody understand, as they’re at rest, what do you want to do to make the murmur louder? You know you want the walls to hit. Just lightly tap, and you want them to hit. So, what’s in between the walls? Blood. So, what makes it sound louder? Oh, standing and Valsalva. Put blood in there, and what will we do with the walls? Push them apart. So how do you put blood in the left ventricle? Oh, I could squat, and I could do hand grip. Exactly. And that’s the whole point I’m trying to make about HOCM. The answer is HOCM.

Podcast Episode 96: Murmurs Made Incredibly Easy (Part 5 of 5) – MVP and HOCM

Murmur Question #10

[00:24:10] Last question. You have a young, healthy 31-year-old female who comes into your clinic, and she’s been complaining of progressive, mild shortness of breath and palpitations. On physical exam, you notice this murmur increases in intensity with Valsalva and standing. You also notice that this murmur goes away with squatting and handgrip. You also note that this murmur sounds louder in mid-systole. Who am I?

[00:25:04] So, let’s think about the information we were given. We were given information that this murmur sounds louder with Valsalva and standing (our low volume maneuvers).

[00:25:13] We also know that this murmur goes away with squatting and handgrip (our high volume maneuvers, and then they give us this mid-systole. So who am I?

[00:25:25] You’re telling me that squatting makes it go away, which means it’s quite the opposite of what we would expect, which means it’s got to be a low volume lover, which is correct because it sounds louder with Valsalva and standing. Also, this murmur is a mid-systolic murmur.

[00:25:43] So wait a second, when I look at my “low volume lover” murmurs, you have to remember there’s really only one low volume murmur. That’s mitral valve prolapse because you remember HOCM has nothing to do with the valves. It has everything to do with the walls. So, you’re like, oh, they’re telling me that this thing sounds louder mid-systole.

[00:26:05] One more time, when is the left ventricular pressure highest? Mid systole. Then there is that redundant mitral valve that has prolapsed, and the valve can’t hold. And then what does it do? The blood blows right on through. And that’s the correct answer – this is mitral valve prolapse.

Podcast Episode 96: Murmurs Made Incredibly Easy (Part 5 of 5) – MVP and HOCM

[00:26:24] All right, listen, I need you to replay this podcast until you get tired of me talking, OK?

[00:26:32] It’s like, oh my gosh, someone put Joe out of his misery, right? Tell him to stop talking to me. And I want you to keep replaying this and replaying this. But most importantly, stop memorizing!

[00:26:46] So let’s go over it again just as a recap.

Upper sternal borders, who are they talking about? Aortic and pulmonic.
Where’s everybody else? The left lower sternal border.
So left lower sternal border is not helping you out much.
But if I say upper sternal border, I’m either pulmonic or aortic. If it’s on the right upper sternal border, that’s aortic. If it’s on the left upper sternal border, that’s pulmonic.
Louder with inspiration → right and louder with expiration → left.
What squatting? Party maneuver, who parties? Everybody, everyone’s going to sound louder.
Who are your low-volume maneuvers? That’s standing and Valsalva. So, you have less blood flow in the heart, and most murmurs sound quieter.
Who are your special needs murmurs? What were the two murmurs or two areas that like low volume? They like less blood in the ventricles. That is mitral valve prolapse, which is a valve problem, and HOCM, which is really a wall problem.
Then inspiration → right and expiration → left. How do you take the mitral valve and put it close to the chest? The left lateral decubitus position. That’s what I do. So, the left lateral decubitus position is best, whether it be mitral stenosis or mitral regurgitation.
And one more time. What’s hand grip? Handgrip is me sitting on the aortic valve. If I have aortic stenosis, I can barely open up, and you sit on the aortic valve, and is it going to be able to open up? Heck no! But if I have aortic regurgitation and now all this blood flow is going back against the aortic valve. Is there anything to stop it? No. And remember if I have a normal aortic valve and perform hand grip, what will I do? Remember what Frank Starling’s curve said, when I increase afterload, I increase preload, so what’s the left ventricle going to do? It’s going to fill it with more blood.
So if I have HOCM, what are you doing to the walls? Well, I’m filling it with more blood, but what am I doing with the walls? Pushing them apart.

[00:28:32] Hopefully, I’ve demystified the heart murmur issues for you, and I hope this makes more sense. Like I said, just replay this podcast episde.

Remember what I’ve been trying to teach about inspiration and expiration and squatting and handgrip and all these maneuvers we can do to make the murmur sound louder and disappear. And if you go with that approach, I promise you, no matter how the PANCE comes at you with a heart murmur question – You’re going to nail it.

[00:28:57] If you go at it from the memorization point of view, you will be in a boatload of trouble. Because all the buzzwords are gone and all those kinds of stuff. So listen, it’s been an honor. And it’s always a pleasure to speak with you out there in podcast land. And so right now, I got pixie.

[00:29:13] My rescue dog whose lying on my bed, sitting here, and she’s giving me that look like she wants to go outside for a walk. So it’s time to take my rescue dog out for a walk. All the best, and please, as you’re getting ready for the PANCE, like I said, in the previous podcast, make sure you take care of yourself, take care of your health and take care of your brain.

[00:29:32] All the best, Joe.

Resources and links from the show

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The post Podcast Episode 97: Murmurs Made Incredibly Easy – Ten PANCE Murmur Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 96: Murmurs Made Incredibly Easy (Part 5 of 5) – MVP and HOCM

Mon, 04 Apr 2022 09:00:00 +0000

Welcome to episode 96 of the Audio PANCE and PANRE PA board review podcast.

Today is part five of this fabulous five-part series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode of the Audio PANCE and PANRE podcast, we continue our discussion of cardiac murmurs with a focus on Mitral Valve Prolapse (MPV) and Hypertrophic Obstructive Cardiomyopathy (HOCM).

We’ll cover the ins and outs of these two NCCPA content blueprint murmurs and learn how to identify and differentiate them from other types of murmurs.

If you haven’t already, make sure to listen to our previous podcast episodes where we covered tricuspid stenosis, aortic valve murmurs, mitral valve murmurs, and pulmonic valve murmurs.

HOCM and MVP (a brief introduction)

Hypertrophic Obstructive Cardiomyopathy (HOCM) is a cardiac abnormality that leads to the muscle in the wall of the heart growing and thickening to the point that it blocks blood flow exiting the heart.

The condition can be mild or severe, and it can lead to a variety of symptoms, including shortness of breath, chest pain, and irregular heartbeat. Complications may include heart failure, an irregular heartbeat, and sudden cardiac death.

HOCM is a hereditary condition, and it is usually diagnosed in adulthood. There is no cure for HOCM, but treatments are available to manage the symptoms and help reduce the risk of complications. With proper care, people with HOCM can live long and healthy lives.

*Hypertrophic cardiomyopathy is covered under the PANCE cardiology content blueprint -> cardiomyopathy -> hypertrophic cardiomyopathy

HOCM is also covered as part of the PAEA EOR pediatric rotation -> cardiovascular topic list -> hypertrophic cardiomyopathy

Mitral Valve Prolapse (MPV) is a condition in which the leaflets of the mitral valve bulge or prolapse back into the left atrium during systole. This may cause blood to flow backward into the left atrium, leading to a heart murmur.

In some cases, MPV may also cause symptoms such as fatigue, dizziness, chest pain, and shortness of breath.

While MPV is usually benign, it can occasionally lead to serious complications such as heart failure or stroke.

Treatment for MPV typically involves lifestyle modification and management of symptoms. In severe cases, surgery may be necessary to repair or replace the mitral valve.

*Miral valve prolapse is covered under the PANCE cardiology content blueprint -> valvular disorders -> mitral valve prolapse

Podcast Episode 96: Murmurs Made Incredibly Easy (Part 5 of 5) – MVP and HOCM

Below is a transcription of this podcast episode edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to this latest episode and access even more resources below.

Welcome back, everybody out there in the podcast world. This is Joe Gilboy, and I work with Stephen Pasquini at Smarty PANCE.

Today is part five of our five-part series covering heart murmurs – one of the most dreaded subjects in PA land.

Today we are going to cover what I call the low-volume lovers.

And who are the murmurs that like low blood volumes? In other words’ low blood volumes make these murmurs sound louder? That is Hypertrophic Obstructive Cardiomyopathy (HOCM) and mitral valve prolapse.

Hypertrophic Obstructive Cardiomyopathy (HOCM)

So, what is happening with HOCM? Let us go back and view this from a pathophysiology point of view. So what do you have with HOCM?

I have this young adult, and he is going to start exercising. So what is the left ventricle going to do on a typical day during exercise? You will stress out the left ventricle, which can lead to hypertrophy.

I want everybody to look in the space you are in right now. Maybe you are in a room. Perhaps you are in a car. I want you to look at the volume of this room or car and look at the wall.

Now I want you to imagine that you start working out. You see, the wall will get thicker.

Now, what happens when those walls are thicker, my muscles get thicker. Thus, what is going to happen next? My stroke volume will go up, my cardiac output will increase, and my resting heart rate will decrease. And that is a nice normal day. That is the way it is supposed to work.

This is why aerobic exercise is so good. That’s what your Apple Watch or Fitbit is telling you. They are going, “Hey, we hit the target zone. You’re stressing out your left ventricle.” Your left ventricle will hypertrophy, which is a normal response to exercise.

Your wall will get thicker, but the volume of the room you are sitting in stays the same. Let this marinate for a second. I stress out my left ventricle, and it’s going to hypertrophy. The wall is going to get thicker, with more healthy tissue. My stroke volume will go up, my cardiac output will go up, my resting heart rate will go down, and my exercise tolerance will improve. That’s a nice normal day.

Hi, I have HOCM by genetics, no fault of my own. I was just born with this genetically. I will stress out my left ventricle, except instead of hypertrophying out, with HOCM, I am going to hypertrophy in.

Okay, please stop and think about what I am saying. Now. See the room you are sitting in, that wall. It is coming in. Not out, but in. Look at the volume. You have in your room now. What have you done? You have decreased the volume (the size) of your room.

Now, since I have less volume, what is the last thing you want to take away from me? Volume? So what drug is contraindicated in HOCM? Diuretics!

The last thing I want to do is have these walls hit with low volume and a high pulse. That’s when bad things can happen. This is the VTACH and the VFIB that you see these young athletes with HOCM die from.

So, these walls get thick and come in and make my room smaller. So, the last thing I want to do is take volume away, and the last thing I want to do is give them a diuretic.

What is a lifestyle thing I can tell my patients with HCOM to do? Drink more water! This will increase the volume, and the walls to be pushed apart. Does everybody see that?

Okay, my patient with HCOM is sitting at the edge of the bed at rest. He is not exercising, and he does not have an elevated pulse and low volume – that’s that nightmare scenario we were talking about where a patient with HOCM is exercising, and they have low volume. They are sweating, and their pulse is high. Now the walls hit, and this is when the bad things happen.

So, I have this patient sitting at the edge of the bed in an exam room at rest. Remember, HOCM is not a valvular issue. No valve is not functioning correctly here. These are walls that are enlarged (hypertrophied).

Now I want to hear the walls hit each other while my patient with HOCM is at rest. That’s all I want. I want the walls to hit. What is in the way between those two walls? Blood!

If I want the walls to hit, I have to get the blood out. I can do this with my low-volume maneuvers. What are my low-volume maneuvers? Standing and Valsalva.

When I have HOCM, if I perform standing and Valsalva (the low volume maneuvers), I can get the blood out of the way so walls can get closer and hit. So, what makes the murmur of HOCM sound louder? Standing and Valsalva.

How do I push the walls of the ventricle apart? I can add more blood. How do I add more blood? If I squat! That is right; squatting is a party. If I go in there and squat and all this blood comes running back home, what will I do with the walls of the left ventricle? I am going to push them apart.

So, this is the opposite of all those murmurs I learned about! This is why I call HOCM and MVP the low volume lovers – because they like low volume.

Handgrip and HOCM

Let us take it one step further. Let’s do that one maneuver everybody hates out there in the podcast world: Handgrip.

Okay, think about it. Stop memorizing. Let’s make sense of this.

So, we perform handgrip. What am I doing? I am sitting on the aortic valve. You sat on the aortic valve and added more pressure to the valve by doing this. You have added more afterload.

What is the left ventricle going to do? Well, since I have more afterload, I need more preload. So, my ventricles are going to have to fill up more. With the increased volume, the walls will move apart from each other.

So, you are telling me that when I squat and put all that blood into the left ventricle, it will push the walls apart? Furthermore, when I do handgrip, it will also cause those walls to move apart because I must increase my preload and increase the volume. Exactly!

So, when I perform handgrip and have HOCM, the murmur goes away.

HOCM summary

HOCM It is not a valvular issue.
To make the murmur of HOCM louder, you want the ventricular walls to hit, which requires lowering the volume of blood between the ventricles.
In contrast, for my patient’s health, the last thing I want to have is low volume, so I do not want my patient to sweat. I do not want to give him a diuretic and lower the volume even more.
And what is his nightmare situation for patients with HOCM? Low volume and high pulse!
What can we give patients with HOCM that will keep their pulse low? We can give them a beta-blocker.
Remember, those walls are disorganized, and the tissue is stiff. So, I want to relax the tissue. What is an excellent smooth most relaxer? Calcium channel blockers!
And that is exactly how we treat HOCM with beta-blockade to lower the pulse and calcium channel blockers to relax the stiff tissue.

This is everything you need to know about HOCM: It is not a valvular issue. To make HOCM louder, you want the volume out so the walls can hit. What are the low-volume maneuvers? Standing and Valsalva. How do you put volume (aka blood) in the room? Standing and handgrip? Exactly. That is precisely how this works.

Mitral Valve Prolapse

The next murmur that likes low volume is the murmur of mitral valve prolapse. In comparison to HOCM, this one takes a bit more thought.

To demonstrate mitral valve prolapse put your two hands together like you are making the letter A.

Okay, see how your fingertips are touching each other. This is how the mitral valve usually closes.

Now point your thumbs in the middle and view your thumbs as the chordae tendineae. They are pulling your fingers down. That is how it works on an average day.

To demonstrate mitral valve prolapse, take your right hand and place it where your metacarpals are – again, kind of like the letter A.

Do you see how your fingers are over the top of the other ones? They do not match up perfectly. This is what we sometimes call a redundant valve. In other words, there is extra tissue, and things are not lining up.

When the left atrium contracts on a normal day, the mitral valve comes down, and everything works as expected. However, we will run into trouble with MVP when the left ventricular pressure is highest. And when is the left ventricular pressure at its highest? Oh, that is right, I memorized that during PA school. It is highest during mid systole. That’s why we get a mid-systolic click – because the valve cannot hold the pressure below it during mid-systole.

That is because the connection is not very good. It is loose. So, the valve pops open during mid-systole, and we call that a mid-systolic click.

How can I crank that pressure up in the left ventricle? Oh, I could exercise. Exactly! This is why we often hear about people with mitral valve prolapse having palpitations with exercise.

Okay. I want the murmur of MVP to sound louder. Think about this. Let us go back to where my hands were in the example above. Remember how my fingers were coming together to form the letter A? Except when I have mitral valve prolapse, my right hand is touching my metacarpals, and I have these extra fingers on top of each other, creating a redundant valve.

So, I want this valve to collapse in on itself. I want it to fall in on itself.

What is down in the left ventricle? Blood. Now we need to get the blood out of there so the valve can fall down on itself. We will need to call in our low-volume maneuvers to do this.

What are our low-volume maneuvers? Standing and Valsalva! Standing and Valsalva are low volume maneuvers and will make the murmur associated with mitral valve prolapse sound louder.

Now, if I put blood back in the ventricle, can that redundant valve fall down on itself? No, it cannot. So, squatting is a high-volume maneuver that puts blood back into the left ventricle, and it is not going to make the murmur of MVP sound louder because the valve is not going to fall in on itself. However, if I take the blood away, there is nothing down there in the left ventricle, and the valve will fall back down. So mitral valve prolapse is also a murmur that gets louder with low volume maneuvers.

Recap

What are your low-volume maneuvers? Standing and Valsalva!
With low volumes and MVP, the valve will fall back down on itself.
With high volumes and MVP, what am I going to hear? I am going to hear a mid-systolic click.
Who is my patient going to be? MVP is more common in females, so we will likely be presented with a young female with palpitations during exercise.
What are you going to write off as a young female with palpitations? Anxiety. These patients are often misdiagnosed with anxiety. What will the patient say to you that will be the clue that this is not anxiety? The patient may talk about the palpitations with exercise. Remember, with exercise, the left ventricle is full of blood, and there is a lot of pressure in the left ventricle. During mid systole, when the volume is the highest, you will hear a mid-systolic click
What if your patient is sitting at the edge of the bed in the clinic resting and not exercising? How can you hear the murmur of MVP – this valve that does not connect very well? I want to make the valve fall back down on itself. What is below the mitral valve? The left ventricle. What is in the left ventricle? Blood that needs to get out! What can I do to decrease the volume of blood in the heart, make the valve fall back down on itself, and increase the sound of the murmur at rest? Standing and Valsalva!

Handgrip and Mitral Valve Prolapse

There is just one more thing we need to cover. The ultimate apex question. Are you ready? Handgrip! With handgrip and HOCM, I could see how by increasing the volume of blood in the heart, the ventricle walls would get pushed apart, and the murmur goes away. Now we will cover handgrip and mitral valve prolapse.

Okay, handgrip, so what did I say? I am sitting on the aorta. Okay. So, what is the left ventricle going to do? I just increased my afterload. This means I also increased my preload.

So what did you do? You just put more blood in your left ventricle! Now you need to push that blood out, and you are pushing out more blood. The mitral valve is prolapsed and does not have a good connection. Is it going to be able to hold? No. So, will I hear the murmur of mitral valve prolapse if I do handgrip? Yes, the murmur of MVP will increase with handgrip.

How do I differentiate the low-volume lovers (MVP and HOCM)? By having the patient perform handgrip. With HOCM, when handgrip is applied, you push the walls of the ventricles apart. With mitral valve prolapse and handgrip, you increase left ventricular pressure, and what happens to the mid systolic click? Oh, it is still there, and if ff anything is louder. Because what did I do? I increased the pressure in my left ventricle.

Come back to this podcast and replay it again when you have a moment. This will make so much sense if you follow my physics, especially the laminar flow physics part.

Remember that HOCM and MVP are low volume lovers – meaning they like low volume – that is when the murmurs sound louder. They are the opposite of mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation. Those usual players like more blood against the diseased valve.

Remember, in HOCM; it is not a valve issue; it is a wall issue. Mitral valve prolapse is a valve issue, but remember that the valve does not connect very well. It is still there. It works well, but the connection does not hold tight.

What’s next?

Next week we are going to start doing murmur questions.

We have covered aortic stenosis and aortic regurgitation, we went over mitral stenosis and mitral regurgitation, we covered pulmonic stenosis and pulmonic regurgitation, we have learned about tricuspid stenosis and tricuspid regurgitation, and in this episode, we covered what I call exceptions to the rule – which is HOCM, and mitral valve prolapse.

What is next? Test questions – where I will present these murmurs to you in a very ambiguous way, and you will have to figure out which murmur it is.

Take care of yourselves, and stay safe. I will see you soon.

Take care, Joe.

Resources and links from the show

View all the episodes in this series Cardiac Murmurs Made Incredibly Easy
View the Mitral valve prolapse and Hypertrophic Cardiomyopathy Smarty PANCE content blueprint lessons
Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook
Check out my list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% off any Picmonic membership by using this link, or if you are a Smarty PANCE member, get Picmonic for Smarty PANCE.

This podcast is available on every device. You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

The post Podcast Episode 96: Murmurs Made Incredibly Easy (Part 5 of 5) – MVP and HOCM appeared first on The Audio PANCE and PANRE.

Podcast Episode 95: Ten PANCE, PANRE, and Rotation Review Questions

Thu, 10 Mar 2022 17:36:24 +0000

Welcome to episode 95 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me as I cover ten PANCE, PANRE and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

Below you will find an interactive exam to complement today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take the Practice Exam

If you can’t see the audio player, click here to listen to the full episode.

Podcast Episode 95: Ten PANCE/PANRE and EOR Topic Blueprint Questions

1. A 52-year-old patient is admitted with a lower gastrointestinal bleed. He is given 2 units of packed red blood cells. A few hours later the patient develops a fever but has no other symptoms or changes in vital signs. Lab studies reveal no significant changes. Which of the following is the most likely diagnosis?

A. Transfusion-associated circulatory overload
B. Acute immune-mediated hemolytic reaction
C. Transfusion-related acute lung injury
D. Febrile non-hemolytic transfusion reaction
E. None of the above

Click here to see the answer

The answer is D. Febrile non-hemolytic transfusion reaction

The most common transfusion reaction is a febrile non-hemolytic transfusion reaction (FNHTR).

Patients with FNHTR may present with a fever a few hours after receiving packed red blood cells (PRBCs), which is caused by the small number of white blood cells and cytokines that can be found in each unit of PRBCs. Treatment consists of giving acetaminophen and ruling out other causes of fever (e.g., central line infection, urinary tract infection, etc).

Incorrect Answers:

Transfusion-associated circulatory overload (Choice A) occurs when the volume of the transfused component causes hypervolemia.

Acute immune-mediated hemolytic reaction (Choice B) occurs when there are antibodies presented to blood donor antigens. Patients may present with hypotension, fever, or coagulopathic lab abnormalities.

Transfusion-related acute lung injury (Choice C) is due to antibodies reacting with antigens leading to the release of mediators that causes edema in the lungs. Symptoms include fever, hypoxia, and dyspnea.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Immunologic disorders ⇒ Transfusion reaction

2. Which of the following is not a side effect of lithium?

A. Hyperparathyroidism
B. Hypothyroidism
C. Cognitive fog
D. Tremors
E. All are side effects

Click here to see the answer

The answer is E. All are side effects

Lithium is the first-line treatment for bipolar disorder. It has many side effects that you should remember, such as hypothyroidism, hyperparathyroidism, nephrogenic diabetes insipidus, cognitive fog, and tremors. Lithium levels should be monitored to avoid toxicity.

Remember, bipolar disorder is characterized by the symptoms DIG FAST: Distractibility, Irritability, Grandiosity, Flight of ideas, Activity increased, Sleep deficits, and Talkativeness.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Bipolar and related disorder

Also covered as part of the Emergency Medicine EOR, Psychiatry EOR, and Family Medicine PAEA EOR topic list

3. Which of the following best explains the pathophysiology of vasovagal syncope?

A. Increase in parasympathetic signals and withdrawal of sympathetic signals
B. Severe narrowing of the aortic valve
C. Drop in blood pressure upon standing due to inadequate peripheral vasoconstriction
D. Occlusion of the pulmonary artery leading to right ventricle dysfunction
E. Blood accumulation in the brain leading to compression of adjacent brain structures

Click here to see the answer

The answer is A. Increase in parasympathetic signals and withdrawal of sympathetic signals

Vasovagal syncope is the most common cause of syncope. Syncope is essentially transient loss of consciousness due to the lack of cerebral perfusion. Vasovagal syncope is usually triggered by something, such as emotion or stress.

A leading hypothesis of vasovagal syncope is that it is due to an increase in parasympathetic signals and withdrawal of sympathetic nervous signals.

Incorrect Answers:

A drop in blood pressure upon standing due to inadequate vasoconstriction describes neurogenic orthostatic hypotension (Choice C).

Occlusion of the pulmonary artery leading to RV dysfunction is describing a pulmonary embolism, which can lead to syncope (Choice D).

Blood accumulation in the brain leading to compression of brain structures is describing an intracranial hemorrhage (Choice E), which is a (rare) cause of syncope.

Narrowing of the aortic valve aka aortic stenosis (Choice B) can lead to syncope, but again, this is not vasovagal syncope.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Vascular Disorders ⇒ Syncope

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, Emergency Medicine EOR, Pediatric EOR, and General Surgery PAEA EOR topic list

4. A 71-year-old male smoker with prostate cancer presents to your clinic complaining of unilateral leg swelling and pain. Vital signs are unremarkable. On a physical exam, the entire leg is swollen with localized tenderness along the venous system. Which of the following is the next best step?

A. Order a d-dimer
B. Order a duplex ultrasound
C. Admit to the hospital immediately
D. Reassurance and follow-up in 6 months
E. Order a CT angiogram

Click here to see the answer

The answer is B. Order a duplex ultrasound

This patient needs an ultrasound because he has a high pre-test probability for thrombosis. Ordering a d-dimer, in this case, would be inappropriate. Lots of things (e.g., cancer, trauma, etc) can elevate d-dimer.

Well’s Score helps us determine a patient’s risk for DVT based on these criteria: active cancer, surgery or bedridden, calf swelling, collateral veins presence, entire leg swollen, localized tenderness along deep venous system, pitting edema, previous DVT, recent immobilization, & alternative diagnosis more likely.

The main idea: d-dimer should be ordered in low-risk patients, and a venous duplex US should be ordered for high-risk patients.

VIEW BLUEPRINT LESSON

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Venous thrombosis

Also covered as part of the General Surgery PAEA EOR topic list

5. Which of the following individuals would be considered to have a positive purified protein derivative test at 6 millimeters of induration?

A. 31-year-old who was in contact with a person who has active TB
B. 65-year-old intravenous drug user
C. 53-year-old who lives in a prison
D. 90-year-old with hypertension
E. None of the above

Click here to see the answer

The answer is A. 31-year-old who was in contact with a person who has active TB

Tuberculosis (TB) is a worldwide health concern and is deadly. A purified protein derivative (PPD) test can be used to screen for TB. A PPD test is considered positive depending on the patient’s risk factors. Remember, we measure induration, NOT erythema. See below for a high-yield list of positive PPD tests (not exhaustive):

>5 mm: HIV, immunosuppressive condition, or recent contact with active TB case

>10 mm: IVDU, came from a country with a high TB prevalence (<5 y prior), health care worker, resident/employee in a high-risk congregate setting

>15 mm: everyone else

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Tuberculosis

Also covered as part of the Internal Medicine EOR, Emergency Medicine EOR, and Family Medicine PAEA EOR topic list

6. A 48-year-old male presents with headaches, vision loss, enlarged jaw, and enlarged hands. Which of the following laboratory studies is the preferred initial diagnostic test?

A. Beta glycoprotein 2a
B. Growth hormone
C. Prolactin
D. Calcitonin
E. Insulin growth factor 1

Click here to see the answer

The answer is E. Insulin growth factor 1

The patient has acromegaly, which is an endocrine disorder characterized by excess secretion of growth hormone after epiphyseal closure. The most common cause is a pituitary adenoma. Clinical manifestations include coarsening of facial features, enlarged hands/feet, macrognathia, bitemporal hemianopsia, sleep apnea, and headaches.

Insulin growth factor-1 is the best initial diagnostic test to screen for acromegaly. A CT or MRI can help confirm the presence of a pituitary adenoma. A glucose suppression can also be ordered. Definitive treatment is transsphenoidal resection of the pituitary adenoma.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Pituitary Disorders ⇒ Acromegaly/gigantism

Also covered as part of the Internal Medicine PAEA EOR topic list

7. A 14-year-old obese male presents to the ER complaining of dull pain in the right hip and thigh for the past few weeks. No history of trauma. On physical exam, the affected leg is held in an externally rotated position and is shorter than the left leg. What is the most likely diagnosis?

A. Legg Calve Perthes
B. Septic arthritis
C. Slipped capital femoral epiphysis
D. Transient synovitis
E. Pelvic stress fracture

Click here to see the answer

The answer is C. Slipped capital femoral epiphysis

The patient most likely has slipped capital femoral epiphysis (SCPE), which is defined as displacement of the capital femoral epiphysis from the femoral neck (through the physeal plate). The classic clinical presentation is hip pain in an obese, adolescent male. Remember, it can be bilateral (~20-40%)!

On physical exam, the affected leg may be externally rotated and shorter than the other leg. Cases are diagnosed via plain radiographs (AP view and lateral views of both hips). Once diagnosed with SCPE, most patients should be made non-weight-bearing and referred to an orthopedic surgeon.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Lower extremity disorders ⇒ Disorders of the hip ⇒ Slipped capital femoral epiphysis

Also covered as part of the Pediatric Rotation PAEA EOR topic list

8. A 32-year-old male with sarcoidosis presents to the clinic complaining of shortness of breath, fatigue, and palpitations for a few months. His in-office EKG reveals QRS prolongation and some premature ventricular beats. A chest radiograph shows cephalization of the pulmonary vessels and cardiomegaly. Which of the following is the most likely diagnosis?

A. Cryptogenic organizing pneumonia
B. Hypertensive encephalopathy
C. Cardiac sarcoidosis
D. Acute coronary syndrome
E. Pneumoconiosis

Click here to see the answer

The answer is C. Cardiac sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder; it impacts the lungs, eyes, lymph nodes, heart, skin, and nervous system. Cardiac sarcoidosis (CS) is often under-recognized and can occur as a clinical feature of sarcoidosis. Presenting symptoms may include palpitations, syncope, fatigue, & dyspnea.

CS happens because granulomas infiltrate the heart, leading to conduction issues, tachyarrhythmias, cardiomyopathies, & heart failure. Holter monitoring and echocardiography are two helpful tests. The gold standard would be a heart biopsy (not routinely done because it is so invasive; cardiac MRI is preferred). Treatment is steroid therapy and anti-arrhythmic drugs.

Incorrect Answers:

Cryptogenic organizing pneumonia (Choice A) is a type of diffuse interstitial lung disease that typically presents with cough, fever, dyspnea, and malaise.

Hypertensive encephalopathy (Choice B) manifests as headaches, vomiting, confusion, and neurological symptoms. The patient has none of these.

Acute coronary syndrome (Choice D) is more likely to present with diaphoresis and crushing chest pain.

Pneumoconiosis (Choice E) is a fancy word that means the accumulation of dust (e.g., coal, asbestos, etc) within the lungs. This patient has absolutely nothing in his history that suggests this.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Restrictive Pulmonary Disease ⇒ Sarcoidosis

Also covered as part of the Internal Medicine PAEA EOR topic list

9. A 64-year-old male presents with tremors in both of his hands. He says the tremors worsen with movement and caffeine. The tremors improve with alcohol use. Which of the following is the best initial treatment option for his likely diagnosis?

A. Dopamine agonist
B. Beta-blocker
C. Alpha antagonist
D. NMDA antagonist
E. None of the above

Click here to see the answer

The answer is B. Beta-blocker

The patient likely has an essential tremor (ET) which is the most common cause of action tremor in adults. It occurs bilaterally in both hands, commonly worsens with anxiety, and improves with alcohol use. The tremor becomes more noticeable when the hands are outstretched or during goal-directed movement (e.g., writing with a pencil).

ET is a clinical diagnosis. Treatment includes beta blockers (propranolol), anticonvulsants (primidone, gabapentin, topiramate) and benzodiazepines. Propranolol and primidone are the most effective treatment options. Remember there is often a strong genetic component (family history is present 30-70% of the time).

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Essential tremor

Also covered as part of the Family Medicine and Internal Medicine PAEA EOR topic list

10. Which of the following is the most common cause of infective lactational mastitis?

A. Escherichia coli
B. Staphylococcus aureus
C. Bacteroides species
D. Staphylococcus epidermidis

Click here to see the answer

The answer is B. Staphylococcus aureus

Lactational mastitis presents as a red, painful, swollen breast usually during the first three months of breastfeeding. It commonly results from poor drainage. The most common cause is Staphylococcus aureus. If it develops over 24 hours, patients may also have flu-like symptoms and a fever — this is considered “infective” lactational mastitis.

Treatment includes cold compresses and complete emptying of the breasts. For infective lactational mastitis, antibiotics (e.g., clindamycin, cephalexin, dicloxacillin) should be given. Remember, patients should NOT stop breastfeeding.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Breast Disorders ⇒ Mastitis

Also covered as part of the Women’s Health EOR and Emergency Medicine PAEA EOR topic list

Looking for all the podcast episodes?

This FREE podcast series is limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

I will be releasing new episodes every few weeks. Smarty PANCE is now discounted, so sign up now before it’s too late!

Resources and Links from the Show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This Podcast is available on iOS and Android

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

The post Podcast Episode 95: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 94: Murmurs Made Incredibly Easy (Part 4 of 5) – Tricuspid Stenosis

Wed, 16 Feb 2022 10:00:52 +0000

Welcome to episode 94 of the Audio PANCE and PANRE PA board review podcast.

Today is part four of this fabulous five-part series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode of the Audio PANCE and PANRE podcast, we continue our discussion of cardiac murmurs with a focus on the tricuspid valve.

We’ll cover the ins and outs of tricuspid valve stenosis and learn how to identify it and differentiate it from other types of murmurs.

If you haven’t already, make sure to listen to our previous podcast episode where we covered aortic valve murmurs and mitral valve murmurs, and pulmonic valve murmurs.

The Tricuspid Valve

The tricuspid valve, or right atrioventricular valve, is a one-way valve that sits between the right atrium and right ventricle of the heart. It is essential for right ventricular filling and for preventing the backflow of blood from the right ventricle into the right atrium when the right ventricle contracts during systole.

When functioning properly, the tricuspid valve is a passive structure that opens and closes in response to the pressure of the blood flowing through the heart.

The right atrium receives deoxygenated blood from the superior and inferior vena cava. The tricuspid valve which separates the right atrium from the right ventricle opens during ventricular diastole, allowing the deoxygenated blood to flow from the right atrium into the right ventricle, and closes during ventricular systole preventing the backflow of blood from the right ventricle into the right atrium as the right ventricle contracts to pump blood into the lungs out through the pulmonary artery.

Tricuspid Valve Stenosis

Tricuspid stenosis is a narrowing of the tricuspid valve or one of its three leaflets.

If the tricuspid valve is narrowed or stenotic, it will not open properly during diastole, increasing the volume of blood in the right atrium. When the right ventricle contracts the stiffened tricuspid valve also fails to close completely and tricuspid regurgitation develops.

Nearly all cases are caused by rheumatic fever.

Podcast Episode 94: Murmurs Made Incredibly Easy (Part 4 of 5) – Tricuspid Valve Stenosis

Below is a transcription of this podcast episode edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to the latest episode and access even more resources below.

Welcome everybody, this is Joe Gilboy PA-C and I work with Stephen Pasquini at Smarty PANCE. Today, we will continue this series on heart murmurs. Today’s topic is tricuspid stenosis.

So, sit back, listen to my voice, and try not to take notes. Don’t do anything other than just listen and follow my logic. I promise you, when this is all said and done, you’ll be looking at heart murmurs and more specifically, tricuspid stenosis in a vastly different light. I want you to view the tricuspid valve. Just think about it. There you are the right atria. The tricuspid valve opens during diastole and closes during systole.

There’s all your blood in the right ventricle, and it goes out through the pulmonary valve to get oxygenated out in the lungs.

So now, I want you to think about this for a second. I have a tricuspid valve that is stenotic. It’s stiff and hard to open.

When are you going to have problems opening this valve? During diastole? Or during systole?

You are going to have problems with this during diastole because that’s when the tricuspid valve is supposed to open up. Because it’s supposed to be closed during systole.

So, it’s a diastolic murmur, it’s considered a mid-diastolic murmur.

Now give this some more thought. Okay, so you’re in the right atria – Is it easier or harder to push through this stenotic valve?

Oh, it’s a lot harder. And so, where’s the blood flow going to back up to? Into the right atrium and now that right atrium, it’s going to have all this increased pressure going into it. So now what are you going to get? You are going to get right atrial enlargement!

Here is another question – If the right atrium is having a tough time pushing blood through the stenotic valve then where’s this extra blood going to back up to? The right side of the body. Exactly! So, I’m going to have JVD and I’m going to get pedal edema? You are going to get right-sided heart failure with tricuspid stenosis.

Can I ask another question? How’s your blood flow to your right ventricle? It is diminished. Well, then how’s your blood flow to the pulmonary area? That’s diminished! How’s your oxygenation? That’s also diminished. So how are you feeling? I’m short of breath. Exactly. And you are short of breath not because you’re in heart failure. You’re short of breath because you’re just not getting blood to oxygenate. Exactly.

So, tricuspid stenosis is on the right side. One more time – Inspiration right. Expiration left. Inspiration right. Expiration left that if you didn’t get it the first two times. Let’s try the third time. Inspiration right. Expiration left.

Hi, I’m tricuspid stenosis, which side of the heart am I on the right or left? I’m on the right. So, tricuspid stenosis is going to sound louder with inspiration. Exactly.

What’s the party maneuver where all the blood flow comes back home and everybody’s just partying as you get more blood flow back home – squatting. What else could make tricuspid stenosis sound louder? Squatting! Exactly!

Squatting is a high-volume maneuver and will make the murmur of tricuspid stenosis sound louder.

What are my low-volume maneuvers? What are the maneuvers that take blood out of my heart? Standing in Valsalva!

So, what would make tricuspid stenosis go away? Standing and Valsalva are low volume maneuvers and will decrease the sound of tricuspid valve stenosis.

So, I have a right-sided heart murmur. It’s diastolic and is considered mid-diastolic. Where am I going to put my stethoscope?

You see, there’s only one thing on the right – that’s the aortic valve at the right second intercostal space, right that we all memorized in school. So, everybody’s on the left.

The left upper sternal space – that’d be pulmonic. But what is on the left – everybody else?

So hi, you’re the tricuspid valve, where are you? I’m on the left… Exactly! You’re going to be on the left at the lower sternal border.

So now I have this mid-diastolic murmur. Left sternal border that sounds louder with inspiration => goes away with expiration => left. It’s going to sound louder with squatting and is going to go away with standing and Valsalva – these are my low volume maneuvers.

And how did you get this? Usually, the most common cause of tricuspid stenosis is rheumatic fever, is it not?

So now, let’s pull back, and let’s look at this from 30,000 feet.

I’ve got a stenotic valve over there on the right side. Who is it? It’s the tricuspid valve.
Where’s the blood flow back going back up to? The right atria.
What’s the right atrium going to do? It’s going to hypertrophy and I’m going to get right atrial enlargement.
Where’s the blood going to go next? Outside to the body. And what do you get? Symptoms that look like right-sided heart failure.
Are you overloading your lungs? No. Did you get any CHF over there on the left? None.
How’s your oxygenation? It’s poor because everything’s backed up on the right. It’s not backed up on the left.
Inspiration right and expiration left? The tricuspid valve is on the right so tricuspid stenosis is going to sound louder with inspiration.
What else can make the murmur sound louder? I could party which happens when I squat – so the murmur of tricuspid stenosis gets louder with squatting.
What will make the murmur of tricuspid stenosis go away? My low-volume maneuvers standing, and Valsalva will decrease the murmurs of tricuspid stenosis.
How did I get tricuspid stenosis? I got tricuspid stenosis through rheumatic fever.
Where am I going to put my stethoscope to listen to the murmur of tricuspid stenosis? Everybody’s on the left sternal border Joe, everybody’s here. The only thing that’s on the left upper sternal border is the pulmonic valve and the only thing on the right is the aortic valve. So, the murmur of tricuspid stenosis is going to be on the left lower sternal border.
How do we treat tricuspid stenosis? We like to keep the volume low because we don’t want the blood to back up. Therefore, we use diuretics sometimes we’ll also add sodium restriction to a patient’s diet.
This is a stenotic valve so it’s harder to open. So, with tricuspid stenosis, we are going to get that opening snap, just like mitral stenosis

Closing thoughts

When you get to the boards (on your PANCE or PANRE) I want you to forget about brute memorization and all these buzzwords.

Just pull back and try to make sense of this from a laminar flow physics point of view. If you do it this way, you’ll always do great.

In the real world when we hear a heart murmur what’s the first thing we do? We order an echocardiogram to figure it out. But what I’m really trying to get you ready for is your boards.

So, on the boards, they give you a patient with a murmur at the left sternal border murmur and they’re going to talk about how it gets louder with inspiration, which means okay, it’s going to be on the right.

Or they say the murmur gets louder with expiration so it’s going to be on the left.

I want you to start viewing it this way. Not the way that you memorized it in school with all the PowerPoints and all the other mnemonics. I’ve seen every mnemonic known to man in my 30 years of teaching, so I don’t want to go down that rabbit hole.

So now that we understand the physics hopefully this makes more sense and I hope this helps you better understand the murmur of tricuspid stenosis better.

And next week, what are we going to do guys? Oh is going to be tricuspid regurgitation. And don’t worry about the following week. Oh, that’s going to be a fun day. That’s when I start asking you test questions and we start trying to pull this all together.

So once again, it’s an honor. It’s an absolute pleasure to speak to all of you. Be safe out there, be healthy, and most importantly take care of yourself. I will talk to you soon.

Joe Gilboy PA-C

This episode was transcribed for your reading pleasure by Stephen Pasquini PA-C

Resources and links from the show

Why is it all in there

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook
Check out my list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
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The post Podcast Episode 94: Murmurs Made Incredibly Easy (Part 4 of 5) – Tricuspid Stenosis appeared first on The Audio PANCE and PANRE.

Podcast Episode 93: Murmurs Made Incredibly Easy (Part 3 of 5) – Pulmonary Valve Stenosis and Regurgitation

Wed, 19 Jan 2022 10:00:05 +0000

Welcome to episode 93 of the Audio PANCE and PANRE physician assistant/associate board review podcast.

Today is part three of this extraordinary five-part series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode of the Audio PANCE and PANRE podcast, we continue our discussion of cardiac murmurs with a focus on the pulmonic valve.

We’ll talk about the different types of murmurs (stenosis and regurgitation) that can occur with the pulmonic valve and how to differentiate them from other types of murmurs. If you haven’t already, make sure to listen to our previous podcast episode where we covered the aortic valve murmurs and mitral valve murmurs.

The Pulmonic Valve

Pulmonic valve stenosis (PVS) and pulmonic valve regurgitation (PVR) are two common heart valve diseases. PVS is a narrowing of the pulmonic valve, while PVR is leakage of blood back through the pulmonic valve. Both conditions can lead to significant heart problems if left untreated.

Pulmonic valve stenosis

PVS is the most common congenital heart disease, affecting approximately 1 in 1000 people. It can lead to right heart failure and/or pulmonary hypertension (high blood pressure in the lung arteries). PVS is caused by an abnormally thickened pulmonic valve or localized stenosis which means that it has a narrowing of the valve. Pulmonic valve stenosis has several different causes including:

Congenital heart disease – this means that the abnormal valve was present from birth but is often undiagnosed until adulthood. For example, children with Down’s syndrome or Noonan syndrome are more likely to have an undiagnosed congenital heart defect such as PVS. It commonly is a component of tetralogy of Fallot.
Cocaine use in pregnancy – research has shown that there is a link between the use of cocaine in pregnant women and children with PVS, particularly if it is used close to the time of conception or later stages of pregnancy.
Infection during pregnancy can cause an inflammatory response which may lead to heart problems for the baby.
Autoimmune disease – PVS is sometimes associated with other autoimmune diseases, such as lupus.

Symptoms of PVS can vary depending on the type of stenosis that is present and how much it has advanced. Mild cases may not cause any symptoms at all; however, it is common for patients to experience breathlessness, fatigue, chest pain, and palpitations.

Heart sounds include increased splitting of S2 and a harsh crescendo-decrescendo ejection murmur heard best at the left parasternal 2nd or 4th intercostal space when the patient leans forward; the murmur grows louder immediately with Valsalva release and with inspiration.

People with PVS may need to take some medication to ease their symptoms. For example, diuretics can help remove excess fluid; beta-blockers reduce the workload on the heart and therefore lower blood pressure and heart rate, and long-acting calcium channel blockers can reduce the force of contraction of the heart’s left ventricle.

Pulmonary valve replacement is an effective treatment for severe PVS, which involves surgically implanting a new pulmonary valve to replace the defective one. Because the valve only affects the blood flow through one part of the heart, this surgery can often be carried out using minimally invasive techniques.

For milder cases of PVS that do not cause symptoms then medication or exercise may be prescribed instead. Regular exercise helps to strengthen the left ventricle (the main pumping chamber) which is important for people with PVS. For more information, view our lesson on pulmonary stenosis.

Pulmonic valve regurgitation

Pulmonic valve regurgitation is leakage of blood back through the pulmonic valve.

It can lead to right-sided heart failure and/or pulmonary hypertension (high blood pressure in the lung arteries). This means that it has a leakage of the valve.

It can be caused by any condition that impairs cardiac function, including pulmonary hypertension (the most common cause), chronic obstructive pulmonary disease (COPD), left ventricular hypertrophy (LVH), and heart failure (HF).

Although 5-8% of the general population has PVR, it is more common in COPD and other respiratory diseases, such as bronchiectasis.

Pulmonary valve regurgitation is an important determinant of functional class and quality of life among patients with chronic obstructive pulmonary disease (COPD), who have a higher incidence of this valvular disease than the general population. It appears to be more frequent than traditionally thought and its impact on patient survival is greater than previously estimated.

Heart sounds when PR is due to pulmonary hypertension include a high-pitched, early diastolic decrescendo murmur that begins with P2 and ends before S1 and that radiates toward the mid-right sternal edge; it is heard best at the left upper sternal border while the patient holds the breath at end-expiration and sits upright.

The murmur of PR without pulmonary hypertension is shorter, lower-pitched, and begins after P2.

Treatment is directed at the cause; valve replacement is usually not needed.

Podcast Episode 93: Murmurs Made Incredibly Easy (Part 3 of 5) – Pulmonary Valve Stenosis and Regurgitation

Below is a transcription of this podcast episode edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to the latest episode and access even more resources below.

Click here if you are unable to view the audio player.

Welcome back, everybody. This is Joe Gilboy PA-C, and I work with Stephen Pasquini PA-C at Smarty PANCE. Today, we will cover the dreaded two words that all PA students hate. What are these dreaded words?

Heart murmurs

We’ve covered the aortic valve. We’ve covered the mitral valve. Who’s the next one up?

The pulmonic valve

Okay. So, let’s erase everything we memorized in school.

Most of you are chuckling right now and saying Joe, it’s already erased, right? I’m sure it is.

So, let’s do it my way. I want you to pull back and forget everything you already know.

What’s the pulmonary valve supposed to do on a typical day? Let’s think about this. The right ventricle contracts and the pulmonic valve is supposed to open up. Then, that deoxygenated blood goes out to the pulmonary vasculature.

And then, on a normal day, the pulmonic valve closes during diastole to keep the blood out in the pulmonary area, and then that deoxygenated blood becomes oxygenated.

So, that diagram that you see in the books where the blood is blue, deoxygenated, then becomes oxygenated and red. And then it comes back to the pulmonary vein and back to the left atria, left ventricle, and up to the rest of the body, it goes. So that’s a nice normal day.

And where is the pulmonic valve located? Well, there’s only one valve on the right. That’s the aortic valve. Everybody else is on the left. So, where is the pulmonic valve? The left upper sternal border.

Pulmonary Stenosis

Okay, I want you to stop and just pull back and think, just think, and stop memorizing.

So, I have this stenotic pulmonary valve, and it’s hard to open up.

When am I supposed to open up? During systole. Does a stenotic pulmonic valve open up easily during systole? No, it has a hard time. So, when are you having difficulty with this valve? During systole. Because during diastole, it’s supposed to close. That’s what it wants to do. It wants to stay closed.

So, I don’t have a problem during diastole. I have a problem with systole. So, pulmonary stenosis is going to be a systolic ejection murmur.

So, here’s my question to you. Where’s the blood flow supposed to go? It’s supposed to go to the pulmonary area. Alright, stop and think about this for a second.

I’ve got a lack of blood flow to my pulmonary area. Lack of it. How is your oxygenation now? It’s pretty poor. So how are you going to present? I will be short of breath.

Imagine I go to walk up a flight of steps. I’m walking down the aisle in Costco. I’m completely tanked out. I am short of breath – I lack so much oxygenation I become syncopal; maybe I lack so much oxygen to my heart I have angina. You’ve got a lack of oxygenated blood because the right ventricle can’t get that blood past that valve.

And now, let’s pull back. Remember from the last podcast that S1 is the date between the mitral and the tricuspid valve, and S2is the date with the aorta and pulmonary valve.

Hi, I’m pulmonary stenosis, and I’m taking longer to open up. How’s your S2?

Well, I’m kind of late to the date. Yes, you are because you’re taking longer to open up. So how is your S2 in pulmonic stenosis? It’s split!

Do you now see what the split S2 means? Either I’m aortic stenosis or pulmonic stenosis – someone’s late to the date because it’s taking longer to open up.

Now that I know I have a split S2, I need more information to determine if this is aortic or pulmonic stenosis. But imagine (on the exam) they give you a split S2, and I’m on the right side – that’s aortic.

Now imagine having a split S2, and I’m on the left? Oh, that’s pulmonic. And now give this some thought. Okay, you’ve got this stenotic pulmonic valve, and I can’t get blood out. So, of course, I’m short of breath.

Can I ask you a question? Just give this some thought. Ready?

Hi, you have a stenotic pulmonic valve. Where’s the blood flow back up to? The right ventricle!

OK, so you’re the right ventricle. What are you going to do with all this extra blood? I’m going to dilate, and I’m going to get right ventricular hypertrophy.

And now imagine, if you can, that right ventricle gets bigger and bigger and bigger – stretching, stretching, stretching, stretching, stretching, stretching your right ventricle wall. Can I ask you a question? Can I bust those wires in the right ventricular wall? Yes, I can!

Welcome to right bundle branch block. So, could I get a right bundle branch block with pulmonary stenosis? Yes, I can.

I get right ventricular hypertrophy.
I get right axis deviation on EKG. That makes sense.
And then I’m going to bust that wall wide open. And we’re going to bust the wires from the hypertrophy, and I get right bundle branch block.

And that’s precisely what we see with pulmonary stenosis.

So, pulmonary stenosis.

I see the shortness of breath, angina, and I can see myself having syncope.
I’ve got a split S2 because I’m late for the date
I have a systolic ejection murmur, and it’s going to be on the left upper sternal border, not the right upper sternal border (as in aortic stenosis).

Imagine you are given a question, and the patient has a systolic ejection murmur on the left side of the sternal border. There is a split S2, and the patient is short of breath. Maybe they are lacking so much blood flow they get syncopal.

What’s the diagnosis? You have all the information you need. It’s pulmonic stenosis!

Now let’s make the murmur sound louder.

Okay, back to our first podcast on murmurs. What’s the maneuver that makes all the blood flow go back home? Squatting, squatting is a party. So, if I bring more blood flow back home, just laminar flow physics, the more blood flow I have against the murmur, the louder it sounds – so squatting. That’s a party, and squatting makes the murmur of pulmonic stenosis sound louder.

Remember this: Inspiration, right = Louder and Expiration, left = louder. Inspiration right => Expiration => left

The pulmonic valve is on the right side, so inspiration will make the murmur of pulmonic stenosis sound louder, and the murmur of pulmonic stenosis would go away with expiration.

What are low-volume maneuvers? Standing and Valsalva. So, if I stand or Valsalva, the murmur of pulmonic stenosis goes away.

So, let’s recap once again:

I have a systolic ejection murmur left upper sternal border.
Blood flow goes back to the right ventricle, and it dilates. I get right ventricular hypertrophy.
I’m going to get right bundle branch block because I stretched the wires.
Inspiration is going to make it sound louder. Expiration is going to make it go away.
Standing and Valsalva are low-volume maneuvers, and it goes away.
Handgrip challenges the aortic valve and does not affect the murmur of pulmonary stenosis.

Pulmonary regurgitation

Okay, so let’s just stop and think about this for a second.

Regurgitation – come and get goes you please, I could care less, my doors are always open. I’ve got regurgitation, and I have an open door, and I can come and go as I please.

So now think about it. During systole, should I be open? Yeah. But diastole, am I supposed to be closed? Oh, yes, I am.

But remember, in pulmonary regurgitation, you’re coming and going as you please. You’re supposed to be closed, but you’re not. So, this is a diastolic murmur, and it’s going to go from the left upper sternal border down to the apex. That’s just physics.

Can I ask you a question? That blood flow, where was it? Well, Joe, it was out in the lungs. Exactly. And so now what are you doing? I’m taking blood flow away from our lungs.

Is anybody late to the date? No, not at all. So that’s going to be okay.

So, it will be a diastolic murmur, and it will decrease. It will be loud in the beginning, and then, of course, as the right ventricle fills up, it’s going to sound less. So, it’s going to be considered a diastolic, decrescendo murmur.

But now I want you to stop and think about this because this is where a lot of the test questions come from.

Okay, so I have to blow through the pulmonic valve, right? Yeah. Okay, so let me think about this.

So, I have to push so hard push against the pulmonic valve that it blows open. So, I could see how right ventricular hypertrophy could cause that.

What does your right ventricle push against? It’s the pulmonary vascular.

I’m going to get pulmonary hypertension. See it? Who’s going to push hard against pulmonary hypertension? You’re like, oh, it’s the pulmonary valve on the right side. Is it built for high blood pressures? Yes, or no? And the answer is no.

So, you tell me if I get right ventricular hypertrophy due to pulmonary hypertension, I may blow my pulmonic valve? That’s precisely what’s going to occur.

What’s the most common cause of pulmonary regurgitation? Pulmonary hypertension because my right ventricle will hypertrophy, and I have to push harder. Exactly. The most common cause of pulmonary regurgitation is pulmonary hypertension.

Now, we can get to this argument of what causes pulmonary hypertension. CHF is a common cause.

Everybody’s on Adderall. What’s one of the side effects of Adderall? Pulmonary hypertension. And then here you are the pulmonary valve fighting, Adderall, and you’re like, Dude, that’s pulmonary hypertension out there. I have to push harder. Then you get right ventricular hypertrophy. And then what could I eventually get blowing through the valve? Pulmonary regurgitation!

What are the most common things that we see in people on Adderall? Pulmonary hypertension and pulmonary regurgitation.

So, when I start to fill in that right ventricular, and it hypertrophies due to all that pulmonary hypertension, I will push hard against your pulmonary valve. I can push so hard that I push right through it. Then what do you get? Pulmonary regulation.

Pulmonic valve disorders recap

Who was pulmonary stenosis? That was a systolic ejection murmur left upper sternal border, right ventricular hypertrophy, right bundle branch block.

This could be congenital. We see with tetralogy of Fallot.

And then we saw pulmonary regurgitation. What was that? It was a diastolic crescendo/decrescendo murmur. As the right ventricle filled up, it started tailing off, henceforth the word decrescendo.

Remember, what caused me to blow through my pulmonary valve? The right ventricle got so big that it just blew through because the pressure was so high. And remember, I’m the pulmonary valve. I’m not built for high blood pressure.

What was my right ventricle fighting the whole time? Pulmonary Hypertension. So, who was that? Well, that could be the Adderall. That could be the Fen-Phen. And then here’s the point. I don’t want you to forget.

Can I ask you a question? Who’s the vasoconstrictor everywhere?

What is nicotine? Nicotine is a drug. What is it? A vasoconstrictor? Where does it vasoconstrict? Everywhere! Who has the highest incidence of hypertension? Smokers!

What is the most common cause of coronary disease? Vasoconstricting and smoking.

What is a risk factor for peripheral vascular disease? Smoking.

I lack blood flow to my fingers and now my toes so much that they lack blood flow. They lack blood flow so much that they can’t grow. What’s clubbing, smoking! And now who saw the vasoconstriction? First, folks?

Your lungs? Yeah. What do you think you have as a smoker with COPD, and you’re going to go, oh, wait a second, Joe? I have pulmonary hypertension! Entirely correct.

Wait a second, Joe; then you’re telling me I get right into ventricular hypertrophy smoking? That’s exactly right. Then I can stretch my walls and get right bundle branch block? 100% correct. Then I can blow through my tricuspid and pulmonic valve with my pulmonary hypertension. Exactly.

What is the most common cause for pulmonic regurgitation or tricuspid regurgitation? Regurgitation blew through because the right ventricle got so big? Hmm. Smoking, COPD! Now, does everybody see the bigger picture?

So, imagine the exam question where a patient presents with a murmur at the right upper sternal border? There’s only one person up there at the right upper sternal border, and that’s the aortic valve.

Now, if they tell you the murmur is at the left sternal border, that’s everybody else. Now I need some more information.

Is it systolic or diastolic?
Does it get better with inspiration => right or expiration => left?
Squatting is a party, so that’s just everybody and anybody.
Handgrip challenges the aortic valve.
Valsalva and squatting are low-volume maneuvers, and that makes everything go away.

Try to make sense of this, and if you do, you will always answer heart murmur questions the best way.

I still remember being in PA school at Duke, and I still remember memorizing all the buzzwords and all this stuff. And I remember my first year in the ER. I couldn’t tell you what murmur I was hearing on the physical exam.

And now that I have stepped back and taken the time to learn the pathophysiology, I can appreciate how the cardiologist calls this a two, or three, or four, five, or six systolic ejection murmur. I really can understand where they’re coming from. I hope one day that you too can appreciate that as well.

So once again, it’s been an honor and, as always, a pleasure to speak to everybody out there in the PA podcast world.

Please be healthy, please be good, and whatever you guys do. Try to make sense of things.

Take care, Joe.

Transcribed for your reading enjoyment by https://otter.ai and Stephen Pasquini PA-C

Resources and links from the show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook
Check out my list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% off any Picmonic membership by using this link, or if you are a Smarty PANCE member, get Picmonic for Smarty PANCE.

This podcast is available on every device.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

Image attribution: LadyofHats, Public domain, via Wikimedia Commons

The post Podcast Episode 93: Murmurs Made Incredibly Easy (Part 3 of 5) – Pulmonary Valve Stenosis and Regurgitation appeared first on The Audio PANCE and PANRE.

Podcast Episode 92: Murmurs Made Incredibly Easy (Part 2 of 5) – Mitral Stenosis and Regurgitation

Wed, 08 Dec 2021 14:41:00 +0000

Welcome to episode 92 of the Audio PANCE and PANRE physician assistant/associate board review podcast.

Today is part two of this extraordinary five-part series with Joe Gilboy PA-C, all about cardiac murmurs. In this week’s episode of the Audio PANCE and PANRE podcast, we continue our discussion of cardiac murmurs with a focus on the mitral valve.

We’ll talk about the different types of murmurs (stenosis and regurgitation) that can occur with this valve and how to differentiate them from other types of murmurs. If you haven’t already, make sure to listen to our previous podcast episode where we covered the aortic valve murmurs.

The Mitral Valve

The mitral valve is located between the left atrium and the left ventricle in the heart. It consists of two leaflets (or cusps) and is responsible for preventing blood from flowing back into the atrium when the ventricle contracts.

The mitral valve can have two types of murmurs: stenosis and regurgitation.

Mitral stenosis is a narrowing (or constriction) of the valve opening, which reduces the amount of blood that can flow through the valve. This type of murmur is of low pitch, rumbling in character, and best heard at the apex with the patient in the left lateral position.
Mitral regurgitation is a leakage (or backflow) of blood from the ventricle into the atrium, caused by weakened or damaged valve leaflets. This type of murmur is a holosystolic (pansystolic) murmur, heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position.

In addition to auscultation, you can also look for certain signs and symptoms that may indicate mitral stenosis or regurgitation. For example, if a patient presents with chest pain (angina pectoris), this could be from decreased oxygen supply due to poor cardiac output in cases of significant stenosis. On the other hand, if a patient presents with an irregular heart rate (arrhythmia), this could be from increased electrical conduction velocity in cases of significant regurgitation.

Also, keep in mind that mitral valve disease can also occur secondary to rheumatic fever or endocarditis, so you may need to consider these diagnoses if a patient has any of the aforementioned signs and symptoms.

Below is a transcription of this podcast episode edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to the latest episode and access even more resources below.

Welcome, everybody. This is Joe Gilboy, and I work with Stephen Pasquini at Smarty PANCE.

Today we’re back to the heart murmur podcast, and we just finished the aortic valve. The next one up is the mitral valve.

Let’s just look at this my way. In school, you memorize a bunch of facts, then someone asks a question about mitral stenosis or mitral regurgitation, and you are completely lost. It’s time to change that. Now, we are going to do it my way. Are you ready? Here we go.

Let’s look at the mitral valve on a normal day. What’s the mitral valve doing?

There is my left atria. It’s contracting during diastole, my mitral valve opens up, and the blood flow goes to the left ventricle.
Then during systole, the mitral valve will close, the left ventricle will squeeze, and the aortic valve opens.

Mitral Valve Stenosis

Let’s start with the first heart murmur, mitral stenosis. Think about it. Slow down and give this some thought.

I’ve got the stenotic mitral valve. See it? It can barely open. It’s like, man; you’ve got to push hard to open this door. So, you are the left atrium, and you’re pushing down on this stenotic mitral valve. It’s like, man; this is hard to open up! I have to push harder. Yes, you do!

Wait for a second; then I’m going to put more blood flow back against my left atrium? Completely correct. So, my left atrium might hypertrophy? Yes, that’s correct!

So, you’re telling me I might get left atrial hypertrophy with mitral stenosis? Exactly!

Now, think about it. There you are in the left atrium pushing against the mitral valve during stenosis that’s supposed to open during diastole. You’re just taking longer to open up. You see, in school, what you memorize is an opening snap. Remember that ridiculous graph where you saw it had S1, S2 on all those bar graphs? You thought you were reading a musical sheet. Do you remember that thing? Or you’re like oh, S1 S2 ……….!? You were looking at it thinking, ” I have no fricking idea what I’m looking at.” Let’s erase that.

Think about this for a second; if the left atrium is pushing on a stenotic valve, it’s going to have trouble during diastole. Because during systole, it has to be closed. It’s going to close without a problem. The problem is opening it up. You can see the left atrium hypertrophy. Then blood flow may back up into the lungs and causes pulmonary hypertension.

Oh, wait for a second, I get pulmonary hypertension? Yes, you do!

Then maybe I have some fluid backed up in the lungs, and I might have a little shortness of breath and CHF. Exactly! Yes, that’s exactly how they’re going to present.

So, I have this diastolic murmur. It’s a diastolic ejection murmur to open that valve up. So, it’s not going to be an accentuated S1. But that’s not what they’re going to say on your boards, are they? No, that’s just a buzzword.

What they’re going to say is, “I have this diastolic rumbling murmur.” Rumbling means I’m trying to open up, and I’m going to radiate down towards the apex. That just makes logical sense.

So, I have this diastolic murmur radiating to the apex. Let’s take a closer look at the mitral valve. Remember, your heart doesn’t sit flat. It sits tilted and towards the back. So, I need this mitral valve to get towards the front. Okay, well, then tilt yourself to the left and lay down. Oh! That’s that left lateral to decubitus position they keep talking about. I’m going to bring it closer to the front.

Oh, that makes sense. I totally see that. So, I have a diastolic murmur that radiates to the apex. I can hear it better if I lay down on the left lateral decubitus position because that will bring the valve closer to the chest. Let’s make it sound louder now.

Okay, one more time back to how we were in the beginning with the aortic valve. Okay, what’s your party maneuver? Oh, I want to party, and I want to bring all the blood flow back home. How do you party? Oh, I squat. Squatting is a party. So, what are you going to do if I squat? How’s mitral stenosis sound? Louder! I get more blood flow pushing against the stenotic valve.

If I perform low-volume maneuvers, which are standing and Valsalva, I get less blood to the heart. Hi, standing and Valsalva, what’s going to happen to mitral valve stenosis. Yes, it’s going to go away!

Inspiration right (louder), and expiration left (louder). Repeat: inspiration right and expiration left. Hi, I have mitral stenosis! Oh, he’s on the left. What’s going to make him sound louder? Expiration? Yes, exactly!

Now, does everyone see this? So, you see, they’re not going to give you that “opening snap” buzzword. All the buzzwords on the PANCE are gone, guys, so just throw them away. What they’re going to give you is some person with a heart murmur, who maybe has a little CHF, has a diastolic murmur, and that’s it. That’s all they’re going to give you now. What you have to think is diastolic: left side, going back to the lungs = stenosis. That makes perfect sense. And that’s mitral stenosis. So, the “open snap,” those buzzwords are gone.

Let’s review one more time:

How do I make mitral stenosis sound louder? Squatting.
Inspiration (right) and expiration (left) => If the murmur is on the left (the mitral valve is on the left) => expiration makes it sound louder.
Standing and Valsalva are low volume maneuvers and the murmur of mitral stenosis goes away.
How do I hear mitral stenosis better? I need to put the murmur towards the chest. Well, the heart is lying towards the back, so I need to lay it towards the front so I can hear the murmur better. The lateral decubitus position repositions the mitral valve towards the front. That makes so much sense.

There you go, that’s mitral stenosis.

Mitral valve regurgitation

Then there’s mitral valve regurgitation. I want you to view mitral regurgitation as “come and go as you please.”

This is a valve that won’t close. Repeat, “come and go as you please.” Let’s review the mitral valve again. “Hi, I’m diastole, I’m the left atria, and I’m coming through a valve that doesn’t care. Do you have any problems? No, I’m supposed to be open. So, I’m coming through during diastole not a problem.”

Now, let’s compare that to systole: “Hi, I’m systole and that mitral valve is supposed to be closed.” But is it going to be closed? Nooo. In systole, blood is coming and going as it pleases. So, wait for a second, then I’m going to be a systolic murmur. 100% correct. And are you having any resistance? Zero.

That’s why we call it a holosystolic murmur. Understand? And now I’m going from the apex at the bottom of the heart, and I’m radiating to the axilla. So, you’re going back up to the left atrium? Exactly.

So how is your blood flow out to the rest of the world? Not that good. Not good at all. So how are you feeling? I’m feeling a bit lightheaded (syncope) and short of breath.

Now let’s go one step further. Remember that LAD, the Windowmaker? Okay, if you look at the left anterior descending artery, it bifurcates into the left anterior descending and septal branches. Both these guys feed the chordae tendineae. It’s that octopus-looking muscle that pulls the mitral valve down. So now think about this for a second. Just give us some thought. Ready?

You just had a LAD MI. You’re in the hospital. The cardiologist has just put down a stent. You’re on the heparin drip. You are getting ready to go home, maybe on Xarelto or Eliquis. Right.

So, there you are, on a blood thinner. Can I ask you a question? Just give it a thought. You know, your chordae tendineae? You know, during the MI, remember that? Yes, your lacking blood flow to the left ventricle, weren’t you? Yes. How was your blood flow to your chordae tendineae? Yes, it was diminished.

Let’s review. The patient is in the hospital and on an IV beta-blocker (you want to rest the heart). Well, they’re going home and back to activities like walking through Costco or Walgreens, or CVS. He’s no longer on a beta-blocker, folks. His heart rates back up.

Is this chordae tendineae ready for normal heart rate? Yes, or no? No, not at all. He’s on the injured reserve list as well. And guess what? His chordae tendineae is not going to hold very well. He says, “Oh my god, I’m so weak. I can’t hold the mitral valve down”. Which means it is going to open back up.

That’s the test question you will see about post the MI patient who comes in two to four weeks later. The patient who’s got a new-onset murmur. What does he have? He’s got mitral regurgitation because his chordae tendineae got hypoxic during the MI, and now he’s got the murmur. So that’s a question that you see on Rosh Review, Hippo, Smarty PANCE, UWorld, and Kaplan. You’ll see this question rear its head, but the root of what they’re really after is something else. They want you to understand that the chordae tendineae itself was actually lacking blood flow during the LAD or ischemic event. So, it’s weakened. As soon as the patient goes to stress it out, it’s not going to work very well. It’s going to give way, and the chordae tendineae will rupture. What you have is mitral valve regurgitation. Does everybody see this?

So, as a recap, let’s look at this again.

What’s the mitral valve supposed to do? Well, I suppose you’d say, “to open up during diastole and close during systole.
I see that I’ve got mitral stenosis.” What’s your problem? Well, my problem is during diastole. It’s trying to open the thing up. Because during systole, don’t worry, it will close. It’s stenotic. It wants to stay closed. So, my problem is during diastole. They will not use the words “diastolic opening and snap.” But they may use the word “rumbling murmur.”
Where’s the blood flow backing up to? The left atria.
What’s the left atria going to do? Hypertrophy. What are you going to get? Left atrial hypertrophy.
Where’s the blood flow going to back up to? It’s going back up to the lungs. What do you have? Pulmonary hypertension.
What do you get? CHF.

This is the test question you’re going to get. An immigrant comes in with a diastolic murmur and shortness of breath. We don’t have the best testing for strep. Remember rheumatic fever? They are in their 30s and 40, and they’ve had rheumatic fever in the past, with mitral stenosis, and now the fluid is backing up to the lungs. That’s why they have shortness of breath.

Now, how do you make that murmur sound louder? Inspiration right, expiration left => expiration!
Squatting, it’s a party, and the murmur gets louder! Standing and Valsalva, it goes away!
Is your problem during diastole with mitral regurgitation? It’s like, come and go as you please. You know, let’s open and come on in. What’s your problem during systole because you should close… what he’s doing? You see, I don’t care. I can come and go as you please. So, my problem is going to be during systole.
So mitral regurgitation is going to be a holosystolic murmur.
And then, make it sound louder. Squatting is a party. Inspiration, expiration. Expiration: standing Valsalva or low volume maneuvers. It goes away. Exactly!

And that’s the point I’m trying to make about the mitral valve. Does everybody see that now?

When you get the test questions, stop and think. You’re going to laugh because one of the things I tell all my students to do all the time is to try to make sense of it. See, what you guys do is memorize these things, and you run into your, what I call your data closet. I call it a closet full of data.

You get into this data closet, and what happens is you get lost in the closet. You say to yourself, “Okay, diastolic murmur, axilla blah, blah, blah, what did I memorize? Let me write down my little mnemonic. Yes, yes. Oh, man, I can’t Oh, man.” Next, you’re just panicking. And you just choose A, B, C, or D.

You say to yourself, “oh my god, I think I got the question wrong.” Exactly.

So next time, just try making sense of it.

So, we did the aortic valve, and we did the mitral valve. So, we did everything on the left. Next week, we are going to the right folks. We’re going to go to the pulmonic valve and the tricuspid valve.

So, one more time, guys. Inspiration right, expiration left. Inspiration right, expiration left. To make the right side of your heart murmur sound better, what are you going to do? Inspiration, so pulmonic and tricuspid sound louder with inspiration.

Expiration left. Who sounds better on the left? Aortic and mitral!

It’s been an honor and a pleasure talking with you today. I hope this makes more sense. Next week we’ll do the pulmonic valve. Till then, be good to yourself and take care.

Joe Gilboy PA-C

Resources and links from the show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook
Check out my list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% off any Picmonic membership by using this link, or if you are a Smarty PANCE member, get Picmonic for Smarty PANCE.

This podcast is available on every device.

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists.

Featured Image attribution (aortic stenosis and regurgitation): Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014“. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. Crop by Stephen Pasquini PA-C, CC BY 3.0

The post Podcast Episode 92: Murmurs Made Incredibly Easy (Part 2 of 5) – Mitral Stenosis and Regurgitation appeared first on The Audio PANCE and PANRE.

Podcast Episode 91: Cardiac Murmurs Made Easy Part 1 of 5 – Aortic Stenosis and Regurgitation

Wed, 01 Dec 2021 10:30:00 +0000

Welcome to episode 91 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Today is part one of an extraordinary five-part series with Joe Gilboy PA-C, all about cardiac murmurs.

It’s time to throw away everything you have ever learned that made you hate cardiac murmurs (you know those crazy line diagrams) and let Joe hard-wire your brain for success.

I promise you that by the end of this podcast, you will no longer be afraid of murmurs, but you will welcome them into your brain with a whole heart, open arms, and the need to share this podcast with all your classmates.

Below is a transcription of this podcast episode slightly edited for clarity.

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.
You can listen to the latest episode and access even more resources below.

Welcome, everybody. This is Joe Gilboy PA-C, and today is part one of a five-part series on the two most dreaded words that every pa student and recert PA hates. Are you ready for the two words?

Heart murmurs!

Today we’re going to start talking about heart murmurs, and we are going to break this down into a five-part series:

The first part is going to be on the aortic valve (today’s episode)
The second part will cover the mitral valve
The third will be all about the pulmonic valve
The fourth part will be about the tricuspid valve
And then, in the fifth part of this series, we’re going to wrap this all together

We’re going to cover each valve one at a time. We will look at it and try to really make sense of it all.

Because I know what you did in PA school, you had that little diagram that you made, you know, systolic or diastolic murmurs. You’ve memorized certain things. And then you get to that test question, and you’re completely clueless on it, you’re like, “I have no idea what they just said, Joe, I have no idea.”

And then you’re back to scrambling, looking for some word that’s going to trigger you. And that’s the key point- all the trigger words, all those high-value trigger words, they’re gone. That’s what the creators of the PANCE did about two to three years ago. They took all the trigger words out.

Key point:

Don’t rely on keywords (trigger words) for your PANCE because they’re gone!

So now, let’s look at this differently. You did it your way. How did it work out? Probably not so well. So, guess what, we’re going to do it my way. And that’s what I want to do here.

Let’s start with the aortic valve.

So, think about it for a second. I want you to picture the aortic valve.

Opening during systole, closing during diastole. That’s really what it’s supposed to do.

Go ahead and picture that in your head. And for those who are in a safe place, close your eyes because it makes more sense.

The valve is going to be open during systole and is going to be closed during diastole.

Now, who gets fed right after the aortic valve? Well, that’d be the coronary arteries.

If I’m lacking blood flow to my coronary arteries, how’s that feel? I’ve got chest pain.

What’s the second thing that gets fed after the aortic valve? Well, that’d be my internal and external carotid arteries.

If I lack blood flow to my internal or external carotids, how will I feel? Lightheaded with syncope and dizziness.

Where does blood flow third? That would be my left subclavian artery, and if I lack blood flow, then I get left arm pain. And then, of course, everything down south after that.

Aortic Stenosis

Okay, so let’s start with the first one—aortic stenosis.

So, think about this for a second. Stop memorizing. Start thinking. I have this stenotic aortic valve, and it can’t open up. So that’s my question to you. When are you going to have problems with this valve? During systole or diastole?

It is supposed to open during systole. And it won’t. It’s too stenotic.

The aortic valve is supposed to be closed during diastole, and it will close. Oh, then I see your point, then that is a systolic murmur. Right? Aortic stenosis is a systolic murmur!

Where’s the aortic valve located? The right second intercostal space. And where does it radiate to? The neck.

I want you to understand something. Who’s got to work harder to push against this stenotic aortic valve. Who’s got to work harder to open the door? It’s the left ventricle.

Okay, you’re the body. Are you going to take this, or are you going to fight back? I’m going to fight back a little bit, Joe.

So, what’s going to happen to the left ventricle? The left ventricle is going to hypertrophy.

And then go and stretch and stretch and stretch and stretch and stretch and stretch and stretch that left ventricle and you’re going to rupture the wires in there. And you’re going to get left bundle branch block.

And for those of you thinking, ahead of the game, will right ventricular hypertrophy, unopposed cause right bundle branch block? The answer is yes.

Back to aortic stenosis – I see the left ventricular hypertrophy because it’s backing up. I can even see the left bundle branch block. That makes sense.

So, aortic stenosis is a systolic ejection murmur. Oh, I see it because it’s supposed to be open during systole. But it’s a tight valve, and it won’t open up. I get it!

Let’s go one step further. It’s the most commonly acquired valvular stenosis, and usually, it’s congenital or from a bicuspid valve. But that’s not what they’re going to ask. That’s too easy. So, how would aortic stenosis present? That’s the right question.

Let’s say you have a stenotic aortic valve; it’s not opening during systole. “Hi, I have aortic stenosis, and I’m walking through Costco.”

So, you are walking through Costco, looking at the Christmas decorations or whatever they have. And how is your valve? Is it opening up? Yes, or no? No, it’s not Joe. And are you demanding more of it? You’re walking through Costco. How’s the blood flow to your coronary arteries? Oh, it’s diminished. Exactly.

Then I get chest pain with exertion – exactly. I could be walking up steps – and that’s the test question you see rear its ugly head – it’s going about the person with chest pain who’s walking up steps or exerting himself.

And then how’s your blood flow to your head? I get lightheaded and dizzy because of a lack of blood flow there. Get it? Do you see this picture?

I have this murmur in the right second intercostal space. It’s going to be systolic. The person is going to complain of chest pain and lightheadedness, and dizziness with exertion.

I can see the left ventricular hypertrophy. I can even see the left bundle branch block. Oh, that all fits.

So, they have chest pain. What do you give them? What do you give to people with chest pain? You give nitroglycerin.

And now the question is this. Well, what’s nitroglycerin? It’s a vasodilator. Where does it vasodilate? Everywhere. That’s right. I always love how people treat nitroglycerin like it’s intelligent, but it’s not. Nitroglycerin is going to vasodilate everywhere – including the left ventricle.

Wait for a second, hold on here. You just vasodilated my left ventricle, and I can’t get through the valve. Then the blood flow to my valve is not increased, but it’s decreased. And now you have less blood flow through that stenotic aortic valve. How’s your blood through the coronary arteries and in your internal and external carotids? It is incredibly diminished.

And what happens to these patients with aortic stenosis who are treated with nitroglycerine? They get syncope. See it now? It makes sense, doesn’t it?

Now, I have this systolic ejection murmur. It’s going to radiate to my neck because that’s how it’s pointing, and it’s going to be in that right second intercostal space.

Inspiration, expiration, squatting, standing, and handgrip

And now comes the questions about inspiration, expiration, squatting, standing, and handgrip! You’re like, I just can’t believe you’re going there, Joe. Yes, we’re going there. But we’re doing it my way, which is a lot more fun.

So now let’s think about this. I want you to imagine that S1 is a date with the mitral and tricuspid valve.

So, there they are, a cute little couple, the mitral and tricuspid valve come together, and they’re the S1. And now I want you to imagine S2 as a date between the aortic and pulmonic valve – so S2 is the combination of the two sounds, and S1 is a combination of the two sounds.

Key points:

S1 is a combination of the mitral and tricuspid valve
S2 is a combination of the pulmonic and aortic valve

Okay. Imagine I have aortic stenosis – does my valve take shorter or longer to open up? It’s taking longer to open up.

Your pulmonic valve opened on time, but your aortic valve is late to the date!

That’s right. You took longer to get ready to open up. So, guess what happens to my S2 – It becomes split.

So, you see, a split means that someone’s late to the date. Now I need more information to figure out whether it’s pulmonic stenosis or aortic stenosis.

Key point:

Both aortic and pulmonic stenosis causes a split S2
If I have a split S2, someone is late to the date
Is it pulmonic or aortic? I need more information, but someone’s late to the date.

Do you remember that ridiculous bar graph that you saw in PA school? You’re like, I have no idea what I’m looking at! What they’re trying to show you is the timing of the valves. Someone is late to the date.

So, I want you to erase what you memorized in PA school. If I have a split S2, someone’s late to the date. Is it pulmonic or aortic? I need more information, but someone’s late to the date.

So now, do you understand the left ventricle hypertrophy?
Do you understand the left bundle branch block?
Do you see the systolic ejection murmur at the right intercostal space?
Do you see the split S2?

Okay. One more step. Can we all agree just from a laminar flow physics point of view that the more blood flow I put across the valve, the louder it sounds?

Think about this for a second. The more blood flow I put across the valve, the louder it sounds.

So, to make aortic stenosis sound louder? What do I need to do? Put more blood flow across the valve!

Key point:

To make the murmur of aortic stenosis louder, you need to send more blood flow across the valve.

Okay, so there is a party, and everybody’s showing up – Your mom, your dad, your cousins, your second cousins, the neighbors, the neighbors, friends. I mean, everybody’s showing up. Everybody’s coming back to the heart. Who’s the party maneuver? Squatting – squatting is a party!

So, what are you doing? I’m shoving all the blood flow back home. Who showed up? The entire neighborhood – and my cousins and my second cousins everybody’s showing up. So, when I squat, you know what I get? More blood flow in the heart. Guess which murmur sounds louder? All of them – mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, pulmonic regurgitation, aortic stenosis, and aortic regurgitation – all sound louder with more blood flow back home. Who’s the maneuver? Squatting!

So, squatting really doesn’t help me much because everybody sounds louder.

Key point:

Think of squatting as a party – everyone comes home and brings more blood flow to your heart. This increases the sound of all the murmurs.

And then who’s your low volume maneuvers? Who makes blood flow go away from the heart? Well, that would be standing – when you stand up, that takes blood flow away from the heart. So, all the blood flows to your legs. How are all your murmurs? They go away. So, standing is a lack of blood flow, and all the murmurs are diminished.

Key point:

Standing is the opposite of squatting and makes all the blood flow go to your legs (away from the heart), and all the murmurs decrease in sound.

And then Valsalva. When you grunt, what you’re doing is Valsalva or if you have a bowel movement – what you’re doing is you’re squeezing the inferior and superior vena cava, and you’re stopping blood flow from going to the right side of the heart.

You’ve got less blood flow in the heart. So, do you have any blood flow to put on my murmurs? No, it went away. So, standing and Valsalva make murmurs go away.

Squatting sounds louder. Standing and Valsalva – these are my low volume maneuvers, and the murmur goes away.

Key point:

Valsalva squeezes the inferior and superior vena cava reducing blood flow into the right side of the heart. So, you have less blood (low volume) and a decreased murmur.

Inspiration and Expiration

Inspiration right. Expiration left. Inspiration right. Expiration left – and for the third time. Inspiration right expiration left – to make right-sided heart murmur sound louder, you breathe in (inspiration). What do you do to make left-sided heart murmurs sound louder? Expiration!

When you inhale, you breathe air in – imagine your inferior and superior vena cava are pushing blood into your right side. So, you get more blood flow on to the right – increasing the laminar flow on the right and increasing the sound of right heart murmurs.

When you exhale and blow air out, you are decreasing that pressure in the chest. So now the blood on the left can get out easier – increasing the laminar flow across the valve and increasing the sound of the murmur on the left.

So, one more time, inspiration right and expiration left. Hi, I’m aortic stenosis – am I on the left or the right? I’m on the left.

So, what’s it going to make it louder? Expiration!

Key point:

With expiration, you blow air out, and you are decreasing the pressure in the chest. So now, the blood on the left can get out easier – increasing the laminar flow across the valve and increasing the sound of aortic stenosis.

Hand Grip

You learned that handgrip increases peripheral vascular resistance.

Okay. Let’s translate that to more layperson terms. When I increase my peripheral vascular resistance, I’m sitting on your aortic valve. What is your only exit valve? Yes, that’s right – it’s the aortic valve. So, if I increase your peripheral vascular resistance AKA, I’m pushing all the blood against your aortic valve AKA I’m sitting on your aortic valve.

So, I want you to get this, I want this visualization of handgrip and sitting on the aortic valve. So, I’m sitting on your aortic valve, and we’re just sitting on it. Got it?

Grab your hands and squeeze them – see how your muscles are tight? Can you visualize the blood flow getting harder to come out? So, you’re pushing it against the exit valve, which is your aortic valve. And now I want you to visualize this as sitting on the valve.

Okay, hi, I’m aortic stenosis, and I can barely open up – squeak, squeak, squeak, squeak, squeak. I can barely open the valve. I’m stenotic, and you did what? You did hand grip. You just sat on my aortic valve, and I can barely open up. Do you think I can open it up anymore?

The answer is no. Exactly. So, guess what murmur is in the right second intercostal space and goes away with handgrip? Aortic stenosis!

Key point:

Imagine handgrip as sitting on an already stenotic aortic valve – blood can’t get out because the valve can barely open up. And what happens to the murmur? It goes away with handgrip.

Aortic Stenosis Recap:

It’s a systolic ejection murmur. Makes sense? Right?
Second intercostal space – that’s where it’s located.
Most commonly congenital bicuspid. That makes sense – typically, the aortic valve has three cusps (tricuspid aortic valve), but some people are born with an aortic valve that has two cusps (bicuspid aortic valve).
I can’t get the flow out, so when I exert myself, I get chest pain, shortness of breath, and dizziness. That makes sense.
Give me nitroglycerin, and you dilate my left ventricle. Well, we’re going to fall down and go good night because less blood flow is going through to the aortic valve.
How’s your S2? Oh, I’m late to the date, and you’re S2 is split.
How’s your left ventricle? It’s going to hypertrophy because I have to fight the aortic valve.
And wait a second. I can stretch the muscles to a point where I break the wires. What do we get? We get left bundle branch block.
Inspiration right => expiration left. Expiration and squatting are a party. Everyone show’s up, and the murmur sounds louder. Standing and Valsalva. These are low volume moves, and the murmur is quieter.
Handgrip – I’m sitting on the valve. Blood can’t get out, so the murmur goes away.

And then, of course, how do we diagnose it? Echocardiogram!

The aortic valve is the one valve that requires an emergent replacement. So, when somebody has aortic stenosis, what is the end game? It’s going to be an aortic valve replacement.

Aortic Regurgitation

Now, let’s discuss aortic regurgitation. Okay, with all these new tools, it’s going to be easy.

With aortic regurgitation, the valve is just flapping in the breeze, come and go as you please. I could care less – come and go as you please.

Are you going to have problems with this valve during systole? Yes, or no? No, because the valve is supposed to be open during systole.

So, when do you have problems with the regurgitating aortic valve? During diastole, when the valve is supposed to be closed!

Key point:

Aortic regurgitation is a diastolic murmur that will be noticeable when the valve is supposed to be closed during diastole.

It’s going to travel from my right-second intercostal space down to my apex.

Anything split? Is anybody late? No, not at all.

So, aortic regurgitation will be a diastolic murmur, and there is a wide arterial pulse pressure. They call this a water-hammer pulse. To understand this, imagine your pulse as a series of train cars. So, imagine a train, and there’s your aortic valve—pulse, pulse, pulse, pulse, pulse, pulse, pulse. But imagine if you’ve got aortic regurgitation – What do you do?

Well, I threw a pulse out there. But did you hold it out there? No, because my valve was open. So, what happened to some of that blood that you threw out there? It sneaks back home!

They call that wide arterial pulse pressure. I want you to view the arteries like this PVC pipe. You threw blood out there, didn’t you? So, it kept it full. But during diastole, I didn’t close the door. So, it all rushed back home, and the pipe collapsed. Exactly. That’s what we call a wide arterial pulse pressure, and this is what’s called a water hammer pulse.

So, I have this diastolic murmur. Right second intercostal space. Radiates to the apex. Okay. Let’s make it sound louder. What do you want to do? Oh, let’s squat – that’s a party!

To make it go away. I could stand or Valsalva. These are my low-volume maneuvers. Does inspiration or expiration make it louder? This is on the left, so expiration makes it louder.

Handgrip

So, I’m sitting on your aorta valve, and what’s the problem? You can come and go as you please. So, what will happen when we perform handgrip with aortic regurgitation is that blood flow is going to go against your valve, and it’s wide open. Blood is going to go right through it!

So now, does everybody see this question rearing its ugly head?

Instead of going for the knee-jerk answers that you’ve memorized (I call this the data closet in a student’s head), try to make sense of the question instead of going for your data closet. Think laminar flow physics.

So now, do you see the difference between aortic stenosis and aortic regurgitation?
Do you understand inspiration vs. expiration?
Do you see that squatting is a party? It’s not going to help with anything (squatting doesn’t do squat – it doesn’t help me delineate the cause of the murmur).
Inspiration, right, and expiration left.
My low volume maneuvers are Valsalva and standing.
Who challenges my aortic valve? Handgrip! And if I have aortic stenosis, it goes away, but if I have aortic regurgitation, the blood goes right through it.

And now, do you see the test question? They’re not going to tell you if it’s systolic or diastolic. That’s too easy. They’re going to tell you about some murmur in the right second intercostal space that either gets louder with handgrip (aortic regurgitation) or goes away with handgrip (aortic stenosis).

And now you will get the answer right every time!

Closing

Now go back and re-listen to this podcast episode a couple of times. I always tell people if they get a chance to listen to this podcast, do yourself a favor and find a quiet room and turn off all the lights.

And then just listen. Keep your eyes closed and visualize this in your head… and that’s just money!

Resources and links from the show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This podcast is available on every device

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, Amazon Music, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

Photo Credit: Bruce Blaus, CC BY 3.0 https://creativecommons.org/licenses/by/3.0, via Wikimedia Commons

The post Podcast Episode 91: Cardiac Murmurs Made Easy Part 1 of 5 – Aortic Stenosis and Regurgitation appeared first on The Audio PANCE and PANRE.

Podcast Episode 90: Ten PANCE, PANRE, and Rotation Review Questions

Wed, 03 Nov 2021 09:27:00 +0000

Welcome to episode 90 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me as I cover ten PANCE, PANRE and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook

Below you will find an interactive exam to complement today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take the Practice Exam

If you can’t see the audio player, click here to listen to the full episode.

Podcast Episode 90: Ten PANCE/PANRE and EOR Blueprint Questions

1. A 32-year-old male presents with acute ascending symmetrical paralysis and diminished reflexes in his bilateral lower extremities. He has a history of bloody diarrhea a few days ago. What did he likely eat that led to his symptoms?

A. Uncooked rice

B. Mayonnaise

C. Uncooked chicken

D. Soft unpasteurized cheese

E. None of the above

Click here to see the answer

C. Uncooked Chicken

This patient has Guillain-Barré Syndrome (GBS), an acute immune-mediated polyneuropathic disorder. Clinical features include ascending symmetrical paralysis, diminished tendon reflexes, and respiratory muscle weakness.

GBS is typically precipitated by an infection. Campylobacter jejuni infection is the most common precipitant of GBS. It is commonly found in uncooked poultry.

Cerebrospinal fluid analysis helps confirm the diagnosis. Treatment includes plasmapheresis and IV immune globulin.

View lesson: Guillain-Barré Syndrome

2. Which of the following disorders is characterized by a scaly, rough erythematous patch that appears on sun-exposed areas?

A. Seborrheic keratosis

B. Keratosis pilaris

C. Actinic keratosis

D. Lichen planus

E. Pityriasis rosea

Click here to see the answer

Answer: C. Actinic keratosis

Actinic keratosis (AK) is a skin lesion that results from atypical keratinocyte proliferation. Risk factors include UV radiation, fair skin, and sunburns.

AK can present in various ways, but classically you will see an erythematous, scaly macule, papule, or plaque. A shave or punch biopsy can confirm the diagnosis. However, AK is often diagnosed clinically.

Treatment depends on the location and extent of the condition. Options include cryotherapy, fluorouracil, and imiquimod. It is important to remember that AK can develop into SCC.

View Lesson: Actinic keratosis (AK)

3. A 42-year-old male is admitted for typical pneumonia. He is given IV azithromycin and ceftriaxone. His QT interval becomes prolonged and he develops a polymorphic ventricular tachycardia. Which of the following is the most appropriate pharmacological management?

A. Intravenous calcium gluconate

B. Intravenous magnesium sulfate

C. Intramuscular epinephrine

D. Oral amiodarone

E. Oral procainamide

Click here to see the answer

B. Intravenous magnesium sulfate

The patient developed torsades de pointes (Tdp), which is a specific type of polymorphic ventricular tachycardia in patients with a long QT interval. It is a ventricular dysrhythmia characterized by rapid (>100 bpm), irregular, wide QRS complexes that vary in size and shape. Diagnosis is made via EKG.

Examples of meds that prolong the QT interval include antiarrhythmics (amiodarone, sotalol), antimicrobials (fluoroquinolones, macrolides), antidepressants (fluoxetine, sertraline), and antipsychotics (haloperidol, quetiapine).

Treatment is usually IV magnesium sulfate.

View lesson: torsades de pointes (Tdp)

4. Which of the following is true about an indirect inguinal hernia?

A. It does not usually enter the scrotum

B. It is caused by a patent processus vaginalis

C. The strangulation risk is lower than a direct inguinal hernia

D. It is the least common type of inguinal hernia overall

E. It is medial to the inferior epigastric vessels

Click here to see the answer

Answer: B. It is caused by a patent processus vaginalis

A hernia is a protrusion or projection of an organ through the body wall that typically contains it. An indirect inguinal hernia is specifically a protrusion of the abdominal organ into a patent processus vaginalis that extends into the inguinal canal.

Indirect inguinal hernias are the most common type of inguinal hernia. An indirect inguinal hernia is found lateral to the inferior epigastric vessels and it usually enters the scrotum. The strangulation risk is actually higher in indirect inguinal hernias. Definitive treatment is surgery.

View lesson: Indirect inguinal hernias

5. Which of the following is the most common cause of death in hemochromatosis?

A. Hepatocellular carcinoma

B. Diabetic-related complications

C. Acute respiratory failure

D. Left ventricular failure

E. Pancreatic cancer

Click here to see the answer

Answer: A. Hepatocellular carcinoma

Hemochromatosis is an autosomal recessive disorder defined by excessive iron deposition in the liver, pancreas, and heart. It is often caused by a mutation in the HFE gene. Clinical features include skin hyperpigmentation, weakness, hepatomegaly, liver function abnormality, and diabetes mellitus.

Lab findings will show elevated serum iron, elevated ferritin, elevated transferrin saturation percentage, and decreased transferrin. Diagnostic tests include genetic testing and liver biopsy (gold standard, not always needed). Treatment consists of life-long phlebotomy. The most common cause of death in these patients is hepatocellular carcinoma.

View lesson: Hemochromatosis

6. A 15-year-old female with no medical history presents to the ER with altered mental status. She is tachycardic. Labs reveal a glucose level of 900 mg/dL and elevated beta-hydroxybutyric acid. Which of the following acid-base issues would you expect to see?

A. Normal anion gap metabolic acidosis

B. High anion gap metabolic acidosis

C. Metabolic alkalosis

D. Respiratory alkalosis

E. Respiratory acidosis

Click here to see the answer

Answer: B. High anion gap metabolic acidosis

The patient most likely has diabetic ketoacidosis (DKA), a life-threatening emergency defined by insulin insufficiency, along with an elevation in counter-regulatory hormones. Patients in DKA will usually have a high-anion gap metabolic acidosis (HAGMA).

An anion gap is calculated by subtracting anions (HCO3- and Cl-) from a cation (Na+). It is normally 8 to 12. The gap is elevated in DKA because unmeasured anions (ketones) are giving off H+, which interacts with bicarbonate. Bicarbonate becomes depleted, thus increasing the gap.

Other causes of HAGMA include acute kidney injury, lactic acidosis, and toxins.

View lesson: Acid-Base Disorders

7. Which of the following is the first-line treatment for nasal polyps in patients with chronic rhinosinusitis?

A. Anti-histamines

B. Intranasal steroids

C. Leukotriene inhibitors

D. Beta-agonists

E. None of the above

Click here to see the answer

Answer: B. Intranasal steroids

Nasal polyps are grayish masses filled with inflammatory mediators in the nasal cavity or sinuses. They are associated with aspirin sensitivity, chronic rhinosinusitis, asthma, allergies, and cystic fibrosis. Symptoms include increased nasal drainage, congestion, anosmia.

Nasal examination via nasal endoscopy can help confirm the diagnosis. The first-line treatment for nasal polyps is typically nasal corticosteroid spray. Surgery may be needed if the nasal polyp obstructs the cavity/airway.

View lesson: Nasal polyps

8. A 52-year-old female with a history of mitral valve regurgitation presents with exertional dyspnea. On physical exam, you notice abdominal swelling and lower extremity edema. You suspect pulmonary hypertension (PH). Which of the following is the gold standard for diagnosing PH?

A. Right heart catheterization

B. Chest radiograph

C. Computed tomography angiography

D. Echocardiogram

E. Polysomnography

Click here to see the answer

Answer: A. Right heart catheterization

Pulmonary hypertension (PH) is defined by a mean pulmonary arterial pressure > 25 mmHg. The World Health Organization lists 5 broad etiologies of PH: pulmonary arterial hypertension (Group 1), left heart disease (Group 2), lung disease (Group 3), chronic thromboembolism (Group 4), and unknown causes (Group 5).

Symptoms are usually related to right ventricle failure and include “body congestion” signs: pitting edema, abdominal swelling, hepatomegaly, etc. A transthoracic echocardiogram is the best initial diagnostic test. A right heart catheterization is the gold standard for diagnosing PH.

View lesson: Pulmonary hypertension (PH)

9. A 72-year-old female smoker with a history of atrial fibrillation presents to the ER with severe abdominal pain for a few hours. Vitals are unremarkable. Physical exam reveals nothing significant. Which of the following is the gold standard diagnostic modality for the most likely diagnosis?

A. Computer tomography scan

B. Right upper quadrant ultrasound

C. Abdominal radiographs

D. Mesenteric angiography

E. None of the above

Click here to see the answer

Answer: D. Mesenteric angiography

The patient most likely has acute mesenteric ischemia, which is the sudden onset of small intestinal hypoperfusion. The most common cause is emboli from the heart (usually from atrial fibrillation). Other causes include thrombosis and atherosclerotic disease. The most common artery occluded is the superior mesenteric artery.

Clinical features include acute onset of abdominal pain out of proportion of exam findings, abdominal distention, and elevated lactate. A good initial diagnostic test for a stable patient is an abdominal CT scan. The gold standard test is mesenteric angiography. Treatment is surgical revascularization and antibiotics.

View lesson: acute mesenteric ischemia

10. Orbital cellulitis most commonly occurs when an infection spreads into the orbit from which sinus?

A. Maxillary sinus

B. Frontal sinus

C. Sphenoid sinus

D. Ethmoid sinus

E. Temporal sinus

Click here to see the answer

Answer: D. Ethmoid sinus

Orbital cellulitis is an ophthalmic emergency, as it can lead to vision loss. Clinical features include diplopia, decreased vision, pain during eye movement, proptosis, fever, and an erythematous, edematous eyelid. The most common bacterial culprits are Staphylococcus aureus and Streptococcus species. The ethmoid sinus is the most common origin of infection (90%).

The best diagnostic test is a high-resolution CT scan. Treatment is intravenous antibiotics, like IV vancomycin and ceftriaxone.

View lesson: Orbital cellulitis

Looking for all the podcast episodes?

This FREE podcast series is limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

I will be releasing new episodes every few weeks. Smarty PANCE is now discounted, so sign up now before it’s too late!

Resources and Links from the Show

Download your Free interactive PANCE, PANRE and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
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My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This Podcast is available on iOS and Android

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

The post Podcast Episode 90: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

Podcast Episode 89: Ten PANCE, PANRE, and Rotation Review Questions

Tue, 21 Sep 2021 09:00:00 +0000

Welcome to episode 89 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten PANCE, PANRE and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
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Below you will find an interactive exam to complement today’s podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take the Practice Exam

If you can’t see the audio player, click here to listen to the full episode.

Podcast Episode 89: Ten PANCE/PANRE and EOR Blueprint Questions

1. The definition of amblyopia is . . .

A. Congenital cataracts noted at birth

B. Retinal detachment seen in premature children

C. Irregular pupillary size

D. Increased distance between the medial and lateral canthus

E. Subnormal visual acuity in one or both eyes despite correction of refractive error

Click here to see the answer

Answer: E. Subnormal visual acuity in one or both eyes despite correction of refractive error

Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to process inputs from one eye and over time favors the other eye. It results in decreased vision in an eye that otherwise typically appears normal

Amblyopia is not correctable by refractive means
Amblyopia occurs in early childhood when nerve pathways between the brain and an eye aren’t properly stimulated
It may be caused by strabismus (crossed eye); uremia; or toxins, such as alcohol, tobacco, lead, and other toxic substances
Symptoms include a wandering eye, eyes that may not appear to work together, poor depth perception, blurred vision, or double vision. Both eyes may be affected

DX: Screening to detect amblyopia in all children younger than five years of age

Screening includes vision risk assessment at all health maintenance visits and vision screening at age three, four, and five years of age

TX: Treatment includes correction of refraction error as well as forced use of the amblyopic eye by patching the better eye

Some children cannot tolerate the patch, in which case the good eye is blurred with glasses or drops (penalization therapy) to stimulate proper visual development of the more severely affected eye
It is more resistant to treatment at an older age; thus, children should be treated early

View lesson: Amblyopia

A 45-year old woman being managed for ulcerative colitis, developed abdominal pain, vomiting, diarrhea, the passage of blood and mucus per rectum, and fever. On examination, she was pale, febrile (temp: 102.2 C), moderately dehydrated, heart rate: 124bpm. There was abdominal distention and tenderness, bowel sounds were hypoactive. Lab results showed Hb: 9g/dl, WBC: 14 x 109/L, elevated CRP. Stool was negative for C. difficile. HIV status was negative. Abdominal radiograph showed dilated transverse colon of about 11 cm. What is the most likely diagnosis of this patient?

A. Hirschsprung’s disease

B. Cytomegalovirus colitis

C. Toxic megacolon

D. Kaposi’s sarcoma

Click here to see the answer

Answer: C. Toxic megacolon

The hallmarks of toxic megacolon (toxic colitis) are nonobstructive colonic dilatation (>6 cm) and signs of systemic toxicity. It occurs following complications from causes of colitis e.g. ulcerative colitis as is the case in the index patient.

Incorrect Answers:

Hirschsprung’s disease (choice A) presents with chronic constipation. Patients are not usually toxic except when intestinal perforation occurs.
Cytomegalovirus colitis and Kaposi’s sarcoma (choice B and D) Occurs in immunocompromised persons.

View lesson: Toxic megacolon

3. Which of the following is not transmitted by blood?

A. Hepatitis A

B. Hepatitis B

C. Hepatitis C

D. Hepatitis D

Click here to see the answer

Answer: A. Hepatitis A

Hepatitis A is transmitted via the fecal-oral route

Incorrect Answers:

Hepatitis B can be transmitted via blood and blood products through close living quarters/playground play as a toddler, vertical transmission, infected unscreened blood, needle stick injury, etc.
Hepatitis D is transmitted via blood.
Hepatitis C is transmitted via blood and blood products through Intravenous drug misuse, unscreened blood products, needle stick injury, vertical transmission etc

View lesson: Acute and Chronic Hepatitis

4. When is PKU testing performed?

A. 24 weeks gestation

B. 24 to 48 h after birth

C. 48 to 72 h after birth

D. at the first well-child visit

Click here to see the answer

Answer: B. 24 to 48 h after birth

In the US and many developed countries, all neonates are screened for PKU 24 to 48 h after birth. Tandem mass spectrometry is the method of choice. It has a low false-positive rate, and excellent accuracy and precision.

View lesson: Phenylketonuria

5. A 20-year-old female with a history of type 1 diabetes presents to the clinic complaining of weight loss, increased flatulence, foul-smelling stools, and a pruritic rash. You notice multiple papules and vesicles on the extensor surfaces of the elbows. Which of the following is most likely to be positive?

A. Anti-cyclic citrullinated peptide antibody

B. Anti-dsDNA antibody

C. Anti-tissue transglutaminase antibody

D. Anti-topoisomerase antibody

E. Anti-beta 2 glycoprotein 1antibody

Click here to see the answer

Answer: C. Anti-tissue transglutaminase antibody

The patient has Celiac disease, which is an immune disorder characterized by sensitivity to gluten. It is more common in patients with Type 1 diabetes, autoimmune thyroiditis, Trisomy 21, and Turner syndrome.

Clinical features include diarrhea with bulky, foul-smelling floating stool, flatulence, and weight loss. Patients may have dermatitis herpetiformis, which is a rash located on the elbows, forearms, and knees.

Laboratory studies to order include anti-tissue transglutaminase antibodies and IgA anti-endomysial antibodies. The best diagnostic test is an upper endoscopy with a small bowel biopsy. Patients must avoid food with gluten, which includes barley, rye, oats, and wheat.

Incorrect Answers:

Anti–cyclic citrullinated peptide antibodies (choice A) are highly specific to rheumatoid arthritis.
Anti-dsDNA antibodies (choice B) are a specific marker for systemic lupus erythematosus.
Anti-topoisomerase antibodies (choice D) are specific to diffuse scleroderma.
anti-beta 2 glycoprotein 1 antibodies (choice E) are specific to antiphospholipid syndrome.

View lesson: Celiac disease

6. Which of the following is the most common cause of postpartum hemorrhage?

A. Severe vaginal laceration

B. Uterine atony

C. Hematoma

D. Retained products of conception

E. Placental abruption

Click here to see the answer

Answer: B. Uterine atony

Postpartum hemorrhage is an obstetric emergency. It is defined as an estimated blood loss ≥ 500 mL during vaginal delivery or ≥ 1000 in a cesarean section. The most common cause is uterine atony.

Uterine atony presents as a soft, boggy uterus after delivery and should initially be managed with fundal massage and IV oxytocin.

In general, the main focus of managing postpartum hemorrhage should be (1) resuscitation and management of hypovolemic shock and (2) identifying and treating the underlying cause.

View lesson: Postpartum hemorrhage

7. A 37-year-old female with no past medical history is brought in by EMS. She is hypotensive. On physical exam, you notice muffled heart sounds and jugular vein distention. What is the most appropriate initial treatment for this condition?

A. Emergent needle decompression

B. IV beta-blockers

C. Pericardiocentesis

D. Thrombolytics

E. None of the above

Click here to see the answer

Answer: C. Pericardiocentesis

The patient is experiencing cardiac tamponade, which is defined as fluid accumulation in the pericardial sac. The most common cause of cardiac tamponade is trauma. Other causes include malignancy, uremia, infection, and iatrogenic.

Patients may have Beck’s Triad – hypotension, muffled heart sounds, and jugular vein distention. They may also have pulsus paradoxus (large decrease in systolic blood pressure on inspiration).

The best diagnostic test is an echocardiogram. The treatment of cardiac tamponade is pericardiocentesis. An open surgical approach (i.e., thoracotomy) is typically needed for traumatic cases though.

Incorrect Answers:

Emergent needle decompression (choice A) is the treatment of choice for a tension pneumothorax, which is when air rapidly accumulates in the pleural space. It typically presents as shortness of breath.
IV beta-blockers (choice B) would be the management of an aortic dissection, not cardiac tamponade. An aortic dissection presents with sharp chest pain, pulse deficits, and hypotension.
Thrombolytics (choice D) would be the preferred treatment for an unstable patient with a massive pulmonary embolism.

View lesson: Cardiac Tamponade

8. Which of the following should be avoided in patients who have an acute kidney injury?

A. NSAIDs

B. Aminoglycosides

C. Macrolides

D. Acetaminophen

E. Both A and B

Click here to see the answer

Answer: E. Both A and B

Acute kidney injury (AKI) is defined by an acute decline in renal function. You will see an increase in serum creatinine with possible oliguria or anuria.

AKI can be broken up into 3 main etiologies: pre-renal, intrinsic, and post-renal. The most common cause of acute kidney injury overall is reduced perfusion. Prolonged pre-renal AKI can lead to ischemic acute tubular necrosis.

Nephrotoxic agents, such as NSAIDs, vancomycin, aminoglycosides, and ACEI/ARBs, should be avoided. Treatment is managing the underlying cause, plus correcting acid-base & electrolyte issues.

View lesson: Acute Renal Failure

9. A 38-year-old male presents to the ER with acute onset of dyspnea, dizziness, chest pain, and diaphoresis, He has had 4 episodes similar in the past. Vital signs are remarkable for mild tachycardia (103 bpm). Lab and imaging studies are insignificant. Which of the following is the best long-term medical treatment for the likely diagnosis?

A. Benzodiazepines

B. Selective serotonin reuptake inhibitors

C. Atypical antipsychotics

D. Calcium channel blockers

E. Melatonin

Click here to see the answer

Answer: B. Selective serotonin reuptake inhibitors

The patient most likely has panic disorder. The DSM V criteria for panic disorder include the following:

1 or more panic attack that reoccurs without warning and at least 4 or more symptoms
Must be worried about having another attack or change behaviors

Symptoms of a panic attack include diaphoresis, chest pain, lightheadedness, shortness of breath, palpitations, sense of doom, or fear of dying. The treatment of panic disorder is selective serotonin reuptake inhibitors. Patients may benefit from taking hydroxyzine or benzodiazepines on a short-term, as-needed basis.

View lesson: Panic Disorder

10. Which of the following best represents values you would expect in a patient with SIADH?

A. High serum sodium, high serum osmolality, low urine osmolality

B. High serum sodium, high serum osmolality, high urine osmolality

C. Low serum sodium, low serum osmolality, low urine osmolality

D. Low serum sodium, low serum osmolality, high urine osmolality

E. None of the above

Click here to see the answer

Answer: D. Low serum sodium, low serum osmolality, high urine osmolality

SIADH or syndrome of inappropriate antidiuretic hormone secretion is characterized by the excessive release of ADH. ADH increases the permeability of the distal convoluted tubule and collecting ducts, increasing the reabsorption of water. This decreases plasma osmolality, increases urine osmolality, and leads to hyponatremia.

Causes include intrathoracic diseases (pneumonia, TB, acute respiratory failure, lung cancer), neurological issues (stroke, hemorrhage, tumors), and drugs (NSAIDs, opioids, ecstasy, and SSRIs). The goal is to determine and manage the underlying cause. Fluid restriction is often used as well.

View lesson: Syndrome of inappropriate antidiuretic hormone secretion

Looking for all the podcast episodes?

This FREE podcast series is limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

I will be releasing new episodes every few weeks. Smarty PANCE is now discounted, so sign up now before it’s too late!

Resources and Links from the Show

Download your Free interactive PANCE, PANRE, and EOR Blueprint Templates
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free 8-week PANRE Blueprint study schedule and the 8-week PANCE study schedule
Get your free Trello PANCE study planner
Get 20% of any Picmonic membership by using this link

This Podcast is available on iOS and Android

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Podcasts, Stitcher, and most podcasting apps.

Download the Interactive Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists

The post Podcast Episode 89: Ten PANCE, PANRE, and Rotation Review Questions appeared first on The Audio PANCE and PANRE.

How to Be a Better PA Part 2: Medical Staff, Administrators, and Supervisors

Tue, 24 Aug 2021 07:01:00 +0000

This is part two of a special three-part podcast series by Joe Gilboy PA-C on becoming a better PA.

Part one was all about building better relationships with our nurses and ancillary staff.

In part two we cover essential strategies on how to stay off the medical staff radar and get the medical staff, administrators, and supervisors on your side.

Let’s jump right into this special episode of The Audio PANCE and PANRE Podcast.

You can listen to the podcast below and read the summarized (and edited version) of the transcript or listen in your podcast player of choice.

The Audio PANE/PANRE Podcast Episode 86: How to be a Better PA (Part 2 of 3)

You can also click here to listen to or download this episode.

Episode Transcript and Summary

This episode was recorded by Joe Gilboy PA-C and edited for clarity and readability by Stephen Pasquini PA-C.

Welcome, everybody. This is Joe Gilboy, and this is a podcast to have a series of three podcasts on how to become a better PA.

Today, we’re going to talk about medical staff, our administrators, and our supervisors, whether a nursing supervisor, PA supervisor, or possibly physician supervisor.

What I will be teaching you here in this podcast is how to interact with them and how to deal with them. And most importantly, how to have you make a better reputation for yourself and how to make you a better PA.

First, we’re going to talk about the medical staff, which is a big group of people.
Second, we need to learn how to deal with administrators. These can also be the office managers at the clinics where you work.
And then your supervisors, these are the people above you, whether a nurse, a PA, or a doc.
Lastly, we will covering how to deal with (or leave) a toxic job

So, let’s talk about all these three people we’re going to have to interact with.

How to be a Better PA with Medical Staff

Let me explain who medical staff really are, not whom you think there are, but I’m going to show you who they really are.

I’ve been a physician assistant in the emergency room for 35 years. You would think that after 35 years, I’ve developed some tough skin. But there’s one group of people that I fear the most, and you will begin to fear them as well. Who are they? The medical staff!

Everybody has a boss. For example, you have a boss, and your boss has a boss, they have a boss, everybody has a boss. But there’s one person who’s at the very top of this pyramid. That’s medical staff.

So, when medical staff asked for something, when do you get it done? Now? Yes, right now, like yesterday was too late.

So, the medical staff has asked for your ACLs card, PALS card, NCCPA card, or DEA number. They want a TB test, a flu shot, or they want your antibody titer for chickenpox.

When are we getting it done?

Now! No, literally right now. Because you see, the last people you want to be on the radar is medical staff.

Let me share with you who medical staff really is.

What’s their job?

Are you ready for this? I hope you’re sitting down?

Their job is to fire you.

Yeah, you heard me. They want to find a problem. That’s their job.

So, when they start asking for things, they’re looking for a problem. So, let’s just say a young physician assistant is working in urgent care that we will call Betty.

So, here’s Betty, the new PA working at the urgent care. Medical staff wants something, and she’s like, well, you know, I’ll get to it tomorrow. I have a birthday party to go to this weekend. And you know, and then it’s my parents, wedding anniversary, I’m going to have that. And then my boyfriend’s taking me to this. And you know, I’ll get back to it when I get back in town. And as this time has gone by, Tick-tock, tick-tock. She’s getting these new emails in her inbox from the medical staff. They’ve sent one, they’ve sent two, they sent three. Now they send one to her, and they’re saying, hey, if you don’t get this done in 10 days, you’re on suspension!

Guess who gets the seat in that email? Your boss.

Let me explain to you how this plays itself out. You see, at the end of the year, when you’re up there for that yearly evaluation, they’re going to say, “Hey, so how’s our new physician assistant? How’s she doing?”

Well, they’re going to talk to a group of people. They’re going to talk to the nurses. They’re going to talk to the physicians. And guess who else they are going to talk to, folks? That’s right, the medical staff.

“Are there any dings with this person? Have they no gotten things done on time?”

Now think about what I’m saying hard.

So, imagine you’re the boss. And there’s these two PAs that show up. One PA gets everything done on time, and the medical staff doesn’t even know they exist.

They’re like, yeah, this person gets his TB test and flu shot and antibody titers done on time.

There’s this other PA. Well, we had him on suspension for a week because he wouldn’t get a TB test. And you’re the boss, and it’s time for her yearly evaluation. Whom do you want to give the raise to?

Yeah, let that bounce around in your head for a second.

Whom do you want to give the raise to? The person that medical staff has no idea that even exists in the department because they’re getting everything done on time or a PA that they had to put on suspension for ten days?

Now, do you get it, guys?

You see, I hate to say this, but getting along with the medical staff is not only the way to preserve your job. But it’s also the way to make more money.

Because when it’s time for that yearly evaluation, your boss is going to look at you like, “Hey, you show up to work on time, you get along with the nurses, and you get along with the medical staff.” They want to keep you.

That’s when you can turn the screw and say, okay, well, to keep me, I would like $10 more an hour, or more vacation time or whatever it is that you’re trying to angle at. That’s how this works, folks.

I get these new grads who get out of school. They tell their supervising physician that they want to make $80 an hour, right? And let’s just say the going rate is $65. And the doc will say, well, wait a sec, you know, I start new PAs off at $65. They’re going to go well; I’m a recent grad, and I deserve this. I deserve that. Or I went to some fancy, dancy school.

Now, can you understand that at the end of the day, your boss does not care where you went to school? It means absolutely nothing. That’s just a piece of paper. What’s going to mean everything to your boss?

Can you see 20 patients, not kill anybody, get along with the nurses, get along with the staff? And most importantly, doesn’t get on the medical staff’s radar.

This is about your reputation.

You want to be the PA that medical staff doesn’t even know exist.

You’re like, so when does this girl get her TB or guy get a TB test, always on time, gets his flu shot on time gets his antibodies done on time. I don’t even know his DEA numbers expire because he turns it in on time. That’s who you want to be.

So never, ever, ever get on medical staff’s radar.

I am going to give you a little inside story. I got an email. This was about nine o’clock in the morning. I got an email from medical staff, and they wanted antibody titers. They’re like, “you know, hey, Joe, we need your antibody titer, Hep B titer, measles titer, and chickenpox titer.”

So that was nine o’clock in the morning. I was in the walk-in clinic at noon, getting my antibodies, titer tests. And then the lady looked at goes I said, Yeah, there’s something about a DPT shot, and she goes, you know, our records down, we can’t pick them up. I said, just give them to give it to me. And lo and behold, they did my antibody titer. And they gave me a DPT shot. And believe it or not, guess who got two DPT shots last year? Yeah, that’s me.

The medical staff emailed me back that afternoon. I emailed them back within four hours. Everything’s been done. And they emailed me back saying, “Hey, thank you for getting things done so expeditiously.”

Does everybody understand my boss is looking at me like the medical staff doesn’t even know you exist? They’re kind of worried because you got two DPT shots. I’m like, you know, I got twice the amount of antibodies. I’m not really worried about it.

So now, at the end of the day, this is what I want to share with you. Don’t ever get on the radar. They want something – you get it done. Right. Now, if you do that, guys, he’ll do great.

How to be a Better PA with Administrators

So now the next group we need people we need to talk about is the administrators.

So, when the administrators come downstairs to your hospital, urgent care, walk-in clinics, surgery center, wherever it is, be polite, and be cordial. Be respectful to them. Say hey, it’s great to see you, how have you been you know, it’s you know, I hope all is well with you and sounds great.

So, if you’re cordial and polite with them and respectful, they’ll remember you. And then when that yearly evaluation comes up, the administrator can go to your boss (who’s your boss’s boss), and they go, hey, you know, I met one of your PAs the day ago, great guy. Very nice. He was very polite and very cordial, and very respectful to me. You’ve got a good kid on board.

And now your boss is going to go, “wait a second. I need to keep this new grad, maybe young pa, on board. That’s what you want to do.

So, in other words, be polite, be cordial. Be respectful to your administrators, and remember, they’re the ones that make policies.

I think it is kind of funny that everyone argues so much about who’s in charge of making policies. At the end of the day, guys, it all boils down to policies. That’s what you must play under.

These are the rules. They’re not the referees. You must play by these rules. You can get mad at the referee, but he’s just enforcing the rule.

So, think of administrators as the person who is just enforcing the policy. So, when you see the administrators, be polite, be cordial, be respectful.

How to be a Better PA with Supervisors

The last group of people that we need to be aware of is our supervisors. So, whether this is a nursing supervisor, PA supervisor, or physician supervisor, they are your supervisor. And I keep telling everybody this again: be respectful, kind, cordial, and very workable.

You want to be the PA that everyone wants to work with. You want to be the PA that when you walk into the OR suite, or you walk into the clinic, or you walk into the surgery center or walk into, you know, medical office or you walk into the ER, you’re going to be that PA.

“Oh my gosh, it’s going to be a great day. Look who’s here.” So, when the nursing supervisor comes up and asks you a question, again, be polite, cordial, and respectful. The same thing with your peers. Most people have a PA supervisor, right?

Just be polite and cordial with them. Your MD supervisors, you want to be that pa that does everything?

No, listen to me. You see, you want to be the PA that the MD is like, oh, god, this person’s work with me today!

I know they’ll pick up the extra patients. They’ll pick up the pace. They’ll do better in the OR. They’re much more respectful. They’re much more cordial. This is the person I want to work with, that guy or that like that girl, that’s who I want to work with, it’s them.

And this is what you need. Because you see at the end of the day, guys, what I’m really trying to share with you. And I’m trying to tie this all in with you. This is about reputation.

You see, guys, at the end of the day, no one cares where you went to school. I mean, I know it’s a congratulation from whatever university or PA program you graduate from. Congratulations.

Okay. But no one cares. No one will care about your GPA. No one will care about your PANCE or your PANRE score. They’ll mean absolutely zero.

What will mean everything, your reputation?

What kind of person is this individual like to work with? Are they good? Are they bad? Do they get along with the staff? Do they get along with medical staff? Do they get along with the administrators? Do they get along with the supervisors?

That’s what’s going to count, folks. Because at the end of the day, let’s just say you leave your job and go to the next job. Who do you think they’re going to call?

Yeah, they’re going to call one of your supervisors. And what are they going to say? They’re not going to say where you went to school. They are not going to say what your GPA was, your PANCE or PANRE score was?

They’re going to say what kind of person you are to work with, which is based upon your reputation.

This is what I keep trying to hammer home is. So how does everyone understand where I’m trying to with this

In other words, the medical staff wants something. When am I getting it done? Now?

How am I going to be to the administrators when they come downstairs? I’m not going to be afraid of them. I’ll walk up to them and shake their hand. I’m polite cordial respectful.

My supervisors, what am I going to be? Polite, cordial, and respectful.

I’m going to be that workable PA? Hey, can you go see these extra four patients? Do you mind staying an hour later? I’d love to. I’d love to stay 10 hours later. Thank you. Can I have another?

That’s who you want to be. Not the person who is like, “well, I need to leave a half-hour early, and can I get my hour lunch? No, I want a two-hour lunch. You know, I just don’t feel like coming in today because I just I’m not feeling it. You know, my chakra’s not in line. You know, I’m just not feeling it.”

Yeah, this is not who you want to be. This is not who they want to hire.

They want the person they can rely upon. They want the person that they can trust the reputation on, and this is what I’m trying to share with you.

The Toxic Job

One other little piece here because I know many of you guys are going to ask this question. Hey, Joe. I’ve got this really toxic supervisor. I got this toxic nursing supervisor, I’ve got this toxic PA supervisor, or I got this toxic physician supervisor, so just say you’ve got a toxic person in your crew, right?

And trust me, I’ve been here, guys; I have Pandora’s box full of bad memories here. I just want to keep this box closed. So, I’m on your side here.

So, what do you do with the toxic nursing supervisor?

Two things. So, whether it be a toxic nursing supervisor toxic, physician assistant supervisor, toxic physician supervisor? So what do I do?

Okay, so this is the way you get out of this. This is how you thread the needle.

One, you go up to them directly. So, let’s just say you have a toxic nursing supervisor, right? So, you go up to whoever this nursing supervisor is and say, “listen, I find some of the things you inappropriate, I don’t find this working for the best interest of the department.”

And remember, that’s a buzz word, best interests of the department or the office, the surgery center, or the ER, this isn’t serving the best interests of our department.

“So, if you don’t mind, I would appreciate it, if you change your policy or attitude towards me or to the group of people.”

So, the first thing you do is you confront you lay down your complaint.

You also followed it up with an email.

Dear nurse supervisor or PA supervisor, or MD supervisor. The other day, we spoke about (x,y,x). Thank you for your time consideration. Sincerely, Joe.

You have verbally stated this to them. And now you have an email, which is very important.

Now, let’s say that they continue to be toxic. Now, what do you do?

Everybody has a boss. Now, you go to their boss’s boss, except this time, you’ve got documentation.

And you say, “so, I presented this to my nursing or physician supervisor, and this is what I presented to them, and they continue this behavior.”

I’ve been at some toxic jobs. I just look back, and I find it amazing that I ever survived. So, what do I recommend when people are in a toxic job?

You’ve completed the steps above. You’ve politely confronted them and verbalized this in an email, and you went to a higher source, and nothing got done.

So, when you leave this toxic job, how do you do it?

You be polite, be respectful, be cordial.

“This is my two-month resignation. Thank you for your time consideration.

You don’t even bring it up. You just exit.

Okay. So, can we all agree that most of us sleep 6-8 hours a day, which means we’re awake for 16, right? Eight to 10 hours is going to be at work.

My wife’s a writer. So, she’s off doing her writer stuff, right? I might see her for a couple of hours. I don’t see her that much.

But my nurses, are you kidding me? I see them eight to 10 hours a day. So, you see, the people you work with are your family. You’re going to spend more time with these people than your own family.

If you have a miserable family at work, you will take home a miserable attitude and then take it out against the people you love the most.

So, these toxic jobs that you sometimes get yourself into. Get out. Get out as soon as you can!

This will literally ruin your soul. And then you’ll take it home to the people you love the most.

“But I’m making so much money.”

I see this all the time; I hear this from all my students all the time.

“But Joe I was making such good money.”

One of the things you learn about life as you get older, it’s not always about money. I agree that money helps. It helps pay off your student loan, mortgage, car payments, bills, etc. I get it, I’ve got the same things.

But at the end of the day, I’m happy with the family I have in my ER. I get along great with everybody. I get along with the medical staff. I get along with the administrators, and I get along to supervisor. I get along with almost everybody. It’s my family.

And so now, when I come home, I’m not in a bad mood. I don’t have any toxic stew on me. So, I can spend time with my wife and my daughter, and my dogs. And I’m just Joe. Nothing came home with me.

Your Reputation Matters

And this is what I keep trying to share with you guys. This is how you develop a good, healthy reputation as a PA.

And now if you go to the next job, what’s your boss going to say?

Oh, this guy is great. Or this girl is great. I don’t want to give her up. She gets along with everybody. You’re the luckiest person in the world to get her. Get him.

That’s what you want to do.

So, listen, guys, it’s been enjoyable. I hope this podcast has helped you out. And this is podcast two or three. The third and the final podcast is getting ready to come up. And at that podcast. We’re going to wrap the first two podcasts up. And what are we going to talk about? Your reputation.

Take care, guys.

Joe Gilboy PA-C

The post How to Be a Better PA Part 2: Medical Staff, Administrators, and Supervisors appeared first on The Audio PANCE and PANRE.

Podcast Episode 87: Ten Internal Medicine EOR Questions

Mon, 14 Jun 2021 09:00:00 +0000

Welcome to episode 87 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.

Special from today’s episode:

Check out the updated Smarty PANCE Internal Medicine Rotation (EOR) Review Course
Download your Free Trello Smarty PANCE PAEA Internal Medicine EOR Tracking Template
Members can take the all-new Internal Medicine Rotation Practice Exam
View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List

Below you will find an interactive exam to complement the podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, Spotify, on Google Play Music or Stitcher.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

Listen Carefully Then Take The Practice Exam

If you can’t see the audio player click here to listen to the full episode.

Podcast Episode 87: Ten Internal Medicine EOR Pulmonology Questions

The following questions are linked to PAEA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member, you will be able to login and view this interactive video lesson.

1. A 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, mid abdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC. Which of the following is the most accurate test for this patient’s condition?

A Barium enema
B Colonoscopy
C CT scan
D. Sigmoidoscopy

Click here to see the answer

Answer: C CT scan

Diverticulitis presents with left lower quadrant abdominal pain, systemic symptoms (such as fever), nausea, vomiting, and leukocytosis on lab values. It typically occurs in a patient with a history of diverticulosis. The most accurate test for diverticulitis is a CT scan. Colonoscopy is contraindicated as it could cause rupture. Further management is keeping the patient NPO and administering ciprofloxacin, metronidazole, and IV fluids. Patients who can not tolerate oral antibiotics should be started on IV antibiotics. (Review topic: Diverticular disease)

Barium enema is contraindicated in diverticulitis as it could cause irritation. A barium enema is the most accurate test in diverticulosis.
Colonoscopy and sigmoidoscopy are contraindicated in diverticulitis as they could cause rupture. Colonoscopy is an accurate test for diverticulosis.

2. A 42-year-old homeless man presents to the emergency department with fever, painful muscle spasms in his arms and legs, and difficulty eating because of painful spasms in his jaw muscles. Until a week ago, he was wandering around the city looking for food and work and taking shelter in a commercial construction site. He reports not having seen a medical professional in more than 15 years. Examination of his feet reveals shoes with holes in the soles and a small, puncture-type wound on the bottom of the right foot. It is surrounded by erythema and somewhat tender to touch. The patient is uncertain what he may have stepped on. X-ray is negative for any radiopaque foreign body. In addition to hospital admission, which of the following is the first-line therapy for this patient?

A Tetanus immune globulin and tetanus toxoid
B Tetanus immune globulin and metronidazole
C Tetanus toxoid and penicillin
D Tetanus immune globulin, tetanus toxoid, and metronidazole

Click here to see the answer

The answer is D Tetanus immune globulin, tetanus toxoid, and metronidazole

Clostridium tetani infection is a vaccine-preventable disease that results in approximately 50 cases per year in the United States. Even with modern medical resources, 20% to 25% of patients with generalized tetanus die. Treatment includes airway protection, benzodiazepines for muscle spasm, tetanus immune globulin immediately, and three doses of tetanus toxoid given by the standard schedule. Metronidazole or penicillin is also administered to destroy the organism and prevent toxin production. (Review topic: Tetanus)

3. A 21-year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with an absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step?

A Order a V/Q scan
B Order a chest x-ray
C Administer a sclerosing agent
D Insert a large-bore needle into the left 2nd ICS stat

Click here to see the answer

The answer is D Insert a large-bore needle into the left 2nd ICS stat

Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted. (Review topic: Pneumothorax)

A V/Q scan is indicated in suspected cases of pulmonary embolism.
Patients in respiratory distress and evidence of a tension pneumothorax, such as tracheal deviation, should have treatment initiated without waiting on a chest x-ray to be taken.
Pleurodesis by the administration of a sclerosing agent is indicated in the treatment of recurrent, not traumatic, pneumothorax.

4. A 55-year-old woman with a history of ulcerative colitis presents to the emergency department with a severe flare. The patient reports numerous bloody loose stools and has been febrile for two days. Vital signs are T 102.0 HR 98 BP 131/86 RR 17 Sat 100%. The abdominal exam is notable for markedly distended abdomen with tympani and tenderness to palpation without guarding or rebound. A CT scan shows a markedly dilated descending and sigmoid colon with no perforations. What is the next best step in management for this patient?

A Oral prednisone
B IV hydrocortisone
C Rectal 5-ASA
D IV Metoclopramide
E IV Ondansetron

Click here to see the answer

The answer is B IV hydrocortisone

This patient is presenting with toxic megacolon secondary to ulcerative colitis (UC). The first-line treatment for patients with toxic megacolon from UC is IV glucocorticoids to reduce inflammation and the need for surgical intervention. (Review topic: Ulcerative colitis)

Oral prednisone is not appropriate, as patients with toxic megacolon require NGT suction and NPO.
While rectal 5-ASA is a treatment option for moderate colitis, but this patient has severe colitis.
Metoclopramide is a Dopamine-2 receptor antagonist used as a prokinetic agent in individuals with a variety of gastric motility diseases. It is also an antiemetic (via 5-HT3 antagonist activity) and has further prokinetic activity by acting as an agonist on 5-HT4 receptors.
Ondansetron is a Serotonin-3 receptor antagonist used as an antiemetic in patients with postoperative nausea or nausea due to chemotherapy.

5. A 21-year-old male with hematemesis. He is brought by his girlfriend who reports that he and his buddies have been out drinking every night last week in celebration of his 21st birthday. He reports having vomited each night, but tonight when he started vomiting, he noticed that there was streaking of blood. Concerned, he decided to come to the emergency department. Which of the following best describes the most likely diagnosis?

A Dilated submucosal esophageal veins
B Gastric mucosal erosion
C Mucosal tear at the gastroesophageal junction
D Transmural distal esophagus tear
E Transmural erosion of the gastric wall

Click here to see the answer

The answer is C Mucosal tear at the gastroesophageal junction

This patient is presenting with blood in his vomitus after forceful vomiting suggesting a diagnosis of a Mallory-Weiss tear. A Mallory-Weiss tear occurs secondary to a mucosal laceration at the gastroesophageal junction. (Review topic: Mallory-Weiss tear)

Dilated submucosal esophageal veins describes esophageal varices. Though variceal bleeds could lead to bloody vomitus, this is a less likely diagnosis given this patient’s young age and lack of a past medical history of cirrhosis. There is no mention of ascites in the case and the normal PT/PTT suggests against a diagnosis of cirrhosis.
Gastric mucosal erosion can occur due to decreased prostaglandin production which occurs in gastritis and peptic ulcer disease and presents with gnawing/burning epigastric pain, and can be associated with nausea and vomiting. This can occur with NSAID use or with alcohol abuse.
Transmural distal esophagus tear describes Boerhaave syndrome which presents after violent retching with similar symptoms to a Mallory-Weiss tear but with the additional findings of subcutaneous emphysema and odynophagia. This is a surgical emergency and is a progression from a simple Mallory-Weiss tear which presents with only bleeding.
Transmural erosion of the gastric wall describes a perforated gastric ulcer which can cause bleeding from the left gastric artery, epigastric pain, and unstable vitals. It is less likely to present after violent vomiting. A perforated peptic ulcer could present with severe abdominal pain and free air under the diaphragm.

6. A 25-year old female presents to the clinic with an 8-month history of intermittent crampy lower abdominal pain, with the passage of loose stools 4 times a day. Pain is usually worse during her menstrual period and is relieved by defecation. She also feels bloated. She says she has been undergoing work-related stress for months. There are no ALARM symptoms and there are no significant findings on physical examination. Which of the following is associated with this patient’s condition?

A Alvarado score
B Ranson criteria
C Rome criteria
D Revised Jones criteria

Click here to see the answer

The answer is C Rome criteria

The diagnosis of IBS can be made using the Rome criteria if patients have no red flag findings, such as rectal bleeding, weight loss, and fever, or other findings that might suggest another etiology. Patients with one of these red flag findings require further imaging studies and/or colonoscopy. (Review topic: Irritable bowel syndrome)

The Alvarado score is used in making a diagnosis of acute appendicitis
Ranson criteria Are used in assessing the severity of acute pancreatitis
Revised Jones criteria are used in diagnosing rheumatic fever

7. A 56-year-old woman came to the clinic complaining of a lump protruding from her anal opening. It was initially reducible, but it now irreducible. There is associated pain and itching. She also noticed bright red blood on her stool when she defecates. There is an associated history of chronic constipation. Examination of the perianal area revealed skin tags and a tender perianal mass covered with mucosa. Inspection of the anal mucosa showed no fissure. What is the grade of the condition?

A Grade I
B Grade II
C Grade III
D Grade IV

Click here to see the answer

Answer: D Grade IV

This is a Grade IV permanently prolapsed hemorrhoid. (Review topic: Hemorrhoids)

Incorrect Answers:

Grade I is bleed only no prolapse
Grade II is prolapsed but reduces spontaneously
Grade III is prolapsed and has to be manually reduced

8. A 45-year-old male presents with complaints of heartburn, belching, and epigastric pain for the past six months. He reports that symptoms occur within an hour of eating a meal and are aggravated by drinking coffee, eating fatty foods, and lying down. He has tried eating smaller meals and avoiding spicy food to no avail. He denies vomiting, difficulty swallowing, recent weight loss, or changes in stool color. His temperature is 98.9 °F, blood pressure is 147/82 mmHg, pulse is 86/min, respirations are 18/min, and BMI is 32 kg/m^2. His abdomen is soft, non-tender, and bowel sounds are auscultated in all quadrants. His laboratories are unremarkable and his fecal occult blood test (FOBT) is negative. What is the next best step in this patient’s management?

A 24-hour pH monitoring
B Endoscopy
C Metoclopramide
D Ranitidine
E. Omeprazole

Click here to see the answer

The answer is E. Omeprazole

GERD is a common complaint at primary care offices. It classically presents with heartburn, epigastric pain, and a sour taste that occurs within an hour of consuming a meal. PPIs are the initial medical management, except in the case of alarm symptoms. Any patient with symptoms of GERD accompanied by dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50 should undergo endoscopy as these are considered high risk for the presence of an upper gastrointestinal malignancy. (Review topic: Gastroesophageal reflux disease)

Incorrect answers

24-hour pH monitoring is considered the gold standard in the diagnosis of GERD. However GERD can usually be diagnosed clinically, and 24-hour pH monitoring should only be employed in order to confirm the diagnosis in atypical presentations or in patients refractory to PPI therapy
Endoscopy for GERD is indicated if patients have alarm symptoms. This patient is under the age of 50 and lacks alarm symptoms; therefore, endoscopy is not indicated.
Metoclopramide is a prokinetic agent that is often used to treat gastroparesis. While it has utility in managing GERD, it is not a first-line medical agent.
Ranitidine is a histamine-2 receptor antagonist that is indicated if patients have failed PPI therapy. Ranitidine products were found to be contaminated with NDMA, a probable human carcinogen that may be linked to many types of cancer, including bladder cancer, colon cancer, and prostate cancer.

9. A 65-year old man who is being managed for lung cancer on the ward makes a complaint of a 2-day history of the passage of nonbloody watery stool up to 4 times per day, anorexia, cramping abdominal pain, and fever. Meanwhile, he had a 10-day course of antibiotics 4 weeks ago on account of a lung infection. Which of the following is the most likely cause of his diarrhea:

A Salmonella
B Rotavirus
C Clostridium difficile
D E. coli

Click here to see the answer

The answer is C Clostridium difficile

Clostridium difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C. difficile, and the release of toxins that cause mucosal inflammation. Antibiotic therapy is the key factor that alters the colonic flora. (Review topic: Gastroenteritis)

Incorrect answers

Salmonella is a cause of diarrhea following food poisoning.
Rotavirus is a common cause of diarrhea in children. Less common in adults. Doesn’t occur as a result of recent use of antibiotics.
E. coli is a cause of diarrhea following food poisoning.

10. A 37-year-old male with a history of daily NSAID use complains of epigastric pain, nausea, and vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day. He was prescribed a course of ranitidine followed by omeprazole after his symptoms did not resolve. He was referred for endoscopy, with findings consistent with a gastric ulcer. Biopsy with silver staining is positive for H-Pylori. Which of the following is the most effective regimen for the treatment of this condition?

A Omeprazole, metronidazole, tetracycline, bismuth
B Omeprazole, penicillin, famotidine
C Amoxicillin, clarithromycin
D Pantoprazole and levofloxacin
E Pantoprazole

Click here to see the answer

The answer is C. Omeprazole, metronidazole, tetracycline, bismuth

This patient presents with H. pylori gastritis complicated by a peptic ulcer. Treatment for H. pylori is with triple or quadruple therapy. Omeprazole, metronidazole, tetracycline, and bismuth are appropriate quadruple therapy. (Review topic: Esophagitis)

Incorrect answers

Omeprazole, penicillin, famotidine is not a treatment regimen for H. pylori infection
Although amoxicillin and clarithromycin is an appropriate antibiotic regimen, this combination requires a PPI such as omeprazole
Pantoprazole and levofloxacin are not a treatment regimen for H. pylori; the combination requires the addition of amoxicillin for effective triple therapy.

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Podcast Episode 86 – How to Be a Better PA Part 1: Nurses, Lab Techs, and X-Ray Technicians

Mon, 09 Nov 2020 13:00:00 +0000

This is part one of a special three-part podcast series by Joe Gilboy PA-C on becoming a better PA.

Part one is all about building amazing relationships with our nurses and ancillary staff.

You may be thinking to yourself, “Hey Stephen, I thought this podcast was about the PANCE and PANRE.” “How does talking about nurses and ancillary make me a better PA or help me pass my boards?”

If you asked this question, then you have come to the right place.

Because as anybody who has ever worked as part of a healthcare team can tell you, the key to your success as a PA has little to do with you and a lot more to do with how you treat other people.

So how do you become a better PA?

Let’s jump right into this unique episode of The Audio PANCE and PANRE Podcast. You can listen to the podcast below and read the summarized (and edited version) of the transcript or listen in your podcast player of choice.

The Audio PANE/PANRE Podcast Episode 86: How to be a Better PA (Part 1 of 3)

You can also click here to listen to or download this episode.

Episode Transcript and Summary

This episode was recorded by Joe Gilboy PA-C and edited for clarity and readability by Stephen Pasquini PA-C.

I’ve been a PA in the emergency department for 35 years. And you can imagine, I’ve had a lot of interaction with nurses and ancillary staff. I want to pass on some wisdom and guidelines to help you deal with the nurses and ancillary staff.

This will help you become the best PA you can become and help you immensely in your career and, most importantly, with your reputation.

Become Best Friends with the Nurses

The first group of people we’re going to talk about is the nurses. And this is a big one, folks, my God, how big is this!

So, to all my new graduates out there, I really need you to listen to me, stop what you’re doing, and let this bounce around in your head for a second. As a new graduate, your nurses will know more than you. That’s right, you heard me, they will know more than you.

So, let’s say you’re working at an urgent care family practice clinic or working in a neurology clinic. There you are seeing your patients, and the nurse will know more than you on how this patient needs to be worked up, which labs or imaging tests to order, and what the doctor likes.

So, what I always tell my new graduates to do, and what you need to do, is become best friends with the nurses because sometimes (a lot of times), they’re going to know more than you!

As time goes on and as you become more experienced and more seasoned, yes, you will know more than the nurses, which is just a byproduct of time and experience. I can’t fast forward time, but I can tell you that the nurses will know more than you initially, so follow them.

They’re going to point you in the right direction. They will say, “Hey, you know Dr. Smith likes it this way, or Dr. Jones likes it that way or, whoever the person that you’re working with, this is how I like to work with them” Follow them, and if they like you, they will lead you in the right direction.

Make the Nurses Part of Your Team

The second thing you need to understand about the nurses is that they like to be part of the team. They like to feel like they’re part of the team and know that you recognize their experience and expertise when working up the patient.

The worst thing you can ever say to a nurse is this: “I’m the PA; you’re the nurse; you must do what I say.”

As soon as you say this, there are two things you should do:

Sign your organ donation card
Pick up the phone and call The Legacy Group, you know, that’s the organ donation team that we have here in California, and they’re going to come and harvest your organs, and you will be dead.

And that’s what’s going to happen. Don’t ever say that to the nurses!

What should you say instead?

Ask for Input from the Nurses

What you should say to the nurses goes something like this: “hey, so what’s your input?”

It’s that easy!

Honor Input from the Nurses

There will come a time, and it’s going to happen to you, where the nurse is going to want to order something that you may not 100% agree with. What should you do then?

If it’s not doing any harm to the patient or it is something that’s no far outside the standard of care, your interaction should go something like this: “Okay, I see your point, I agree with you, let’s add this lab test (or this other study) that we may want to do.”

Now let’s say the recommendation made by the nurse is way outside the standard of care. For example, let’s say you have someone with an ankle sprain and your nurse wants to order a CAT scan of the head. And you’re like, “okay, this is not going to work out well.”

So now, at that point, what’s the best way to disagree with nurses, but do it politely?

You can say this: “I hear you loud and clear. However, I think that what’s going to serve our patient best is not a CT of his head, but let’s x-ray his ankle.”

“I hear you!” This is the magic word. This is what they need to know: That you hear them, you respect them, and that they are part of the team.

Embrace “The Doughnut Theory”

The doughnut theory works like this: You bring doughnuts to your clinic or hospital department once a week, then watch what happens!

That $7 worth of doughnuts is going to change everything!

The nurses are going to be like, “who brought the doughnuts?” “Oh look, you know the new PA Allison over here she brought the doughnuts, and we love Alison.”

Suddenly, PA Allison is a superstar! Like, oh my gosh, we love Alison! And every Wednesday, they’re going to be looking at the door like, hey, did Alison bring the doughnuts?

Feed the nurses! I know this sounds crazy, but feed your nurses, and they will love you!

Another thing that you should bring the nurses once a month is pizza. I know this sounds crazy. Again, you’re like, what’s Joe talking about? But trust me when I tell you that you should buy the staff pizza once a month. Pizza is a universal food. I even think aliens from other galaxies like pizza!

We are Family . . . All the Nurses, MAs, and Me!

The nurses need to feel like you are part of the community. You’re part of the family. Because what this is about is family.

They did a recent study in the ER about how much time we spend with the nurses. Do you realize that I spend more time with my nurses than I do with my wife?

This is a well-documented fact. Because anybody who’s been married knows what I’m talking about. When you come home, what’s going on? You’re doing this, and your spouse’s doing that. They’re picking up the kids, and you’re going to Costco. You’re over here, and they’re over there.

But to have quality time with your spouse? That’s exceedingly rare!

How many times are you two feet from your nurse? Discussing issues? My nurse is my spouse!

I tell everybody I have twenty-seven work spouses at my job. I’ll be talking to my wife on my cell phone, and the nurses show up, I will hang up on my wife to talk to the nurse.

Their Opinion Matters

At the end of the year, when you show up for that evaluation with your boss, do you know who she’s talking to? Yes, that’s right, the nurses!

Your supervisor will ask, “So what’s Allison like to work with?”

And if you have implemented the above tactics correctly, the nurses go, “Man, we love Allison! she brings doughnuts, she brings pizza, she talks to us very respectfully, if we disagree, she’ll listen and talk to us.”

You need to treat them with respect and treat them like family members. Because that’s what they are. If you feed them, treat them like family, and treat them with respect. Oh, wow. Watch what happens.

Your nurses will look at you like, “Oh, man, Allison’s here today!” And this is what you want to be the PA that everybody’s excited to see when you walk through the clinic door, the OR door, the emergency room door, the urgent care, or wherever it is that you’re working. It’s like, “Oh, my gosh, Alison’s here today.” “All right, this is a great shift!” And when you showed up, you brought doughnuts.

And that is the sweet spot. That is where your reputation really starts to grow.

When you apply to a new job, what do they always ask for? Your background and experience! And when they call your boss, it’s about your reputation.

One of the questions they always ask is, “What is Allison like?” “Oh, Allison’s great, and the nurses love her!” And that is a slam dunk! Once they hear that, their next thought is, “Oh, wow, we want this person!”

Think about it for a second. Really pull back and give this some thought. Imagine you’re a physician hiring a PA. Imagine that the other previous employer tells you, “Well, you know, he’s had some run-ins with the nurses.” And then you call the other applicant who’s applying for the same job, and their supervisor is like, “Oh, he’s great, and the nurses love him.” Which PA are you going to hire?

Exactly, the one that has a good relationship with the nurses!

What I’m really trying to encapsulate here is this:

Always be respectful to the nurses.
Understand that sometimes the nurses will know more than you, and that’s OK.
Feed the nurses doughnuts and pizza
Treat them like a family member – like your mom, dad, brother, or sister.

And you will see how well this works! Make no mistake, in my 35 years as an ER PA, I’ve seen so many PhDs who’ve been disrespectful to nurses, and what has happened to them? It’s not good!

Remember, at the end of the year, this is what your boss is looking at. And then if you have a good relationship with the nurses, guess who gets to ask for more money? That would be you. And guess whose reputation just grew? That would be you.

Love Your Lab Techs

The next group of people you need to be nice to and get to know very well are your lab techs.

As you go through your PA career, make sure you become very friendly and are exceedingly kind to your lab techs. Let me tell you why.

The lab techs have an important job that often goes unseen. They come, they draw the blood, do the cultures, etc. etc. They do much of their work behind the scenes. You don’t see it. You see the results.

When you’re nice to the lab techs, and you treat them with love and respect, one of these days, you’re going to have trouble ordering a specific test. There you are poking around your EMR, maybe you are in Epic, and you can’t figure out what to order.

Then lo and behold, you call the lab to ask their advice, and they’re going to say, “Hey, you know, this is Allison. And we’re good friends with Allison, and she’s nice to us, right?”

Then suddenly, when you call down to the lab and say, “Hey, guys, how do you put in the order for this specific test?” And what’s going to happen? They’ll walk you right through it, and they’re going, “Hey, no problem, we’ll take care of it!” “And you know what, Allison, we’ll put in the order for you? No big deal.”

When you are friendly with the lab techs, they’ll draw extra tubes of blood, saying, “Hey, you know, just in case Allison forgot to ask to order this, we’ll have it done for her.”

Or say you’re working at a family practice clinic, a neurology clinic, or an OBGYN clinic. And there you are, it’s 4:30 in the afternoon, and you want to get off at five. You just sent down a urinalysis and a pregnancy test, which usually takes about 45 minutes to an hour to result.

And there you are, waiting to meet friends at 5:20, and it’s 4:30 pm, and you are thinking, “How am I going to get this done?”

Well, if you’re friendly with the lab techs, and you call down and say, “Hey guys, is there any way we can rush this pregnancy test and urinalysis?” And they say, “Oh, for you, Allison, anything!”

And there it is!

So, in other words, they will help you get things done on time and make you a better PA.

The lab techs are some of the most important people you’ll meet in the hospital, not hospital administrators.

So, as you go through your PA career, get to know your lab techs. Be friendly with them, get to know their first names, and take time to understand how they do things.

X-Ray Technicians

The last group of people we’re going to talk about is our X-ray department, including our X-ray techs, our ultrasound techs, CT techs, and even the radiologists.

When you’re working your patients up, you must wait for your labs, you must wait for your nurses to do their work, and then you’re waiting for the X-ray tech or CT tech, or the ultrasound tech to get that imaging study done. And what I’ve learned in my 35 years is that the radiology department can slow you up the most.

I agree; sometimes, the lab can slow you up. But what you’ll find out nine times out of ten, when you get to the end of the day, what was really the thing that took the longest? Your radiology imaging test.

So please get to know your X-ray techs or your CT techs, and get to know the girls or the guys in the ultrasound department, get to know them on a first-name basis.

Because soon, the day will come that you’re working in the ER, the urgent care, family practice, or in the surgical suite, and you need the X-ray tech to come and perform a chest X-ray or bring in the CRM fluoroscope. You need this done quickly because you’re in a rush, or the patient is in critical condition.

Or maybe you’re reducing a fracture, and you want to see what the post-reduction looks like before you even put in the splint.

This is when knowing the folks in the radiology department are going to serve your best interests.

So, let’s say you’re ordering a post-reduction study on a wrist fracture. So, there you are, you have reduced the fracture, and before you place the patient in the splint, you need the post-reduction study.

Now, since I’m good friends with the X-ray techs, I can give them a call and say, “Hey can you guys come over here and take a post-reduction x-ray really quick?”

And they’re going to be like, “No problem, Allison, we’ll come over and take it because it’s you, you’re the one that’s nice to us, don’t worry, we’ll put the order in for you.”

And then everything goes nice and smooth.

One of these days, it will be 4:30 in the afternoon, and you’ve got a patient with a finger fracture. Your patient is the fifth one in the row, which means you’ll be there for the next hour.

But you’ve got to go to your kid’s soccer game in an hour. And now you’re like, “Man, I wish there’s some way I could get this x-ray done quickly.” This is when knowing the x-ray techs becomes valuable.

Be Nice to Everybody

Be nice to everybody!

This entire podcast episode is about building your reputation. This is about you as a PA. If you follow this advice, your colleagues will start viewing you as the nice PA that’s always respectful, knows everyone by their first name, and is always polite. And as a byproduct, everyone will be more than happy to do something nice for you.

It’s a human behavior thing; it’s not a medical thing; it’s a human thing. When human beings are nice to you, you’re more likely to be nice back and do favors for them in return.

That’s exactly what this boils down to. And I’m trying to make your job more efficient. Most importantly, I’m trying to get you to work on a better reputation, and this is what’s going to carry the most weight because every job you apply for, what do they ask for? Your references!

And what are they going to do? They’re going to call your previous employers. What is their conversation going to be based upon? It will have nothing to do with where you went to PA school. It will have absolutely nothing to do with your PANCE scores. It’ll have everything to do with your reputation.

Podcast two, which is coming up next, will be all about medical staff, administrators, and office managers and how to handle them. And that one is a big one, folks. So be your best, do your best. And try to build a great relationship with everybody you work with!

I’ll see you soon for podcast number two.

– Joe Gilboy PA-C

The post Podcast Episode 86 – How to Be a Better PA Part 1: Nurses, Lab Techs, and X-Ray Technicians appeared first on The Audio PANCE and PANRE.

Podcast Episode 85: Ten Mixed Multiple Choice PANCE and PANRE Board Review Questions

Mon, 14 Sep 2020 14:49:26 +0000

Welcome to episode 85 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten PANCE and PANRE Board review questions from the SMARTYPANCE course content following the NCCPA content blueprint (download the FREE cheat sheet).

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This week we will be covering ten general board review questions based on the NCCPA PANCE and PANRE Content Blueprints.

Below you will find an interactive exam to complement the podcast.

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Podcast Episode 85: Ten MIXED PANCE and PANRE Board Review Questions

The following questions are linked to NCCPA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member, you will be able to log in and view this interactive video lesson.

1. A 14-hour-old boy has failed to pass stool and is vomiting greenish fluid. He was born at 40 weeks gestation with no complications during delivery or pregnancy. His temperature is 97.6°F (36.4°C), blood pressure is 64/34 mmHg, pulse is 140/min, respirations are 33/min, and oxygen saturation is 98% on room air. The child is currently breastfeeding and appears irritable. Physical exam is notable for a distended and non-tender abdomen. The rectal exam is unremarkable. An abdominal radiograph demonstrates distended loops of bowel. What is the most likely diagnosis?

Cystic fibrosis
Hirschsprung disease
Jejunal atresia
Pyloric stenosis
Tracheoesophageal fistula

Click here to see the answer

Answer: A. Cystic fibrosis

Cystic fibrosis (CF) commonly presents with meconium ileus, characterized by bilious vomiting, distended loops of bowel on radiography, and failure to pass meconium. CF is an autosomal recessive disease and is common in Caucasians. Neonates with CF commonly present with failure to thrive, respiratory compromise, and meconium ileus. In meconium ileus, abnormally thick meconium results in bowel obstruction, perforation, or volvulus. CF is diagnosed by the sweat chloride test or genetic testing. Radiography in ileus can demonstrate distended loops of bowel from the obstruction.

Hirschsprung disease would present with abdominal pain with chronic constipation. There would be an absence of stool in the rectal vault on rectal exam and a positive squirt sign on physical exam (expulsion of stool/flatus on rectal exam).
Jejunal atresia is characterized by the “triple bubble” sign on abdominal radiographs as well as bilious vomiting.
Pyloric stenosis presents with non-bilious and projectile vomiting with a palpable mass on abdominal exam. This diagnosis can be confirmed with an ultrasound. The patient should first be rehydrated and have their electrolytes repleted prior to imaging.
Tracheoesophageal fistula presents with coughing and choking with feeding. This breastfeeding and asymptomatic child in terms of his respiratory status suggests against this.

Review NCCPA Blueprint Topic: Cystic fibrosis

2. A 34-year-old female presents to her ophthalmologist with 6 hours of blurry vision in her right eye. She reports severe pain with eye movement that has not been relieved with NSAIDs. She feels that she has been generally healthy all her life, although she does note one week of right arm weakness during the previous year that resolved without treatment. On exam, she has no noted ocular secretions. On her fundal exam, you note blurred borders on the optic disc. Which of the following additional findings is likely to be present in this patient?

Polycythemia
Elevated IgG in the cerebrospinal fluid (CSF)
Multiple areas of periventricular hyperintensity on T2 FLAIR imaging
Subdural hematoma
Small, punctate hypointensities on gradient-echo MR

Click here to see the answer

The answer is B. Elevated IgG in the cerebrospinal fluid (CSF)

This patient’s clinical presentation is consistent with multiple sclerosis (MS), which is associated with an elevated IgG in the CSF.

MS is associated with oligoclonal bands on CSF evaluation in 80% of cases. The bands result from IgG overproduction, likely as a result of the autoimmune processes that occur in MS. Patients with MS frequently present first with symptoms of optic neuritis, which include loss of vision or blurry vision (usually unilateral), with severe pain with eye movement. The prognosis of MS differs drastically from patient to patient, but most commonly has a relapsing-remitting course.

Incorrect Answers:

Mononuclear pleocytosis, not polycythemia, is associated with MS.
MS plaque is hyperintense, not hypointense, on T2 FLAIR.
MS is not associated with subdural hematomas. In addition, a subdural hematoma would be unusual in this young patient without a history of trauma.
Small, punctate hypointensities on gradient-echo MRI is typical of diffuse axonal injury, which would be unlikely in this patient without a history of trauma.

Review NCCPA Blueprint Topic: Multiple sclerosis (ReelDx + Lecture)

3. A 43-year-old man is brought to the emergency department after having a seizure. His wife states that the patient has been struggling with alcohol abuse and has recently decided to “quit once and for all”. Physical exam is notable for a malnourished patient responsive to verbal stimuli. He has moderate extremity weakness, occasional palpitations, and brisk deep tendon reflexes (DTRs). EKG demonstrates normal sinus rhythm and a prolonged QT interval. What nutritional deficiency most likely contributed to these findings?

Potassium
Calcium
Folate
Magnesium
Vitamin D

Click here to see the answer

The answer is D. Magnesium

This patient in this vignette demonstrates a constellation of findings related to the complications of hypomagnesemia. Although alcohol withdrawal may present with seizures, the constellation of brisk DTRs, weakness, and prolonged QT suggest hypomagnesemia. The treatment for this patient will be multi-faceted, with magnesium repletion a necessity.

Hypomagnesemia (<1.5 mg/dL) is a potentially serious condition that may be difficult to recognize due to non-specific manifestations. Mild signs of hypomagnesemia include: generalized weakness, fatigue, nausea and vomiting. As deficiency progresses patients may complain of numbness, cramping, and dysphagia. Physical exam findings may reveal increased DTRs and fasciculations. If hypomagnesemia is acute in onset and/or severe, patients may develop altered mental status, seizures, or cardiac conduction abnormalities. Low magnesium levels also have the potential to affect other electrolyte levels. In patients with hypomagnesemia it is not uncommon to see hypokalemia (K+ conductance changes increasing renal losses) and hypocalcemia (due to PTH resistance).

Incorrect Answers:

This patient is likely hypokalemic secondary to hypomagnesemia. In fact, hypokalemia may contribute to the EKG findings. If the patient is solely hypokalemic, without any other electrolyte disturbances, DTRs will be decreased rather than increased.
A patient with hypocalcemia may present in the same fashion as this patient (altered mental status, seizures, increased DTRs, and prolonged QT). While hypomagnesemia can lead to hypocalcemia, it is important to understand that a deficiency in magnesium itself can independently cause neuromuscular abnormalities. Seeing as this patient is malnourished and a chronic alcoholic, magnesium deficiency is the likely etiology.
Folate deficiency is common in chronic alcoholics. It typically presents with macrocytic anemia without neurological complications
Vitamin D deficiency is often asymptomatic but may present with signs of osteomalacia in adults and rickets in children.

Review NCCPA Blueprint Topic: Fluid and Electrolyte Disorders (PEARLS)

4. A 17-year-old female presents to her physician’s office after noticing a round lump in her left breast 2 months ago. She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses. It is otherwise painless, and the patient denies any discharge or skin changes. She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast. The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use. On exam, the breasts appear symmetric and normal. A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast. There is slight tenderness to deep palpation of the mass. There is no axillary lymphadenopathy on either side. Which of the following is the most likely outcome of this patient’s condition?

This mass will likely require excision
This mass will decrease in size if the patient starts oral contraceptives
This mass slightly increases this patient’s risk of breast cancer in the future
This mass will most likely decrease in size or disappear over time
If this mass grows rapidly to greater than 5 cm, radiation and chemotherapy are indicated

Click here to see the answer

The answer is D. This mass will most likely decrease in size or disappear over time

This patient is a young female with a round, mobile mass that seems to respond to hormonal fluctuations, most likely a fibroadenoma, a benign mass common in reproductive-aged women. In adolescents, the majority of lesions will diminish or completely resolve over time, so only reassurance and observation are required.

Classic fibroadenomas are relatively small (2-3 cm in size), in the upper outer quadrant of one or both breasts, and feel rubbery to palpation. They are generally painless but may become tender around the time of menses, as in this patient. There should be no skin changes, breast drainage, or lymphadenopathy. For an adolescent patient without concerning features or strong family history of premenopausal breast cancer in multiple first-degree relatives, there is no increased risk of malignancy from fibroadenomas. Fat necrosis is also a possible diagnosis in this softball player, as many patients do not recall a specific inciting trauma. However, given that the mass has been present for 2 months and undergoes hormonal changes, fibroadenoma is still the most likely diagnosis. Either way, the mass should eventually resolve and ultrasound is only indicated if the patient is older or there is persistence or change in the mass (Illustration A). Ultrasound is preferred in young women due to high breast density and the radiosensitivity of their tissues, but if the patient is over 35, mammography may also be performed. It would show a “popcorn” appearance (Illustration B). Upon confirmation of the diagnosis, either by imaging findings or core needle biopsy, surgical excision can be performed only if the patient experiences significant symptoms. Otherwise, routine follow-up is sufficient.

Incorrect Answers:

Excision is usually not required for fibroadenomas given that they are not associated with increased risk of malignancy. If a patient feels the symptoms are too bothersome, surgical resection can be performed. If the diagnosis is called into question due to persistence or growth and there is concern for malignancy, excision may be required after imaging and biopsy are performed.
Oral contraceptives containing estrogen may increase, not decrease, the size of the fibroadenoma. Since these tumors are hormonally receptive, they often grow and become tender around the time of menses, during pregnancy, and with estrogen administration (as in an OCP). For this reason, they also typically regress in menopause.
Breast cancer risk is not increased by fibroadenomas, especially ones that are simple (no skin changes, drainage, lymphadenopathy, etc.), as in this patient. This patient’s family history of postmenopausal breast cancer in a second degree relative does put her at minimally higher risk of breast cancer, but this is unrelated to her fibroadenoma.
A rapid growth to over 5 cm suggests that the mass is actually not a fibroadenoma but a phyllodes tumor (Illustration C). This is a rare neoplasm that can be benign or malignant, and although most phyllodes tumors occur in older women, they have been reported in patients as young as 10 years old. They are known for their rapid increase in size within weeks and any such growth should be evaluated with ultrasound and core needle biopsy (and mammography if the patient is over 35). Given the malignant potential, wide local excision is the standard of care. Chemotherapy and radiation are generally not indicated as effectiveness is unclear.

Review NCCPA Blueprint Topic: Fibroadenoma

5. A 26-year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination, her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis?

Ovarian cancer
Endometriosis
Functional ovarian cyst
Pelvic inflammatory disease

Click here to see the answer

The answer is B. Endometriosis

With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or “chocolate cyst”. The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia.

Incorrect answers:

It is important to consider ovarian cancer in a patient with a pelvic mass however, ovarian cancer usually occurs in older women over age 55 and patients are often asymptomatic until the disease is more advanced
Functional ovarian cysts occur from ovulation and usually are not symptomatic.
With PID the patient will have abdominal tenderness, adnexal tenderness, cervical motion tenderness, and elevated temperature.

Review NCCPA Blueprint Topic: Endometriosis (Lecture)

6. A healthy 29-year-old woman at 30-weeks gestational age has gained 35lbs since becoming pregnant. She complains of several weeks of bilateral numbness and tingling of her palms, thumbs, index, and middle fingers that is worse at night. She also notes weakness gripping objects at the office. Which nerve is most likely affected?

Median nerve
Ulnar nerve
Radial nerve
Axillary nerve
Anterior interosseous nerve

Click here to see the answer

The answer is A. Median nerve

This clinical presentation is consistent with carpal tunnel syndrome (CTS), the most common entrapment neuropathy, caused by compression of the median nerve as it travels under the flexor retinaculum. During pregnancy, increased edema causes a narrowing of the carpal tunnel, which predisposes the entrapment of the median nerve. The median nerve is responsible for sensory and motor distribution of the thumb, index, middle and radial half of the ring finger. Hallmark symptoms of CTS include numbness and paresthesias in the median nerve distribution. Weakness and atrophy of the thenar muscles may be evident if CTS is left untreated.

Incorrect Answers:

The ulnar nerve supplies sensory innervation to the 5th digit and the medial half of the 4th digit and motor innervation of the forearm flexors, and several intrinsic muscles of the hand. The ulnar nerve is most commonly injured at the elbow as it courses adjacent to the humeral medial epicondyle or it may be compressed between the two heads of the flexor carpi ulnaris muscles (cubital tunnel syndrome).
The radial nerve supplies the medial, lateral, long heads of the triceps brachii, 12 muscles in the posterior compartment of the forearm and the associated joints and overlying skin. Radial nerve injury may result from spiral fracture of the midshaft of the humerus and result in “wrist drop”
The axillary nerve supplies the deltoid, teres minor, and the long head of the triceps brachii. Axillary nerve injury may result from dislocation of the head of the humerus
The anterior interosseous nerve branch of the median nerve supplies the deep muscles on the anterior of the forearm. This includes the flexor pollicis longus, pronator quadratus, and the radial half of flexor digitorum profundus

Review NCCPA Blueprint Topic: Carpal Tunnel Syndrome

7. A 55-year-old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On the physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with a tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?

Timolol ophthalmic solution
Epinephrine ophthalmic solution
Laser peripheral iridotomy
Anti-cholinergic ophthalmic solution
NSAID ophthalmic solution

Click here to see the answer

Answer: A. Timolol ophthalmic solution

Acute angle-closure glaucoma, also known as narrow-angle glaucoma, presents with sudden onset blurry vision, hardened eyeball, and increased IOP. First-line emergency treatment includes alpha 2 selective adrenergic agonists, beta-blockers, or carbonic anhydrase inhibitors. Acute angle-closure glaucoma is caused by relative pupillary block of aqueous humor as it flows from the posterior to the anterior chamber through the iris-lens channel (the canal of Schlemm). Sudden attacks are more likely to occur when the pupil is partially dilated, for example, being in a darkened room such as a movie theater, or when eye drops are taken that dilate the pupil. If not treated immediately, it can damage the optic nerve and result in permanent vision loss within hours. Risk factors include certain medications (dilating drops, anticholinergic, antidepressants).

Incorrect Answers:

Epinephrine would cause pupil dilation which would worsen acute angle glaucoma.
Laser peripheral iridotomy is an appropriate and definitive treatment for acute angle glaucoma in the post-acute phase of treatment once IOP is controlled.
Anticholinergics would cause pupil dilation which would worsen acute angle glaucoma
NSAID ophthalmic solution can theoretically worsen acute angle glaucoma because of its anti-prostaglandin effect.

Review NCCPA Blueprint Topic: Glaucoma (Lecture)

8. A 68-year-old woman presents to your office for her annual check-up. Her vitals are HR 85, T 98.8 F, RR 16, BP 125/70. She has a history of smoking 1 pack a day for 35 years but states she quit five years ago. She had her last pap smear at age 64 and states all of her pap smears have been normal. She had her last colonoscopy at age 62, which was also normal. Which is the following is the next best test for this patient?

Abdominal ultrasound
Chest CT scan
Pap smear
Colonoscopy
Chest radiograph

Click here to see the answer

The answer is B: Chest CT scan

The patient presents between the ages of 55 and 80 and has quit smoking within the last 15 years. She should undergo an annual low dose chest CT scan for lung cancer screening.

Cigarette smoking is the leading cause of preventable death in the United States and significantly contributes to deaths from cancer along with cardiovascular and pulmonary diseases. Smoking not only harms adults but also results in the deaths of about 1,000 infants annually. The USPSTF report on the guidelines for lung cancer screening states that age, total cumulative exposure to tobacco smoke, and years since quitting smoking are the most important risk factors for lung cancer. They report that annual screening for lung cancer with low-dose CT in a defined population of high-risk persons can prevent a substantial number of lung cancer–related deaths as evidenced by large randomized controlled trials.

Incorrect Answers:

An abdominal ultrasound is recommended for men between the ages of 65 and 75 who have ever smoked, but this recommendation does not hold for women
The patient does not require a pap smear because she is older than 65 and does not have a history of cervical or endometrial malignancy, and all of her previous pap smears have been negative.
The patient should next get her colonoscopy at age 72 since her last colonoscopy was at age 62 and was normal
The patient does not have any acute respiratory or pulmonary problems and therefore does not need a chest radiograph

Review NCCPA Blueprint Topic: Substance-related and addictive disorders (ReelDx)

9. A 22-year-old man presents to the emergency room complaining of pain upon urination and a watery discharge from his penis. It started a few days ago and has been getting progressively worse. His temperature is 98.0°F (36.7°C), blood pressure is 122/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tender urethra with discharge. Gram stain of the discharge is negative for bacteria but shows many neutrophils. Which of the following is the most likely infectious etiology of this patient’s symptoms?

Chlamydia trachomatis
Escherichia coli
Neisseria gonorrhoeae
Staphylococcus saprophyticus
Trichomonas vaginalis

Click here to see the answer

The answer is A. Chlamydia trachomatis

This patient is presenting with a tender urethra with a discharge and a negative Gram stain suggesting a diagnosis of urethritis from Chlamydia trachomatis.

Urethritis in men presents with dysuria and urethral discharge with numerous neutrophils on urethral swab. Urethritis in men is most commonly caused by 2 categories of sexually transmitted infections. In gonococcal urethritis, patients present with purulent discharge and gram-negative diplococci on Gram stain, with N. gonorrhoeae as the offending agent. In nongonococcal urethritis, patients present with watery discharge which shows no bacteria on Gram stain (it is intracellular). Chlamydia is the most common offending agent in nongonococcal urethritis and is the most common cause of urethritis overall. Azithromycin is a good choice for the treatment of nongonococcal urethritis because it covers Chlamydia and other common causative organisms. It is often given with ceftriaxone which offers double coverage for N. gonorrhoeae.

Incorrect Answers

Escherichia coli is the most common cause of cystitis which presents with dysuria and leukocytes, bacteria, and nitrites on urinalysis. TMP-SMX is a first-line agent for the treatment of uncomplicated cystitis.
Neisseria gonorrhoeae is the most common cause of gonococcal urethritis which presents with a purulent urethral discharge and gram-negative diplococci on Gram stain. Ceftriaxone (a single injection) is the most common treatment for gonococcal urethritis. Ceftriaxone would be appropriate if the patient presented with purulent urethral discharge and a supportive Gram stain. Patients treated for gonococcal urethritis are generally treated for a Chlamydia trachomatis infection since there is a high rate of co-infection.
Staphylococcus saprophyticus is a common cause of UTI in young and sexually active women. It is still less common a cause of a UTI when compared to Escherichia coli.
Trichomonas vaginalis is a less common cause of male urethritis. It can present with pruritus but with less specific symptoms when compared to women with this condition. If the patient did not respond to antibiotics, this diagnosis could be suspected. Metronidazole is the treatment of choice.

Review NCCPA Blueprint Topic: Chlamydia (Lecture)

10. A 6-year-old boy is admitted with a one-week history of diarrhea, which was sometimes bloody and originally began after a birthday party. He has become lethargic and has not been eating or drinking. His vital signs are as follows: T 38.5 C, HR 135, BP 82/54. Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation. Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count < 10,000. PT and PTT are within normal limits. Which of the following would be expected on a peripheral blood smear?

Rouleaux formation
Fragmented red blood cells
Spur cells
Giant platelets
No abnormalities

Click here to see the answer

The answer is B. Fragmented red blood cells

The boy in this vignette most likely has hemolytic uremic syndrome (HUS), which is characterized by microangiopathic hemolytic anemia with schistocytes.

HUS usually occurs in children and is caused by an E. coli 0157:H7 infection. The classic presentation follows an acute diarrheal illness. HUS is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. The presentation is similar to thrombotic thrombocytopenic purpura (TTP) but without the fever and neurologic symptoms. The key differentiating factor, in this case, is diarrhea + elevated BUN. Keep in mind that in HUS uremia is elevated to a greater extent than TTP. On the other hand, TTP presents with more neurologic signs, and will not be preceded by diarrhea on the PANCE exam.

Incorrect Answers:

Rouleaux (stacked RBCs) are seen most notably in multiple myeloma. As well as many other hyperviscosity syndromes. This finding is highly non-specific.
Spur cells are seen with liver disease.
Giant platelets are seen in idiopathic thrombocytopenic purpura (ITP) as well as Bernard-Soulier syndrome.
Schistocytes would be expected in HUS.

Review NCCPA Blueprint Topic: Infectious Diarrhea (ReelDx + Lecture)

Looking for all the podcast episodes?

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Resources and Links From The Show

Check out the new EOR, PANCE, PANRE search and study tool
My list of recommended PANCE and PANRE review books
Interactive PANCE and PANRE NCCPA Exam Content Blueprints
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free Trello PANCE study schedule
Get 20% of any Picmonic membership by using this link
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
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This Podcast is also available on iOS and Android

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Download The Content Blueprint Checklist

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Download for PANCE Download for PANRE

The post Podcast Episode 85: Ten Mixed Multiple Choice PANCE and PANRE Board Review Questions appeared first on The Audio PANCE and PANRE.

Cardiac Pharmacology Part One: The Audio PANCE and PANRE Episode 84

Tue, 11 Aug 2020 17:04:16 +0000

Welcome to episode 84 of the Audio PANCE and PANRE PA Board Review Podcast

Today we welcome back PA board review expert Joe Gilboy PA-C as he covers the exceptionally important topic of cardiac pharmacology.

Below you will find a downloadable audio version of this podcast as well as links to resources mentioned in today’s episode. Members of Smarty PANCE can sign in and listen to the second half of Joe’s lecture as well as part two of this high-yield cardiac pharmacology lecture series by clicking here.

Not a Smarty PANCE member? You can gain instant access to this lecture as well as all the Smarty PANCE resources instantly by clicking here.

From today’s episode:

To listen to the second half of this lecture as well as cardiac pharmacology part 2 with Joe Gilboy sign in to Smarty PANCE then click here.
Listen to Joe’s previous podcast episodes:
Content Blueprint PANCE/PANRE Review Course and EOR (Rotation) Courses

The Audio PANCE and PANRE Board Review Podcast Episode 84: Cardiac Pharmacology

You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Play Music, Stitcher, or just search “The Audio PANCE and PANRE” in your favorite podcast listening app.

If you can’t see the audio player click here to listen to the full episode.

Looking for all the podcast episodes?

This FREE podcast series is often limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

Additional Resources

Check out our new PANCE + PANRE + EOR All in One Search and Sort (2,075 topics)
Take the FREE Internal Medicine Rotation Cardiovascular Practice Exam
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Interactive PANCE and PANRE NCCPA Exam Content Blueprints
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free Trello PANCE study schedule
Get 20% of any Picmonic membership by using this link
Smarty PANCE members get 50% off Osmosis (link in the member’s area)

This Podcast is available on all platforms

Just search for “The Audio PANCE and PANRE” in your favorite podcasting program or use the following links.

Download The Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

Download for PANCE Download for PANRE

The post Cardiac Pharmacology Part One: The Audio PANCE and PANRE Episode 84 appeared first on The Audio PANCE and PANRE.

How to Answer Tricky PANCE and PANRE Test Questions Part 2: Podcast Episode 83

Tue, 09 Jun 2020 18:43:12 +0000

Welcome to episode 83 of the Audio PANCE and PANRE PA Board Review Podcast

Join me as we welcome Joe Gilboy PA-C back again to cover best practices that make answering even the toughest PANCE and PANRE Board review questions (and EOR exam questions) a breeze!

Below you will find interactive audio with clips covering the most important points. It’s a perfect companion to the podcast.

From today’s episode:

Listen to Joe’s previous podcast episodes:
Start with high-quality PANCE practice questions in tutor mode
Content Blueprint PANCE/PANRE Review Course and EOR (Rotation) Courses

The Audio PANCE and PANRE Board Review Podcast Episode 83: How to Answer PANCE and PANRE Test Questions Part 2

You can download and listen to past FREE episodes here, on iTunes, on Google Play Music or Stitcher Radio.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

If you can’t see the audio player click here to listen to the full episode.

Audio clips from today’s episode

Here are selected audio tips from today’s episode covering the most important points.

How to answer: “What is the most accurate test (what is the gold standard)?”

How to answer “What would you like to do next?” or “What is the next step?”

How to answer: “What’s the most likely answer/diagnosis – which one fits best?” (the simplest answer always wins)

In other words, if something carries 51% weight versus 49% weight, the 51% weight wins.

How to answer: “What is the most common etiology?”

How to answer: “What is second-line therapy?”

Looking for all the podcast episodes?

This FREE podcast series is often limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

Additional Resources

Check out the new Smarty PANCE Internal Medicine Rotation (EOR) Review Course
Download your Free Trello Smarty PANCE PAEA Internal Medicine EOR Tracking Template
Take the FREE Internal Medicine Rotation Cardiovascular Practice Exam
View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Interactive PANCE and PANRE NCCPA Exam Content Blueprints
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free Trello PANCE study schedule
Get 20% of any Picmonic membership by using this link
Smarty PANCE members get 50% off Osmosis (link in members area)

This Podcast is also available on iOS and Android

iTunes: The Audio PANCE and PANRE Podcast iTunes
Stitcher Radio: The Audio PANCE and PANRE Podcast Stitcher
Google Play: The Audio PANCE and PANRE Podcast Google Play

Download The Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

Download for PANCE Download for PANRE

The post How to Answer Tricky PANCE and PANRE Test Questions Part 2: Podcast Episode 83 appeared first on The Audio PANCE and PANRE.

How to Answer The Hardest PANCE/PANRE Test Questions: Podcast Episode 82

Tue, 31 Mar 2020 19:32:48 +0000

Welcome to episode 82 of the Audio PANCE and PANRE PA Board Review Podcast

Join me as we welcome Joe Gilboy PA-C back again to cover best practices that make answering even the toughest PANCE and PANRE Board review questions (and EOR exam questions) a breeze!

Below you will find interactive audio breaking down each question. It’s a perfect companion to the podcast.

Special from today’s episode:

Listen to Joe’s previous podcast episodes:
- How to Study for Your PANCE: Podcast Episode 79
- Podcast Episode 65: Hepatitis B Breakdown
Start with high-quality questions in tutor mode (untimed with hints on we have a TON on Smarty PANCE)
Poem “lockdown“ by Brother Richard Hendrick
Content Blueprint Review Course and EOR Courses

The Audio PANCE and PANRE Board Review Podcast Episode 82: How to Answer The Hardest PANCE/PANRE Test Questions

You can download and listen to past FREE episodes here, on iTunes, on Google Play Music or Stitcher Radio.
You can listen to the latest episode, take an interactive quiz, and download more resources below.

If you can’t see the audio player click here to listen to the full episode.

Questions we break down in this episode:

The following questions are linked to NCCPA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website

Question 1: Developing good test-taking habits

1. 10-year-old boy presents to the emergency department complaining of sudden onset lightheadedness and chest discomfort, vital signs, 98.6, heart rate of 205, respiratory rate of 30 and 98% oxygen saturation, his EKG demonstrated sinus tachycardia with no p waves. What is the most likely diagnosis?

A-fib
A-flutter
Atrioventricular reentry tachycardia
V-tach

Steps to answering this question

Question 2: Choosing between two good answers

2. A 60-year-old woman with a history of hypertension, dyslipidemia, and coronary heart disease was sent to the emergency room from her primary care physician’s office for a heart rate of 40. She has no complaints, except for mild fatigue. Medications include metoprolol, atorvastatin, lisinopril, and baby aspirin. Her EKG reveals sinus bradycardia and her physical exam is normal. Which of the following is the most appropriate next step and management?

Atropine
Make a medication adjustment
Schedule for a temporary pacemaker
Watchful waiting

Steps to answering this question

Question 3: The long test question

3. A 32-year-old previously healthy man comes to ER with a four-hour history of palpitations. He denies chest pain, shortness of breath or history of similar palpitations. He does admit to heavy alcohol use in the past week drinking one pint of vodka and 24 packs of beer each day in the ED his vital signs of blood pressure 135/75, heart rate of 115, respiratory rate of 14, and oxygen saturation of 98% on room air. He’s got an irregularly irregular rhythm heard on auscultation and EKG shows atrial fibrillation. What is the next step in management?

Chemical conversion
Observation
Rate control
Synchronized cardioversion

Steps to answering this question:

Question 4: The short question with long answer choices

4. Which of the following patients should be classified as having unstable angina?

A 51-year-old woman who has chest pain three days ago, but is now chest pain-free, is found to have a positive troponin with q waves in II, III, and aVF without ST-segment elevation
A 55-year-old woman with a history of hypertension, but no prior cardiac disease who complains of one episode of chest pain that began while pushing her grocery cart and lasted 30 minutes
A 65-year-old male with a known history of coronary artery disease who gets chest pain and shortness of breath every time he climbs the steps to his bedroom
A 71-year-old man who underwent a coronary cardiac catheterization one month ago for early morning chest pain but shows minimal coronary artery disease with no fixed lesions presents with recurrent early morning chest pain that is relieved with nitroglycerin

Steps to answering this question:

Looking for all the podcast episodes?

This FREE podcast series is often limited to every other episode, you can download and enjoy the complete audio series by becoming a Smarty PANCE member.

Additional Resources

Check out the new Smarty PANCE Internal Medicine Rotation (EOR) Review Course
Download your Free Trello Smarty PANCE PAEA Internal Medicine EOR Tracking Template
Take the FREE Internal Medicine Rotation Cardiovascular Practice Exam
View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List
Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram
Follow Smarty PANCE and The Daily PANCE Blueprint on Facebook
My list of recommended PANCE and PANRE review books
Interactive PANCE and PANRE NCCPA Exam Content Blueprints
Sign up for the FREE Daily PANCE and PANRE email series
Join the Smarty PANCE NCCPA Content Blueprint Website
Get your free Trello PANCE study schedule
Get 20% of any Picmonic membership by using this link

This Podcast is also available on iOS and Android

iTunes: The Audio PANCE and PANRE Podcast iTunes
Stitcher Radio: The Audio PANCE and PANRE Podcast Stitcher
Google Play: The Audio PANCE and PANRE Podcast Google Play

Download The Content Blueprint Checklist

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

Download for PANCE Download for PANRE

The post How to Answer The Hardest PANCE/PANRE Test Questions: Podcast Episode 82 appeared first on The Audio PANCE and PANRE.

Podcast Episode 81: Internal Medicine EOR Cardiology Questions

Mon, 23 Mar 2020 15:15:19 +0000

Welcome to episode 81 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten internal medicine rotation EOR content blueprint questions from the Smarty PANCE physician assistant board and rotation review website.

Special from today’s episode:

Check out the new Smarty PANCE Internal Medicine Rotation (EOR) Review Course
Download your Free Trello Smarty PANCE PAEA Internal Medicine EOR Tracking Template
Take the FREE Internal Medicine Rotation Cardiovascular Practice Exam
View the interactive Smarty PANCE Internal Medicine Rotation (EOR) Topic List

Below you will find an interactive exam to complement the podcast.

The Audio PANCE/PANRE and EOR PA Board Review Podcast

You can download and listen to past FREE episodes here, on iTunes, on Google Play Music or Stitcher Radio.
You can listen to the latest episode, take an interactive quiz and download more resources below.

Listen Carefully Then Take The Practice Exam

If you can’t see the audio player click here to listen to the full episode.

Podcast Episode 81: Ten Internal Medicine EOR Cardiology Questions

The following questions are linked to PAEA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member you will be able to log in and view this interactive video lesson.

1. 55-year-old woman is admitted to the hospital because she has shortness of breath and pain on both sides of her chest with deep breathing which has worsened over the past 5 days. In recent weeks, she has been feeling fatigued and has had low-grade fevers and night sweats, and was found to have a new cardiac murmur on examination. Her temperature is 38.1°C (100.6°F), pulse is 106/min, respirations are 26/min, and blood pressure is 136/88 mm Hg. She appears diaphoretic and is in mild respiratory distress. Cardiac auscultation reveals a faint systolic murmur heard over the lower left sternal border. Her neck veins are distended and abdominal examination shows hepatomegaly. Which of the following is the most likely cause of her clinical presentation?

A. Fat embolism
B. Infective endocarditis
C. Myocardial infarction
D. Rheumatic fever
E. Small cell lung cancer

Click here to see the answer

Answer: B, Infective endocarditis

Infective endocarditis (IE) is an infection of the endocardial surfaces of the heart, most commonly the heart valves. IE occurs when a microorganism begins to invade the heart valves causing an inflammatory reaction that damages the valve – sometimes leading to stenosis and sometimes leading to regurgitation. This patient developed a new cardiac murmur in recent weeks that is described as a faint systolic murmur heard over the lower left sternal border. This is most consistent with tricuspid regurgitation. She also has distended neck veins and hepatomegaly, both of which suggest right-sided heart failure which can result from tricuspid regurgitation. Small infectious emboli can break away from the primary lesion on the tricuspid valve and go into the pulmonary vasculature causing shortness of breath and pleuritic chest pain. Most cases of IE are caused by Staphylococcus aureus and Viridans streptococci, and diagnosis is confirmed by obtaining multiple blood cultures that show that there is continuous bacteremia.

Fat embolism to the pulmonary circulation almost always occurs with major trauma, including surgical procedures like intramedullary nailing of long bones. Fat emboli can occlude the microvasculature, triggering a systemic inflammatory response. The woman did not have recent trauma, and a fat embolism would not explain her cardiac murmur.
Clinical presentation of myocardial infarction most often includes substernal crushing chest pain, radiation of pain to the arms, left shoulder, back, neck, and jaw, as well as shortness of breath, anxiety, and fatigue. A myocardial infarction would not explain her developing a new cardiac murmur in recent weeks.
Rheumatic fever is an autoimmune inflammatory process that develops as a sequela of streptococcal infection. Clinical manifestations include polyarthritis, carditis, erythema marginatum, chorea, and subcutaneous nodules. Rheumatic fever can cause some of the symptoms seen in this case, but the acute onset makes this option less likely.
Although small cell lung cancer can present with pulmonary symptoms and low grade fevers, it wouldn’t easily explain her new cardiac murmur or the signs of right-sided heart failure.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Endocarditis

2. A 54-year-old man comes to the emergency department following a four-day history of left-sided chest pain and shortness of breath. One week ago, he experienced upper respiratory symptoms along with myalgias and general fatigue. He has no known past medical history. He has not traveled outside the US. His temperature is 38.1°C (100.6°F), pulse is 104/min, respirations are 17/min, oxygen saturation is 94% on room air, and blood pressure is 100/72 mm Hg. Physical examination shows an ill-appearing man with bibasilar rales, jugular venous distention of 11 cm with no murmurs, rubs, or gallops, and 1+ bilateral pitting edema of the lower extremities. His labs are within normal limits and his blood cultures are negative. An echocardiogram shows an ejection fraction of 35%. Which of the following is the most likely cause of this patient’s condition?

A. Adenovirus
B. Coxsackie A virus
C. Staphylococcus aureus
D. Corynebacterium diphtheriae

Click here to see the answer

The answer is A. Adenovirus

Myocarditis in the United States is most commonly caused by a viral infection, typically adenovirus, coxsackie B, parvovirus B19, or others. It often presents with systemic symptoms such as fatigue and chest pain, but may cause sudden death.

Though coxsackie B virus is one of the most common causal pathogens of acute myocarditis, Coxsackie A causes herpangina, aseptic meningitis, and hand, foot, and mouth disease.
Staphylococcus aureus is a common cause of bacterial endocarditis, not myocarditis. Endocarditis is more likely to present with a new murmur and signs of distant emboli such as nail-bed hemorrhage and Janeway lesions.
Corynebacterium diphtheriae is the causal agent of diphtheria, which may involve myocarditis. However, the patient would then most likely have other symptoms of the disease, including pseudomembranous pharyngitis, lymphadenopathy, or an arrhythmia.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Myocarditis

3. A 42-year-old woman comes to the emergency department because of chest pain, dyspnea, and lightheadedness. She recently recovered from a presumed viral upper respiratory infection and has a 10-year history of systemic lupus erythematosus. Physical examination shows a decrease in systolic blood pressure by 20 mm Hg during inspiration. An ECG is shown here. Which of the following is the most likely diagnosis?

A. Aortic dissection
B. Tricuspid regurgitation
C. Pericardial effusion
D. Aortic stenosis
E. Mitral stenosis

Click here to see the answer

The answer is C. Pericardial effusion

Pericardial effusions are associated with a variety of causes, including autoimmune disorders and infectious pericarditis. If pericardial effusion leads to cardiac tamponade, patients may have pulsus paradoxus, or a decrease in systolic blood pressure during inspiration of more than 10 mm Hg. Certain ECG findings are characteristic for pericardial effusion. In particular, electrical alternans (shown by arrows) is highly specific for pericardial effusion (usually in association with cardiac tamponade) but not particularly sensitive. This pattern, characterized by beat-to-beat changes in the QRS axis in the limb and precordial leads, is caused by swinging of the heart within the accumulated pericardial fluid. Other common findings on ECG include sinus tachycardia and low QRS voltage.

Patients with aortic dissection classically present with a tearing or ripping pain in the chest or back and may have a significant variation in systolic blood pressure between arms (not across respirations).
The severity of tricuspid regurgitation varies widely, ranging from asymptomatic disease to symptoms of right-sided heart failure (hepatosplenomegaly, ascites, peripheral edema).
Patients with aortic stenosis, the most common cause of left ventricular outflow obstruction, typically present with exertional dizziness or angina. In end-stage disease, symptoms may progress to heart failure.
Mitral stenosis obstructs the flow of blood from the left atrium to the left ventricle and typically manifests as exertional dyspnea and decreased exercise tolerance.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Pericarditis

4. A 57-year-old man comes to the emergency department because of intermittent, severe leg pain in both his calves for 2 weeks. He has a history of untreated high blood pressure, diabetes, and high cholesterol. For the past 3 years, the pain started after walking three blocks and only going away upon resting. In the past 2 weeks, he has had the same pain at rest. His temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 160/89 mm Hg. Examination shows both calves are atrophied and there is a paucity of hair, but no swelling or discoloration. Additionally, his lower calves are cool to the touch and dusky in appearance. Doppler ultrasound shows perfusion to both feet, and blood pressures of 35/20 mm Hg in the posterior tibial artery are obtained bilaterally. Which of the following is most appropriate next step in management?

A. Immediate high-dose statin therapy
B. Immediately consult vascular surgery
C. Intravenous alteplase
D. Pain control and discharge; refer to vascular surgery as an outpatient
E. Rest, elevate, and compress the affected leg

Click here to see the answer

The answer is B. Immediately consult vascular surgery

Peripheral vascular disease with intermittent claudication and signs of decreased perfusion should be examined using Doppler ultrasound and the ankle-brachial index (ABI). An ABI of <0.41 is grounds for the immediate surgical consultation.

Statin therapy has shown to be effective in treating intermittent claudication. However, this intervention is appropriate only when the patient is deemed to be stable, and the risk of limb ischemia has been addressed.
Alteplase (tPa) has been used to treat intermittent claudication, but its use is outside the scope of the emergency room. Treatments initiated in the emergency department are unfractionated heparin, aspirin, pain control, and positioning of the leg to maintain perfusion.
The patient has significant impairment of perfusion to his legs. Discharge and vascular surgery follow-up as an outpatient would be inappropriate and likely to result in morbidity or mortality.
While this leg should be rested, compression and elevation are the opposite of what is needed. These therapies will further decrease the blood flow to the leg and put the patient at increased risk of complications.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Peripheral vascular disease

5. A 6-year-old boy comes to the pediatric clinic because of 4 weeks of fatigue and shortness of breath. His medical history is notable for poor follow-up with yearly check-ups, but his mother notes that he has been fairly healthy for the duration of his life, except for a “bad sore throat that needed antibiotics” about 6 months ago. On examination, the boy appears fatigued, but is appropriately oriented and responsive, and is generally non-toxic appearing. He is afebrile. Cardiac examination is notable for a widely split S2, a quiet S1, and point of maximum impulse displaced to the left. Which of the following is the next best step in the management of this patient?
Elimination tool

A. Digoxin
B. Long-term penicillin
C. Short-term course of clindamycin
D. Reassurance & routine care
E. Intramuscular ceftriaxone

Click here to see the answer

The answer is B. Long-term penicillin

Rheumatic heart disease is caused by autoimmune cross-reactivity following a Streptococcal infection. Development of antibody-mediated mitral valve damage is common. Long-term penicillin is suitable for acute treatment and prophylaxis from complications.

Digoxin is a purified cardiac glycoside that is typically used in the treatment of various heart conditions, such as atrial fibrillation, atrial flutter, and heart failure that cannot be controlled by other medication. It is not recommended for use in rheumatic fever.
Clindamycin is an antibiotic used to treat middle ear infections, bone or joint infections, pelvic inflammatory disease, strep throat, pneumonia, and endocarditis. Clindamycin is typically used as endocarditis prophylaxis for patients that are already receiving penicillin for secondary rheumatic fever prophylaxis.
This patient is suffering from rheumatic fever, which can lead to rheumatic heart disease. This can cause significant carditis which manifests as congestive heart failure.
Ceftriaxone is an antibiotic used to treat numerous bacterial infections, such as pneumonia, ear infections, skin infections, urinary tract infection, and meningitis. It is not used in the treatment of rheumatic fever.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Rheumatic heart disease

6. A 35-year-old woman, gravida 2, para 1, comes to the office because of her first prenatal visit at 12 weeks’ gestation. She has no current concerns, and her first child was born without complications. She has a history of long-standing untreated hypertension. Her temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 150/89 mm Hg. Which of the following medications would most likely be appropriate as initial treatment?

A. Atenolol
B. Hydrochlorothiazide
C. Labetalol
D. Lisinopril
E. Losartan

Click here to see the answer

The answer is C. Labetalol

Chronic hypertension in pregnancy can be treated with some medications and labetalol is recommended as a first-line therapy for treatment of hypertension during pregnancy. Angiotensin-converting enzymes (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should be avoided.

Atenolol is a β-blocker medication, which decreases blood pressure by decreasing heart rate and stroke volume. It is contraindicated in pregnancy because it has been associated with fetal growth restriction. β-blockers considered safe in pregnancy are metoprolol and labetalol.
Hydrochlorothiazide is a thiazide diuretic which decreases blood pressure via volume depletion. Diuretics do not cause fetal malformations but are generally avoided in pregnancy, as they prevent the physiologic volume expansion seen in normal pregnancy. They may be used in states of volume-dependent hypertension, such as renal or cardiac disease.
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor which decreases blood pressure through inhibition of the renin-angiotensin-aldosterone system. ACE inhibitors and the closely related angiotensin-receptor blockers are contraindicated in pregnancy because of the risk of birth defects including renal dysgenesis and oligohydramnios.
Losartan is an angiotensin II receptor blocker (ARB) which decreases blood pressure through inhibition of the renin-angiotensin-aldosterone system. ARBs and the closely related angiotensin converting enzyme (ACE) inhibitors are contraindicated in pregnancy because of the risk of birth defects including renal dysgenesis and oligohydramnios.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hypertension

7. A 42-year-old man comes to the office for a routine check-up. Medical history includes diabetes mellitus and a long history of smoking. Family history includes coronary artery disease. Temperature is 36.5°C (97.7°F), pulse is 78/min, respirations are 17/min, and blood pressure is 160/89 mm Hg. A repeat blood pressure taken 2 days later shows 143/88 mm Hg. Which of the following is most likely the best initial therapy?

A. Enalapril
B. Furosemide
C. Hydrochlorothiazide
D. Metoprolol
E. Nifedipine

Click here to see the answer

Answer: A. Enalapril

Hypertension in the setting of diabetes should be treated, with a goal systolic blood pressure of <130 mm Hg. The best first choice of medication is an angiotensin-converting enzyme inhibitor (ACEi).

Incorrect Answers:

Furosemide is a loop diuretic that can be used to treat hypertension but it is not a first line agent. Unlike ACE inhibitors, loop diuretics have no renoprotective qualities and therefore are a worse initial choice in a hypertensive diabetic patient.
Hydrochlorothiazide is a thiazide diuretic and a first-line agent for the treatment of hypertension in non-diabetic patients. It is relatively contraindicated in diabetes because it has the potential adverse effect of hyperglycemia. It may also precipitate attacks of gout by increasing uric acid concentrations.
Metoprolol is a β-blocker that is used for the treatment of hypertension but is not a first line treatment. Also, β-blocker are contraindicated in asthma, as well as in diabetic patients due to its potential to mask signs of low blood sugar.
Nifedipine is a calcium channel blocker that is used in the treatment of hypertension but it is not a first line therapy. It has no renoprotective effects, and commonly causes peripheral edema as an unwanted adverse effect.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hypertension

8. A 45-year-old obese Caucasian gentleman arrives at your clinic for a routine check-up after having some blood work done during a workplace health screening. He is found to have an LDL cholesterol level of 550 mg/dL. He states that his father and brother had high cholesterol and both died at a young age from a heart attack. He has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes. He is started on high dose statin and his LDL at 12 weeks is 350 mg/dL. What is the next best step in this patient’s management?

A. Continue high dose statin, the patient’s LDL is at goal
B. Add niacin 100 mg three times daily
C. Add ezetimibe (Zetia) 10 mg daily
D. Add a PCSK9 inhibitor
E. Refer to a lipid specialist

Click here to see the answer

The answer is C: add ezetimibe 10 mg

If LDL-C is not at goal after 6-12 weeks the next best step for the treatment of familial hypercholesterolemia is to add ezetimibe 10 mg daily and check again in 6-12 weeks. If at that time the patient’s LDL is still not at goal (ideally < 150) refer to lipid specialist to consider adding a PCSK9 inhibitor.

Pearls

Familial hypercholesterolemia (FH) is the most common autosomal dominant genetic disease. The clinical syndrome (phenotype) is characterized by extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) and a propensity to early-onset atherosclerotic cardiovascular disease. In general, homozygotes manifest the disease at a much earlier age than heterozygotes and the disease is more severe.
Homozygous FH patients are rare and have an estimated prevalence of approximately 1:300,000 to 1:400,000
Heterozygous FH is estimated to occur in 1 in 200 to 250 individuals in the United States.
It is estimated that about 7 percent of American adults have an untreated lipoprotein cholesterol ≥190 mg/dL but only 1.7 percent carry an FH mutation
Patients with undiagnosed homozygous familial hypercholesterolemia (FH) develop severe, premature, atherosclerotic cardiovascular disease and die before age 20 in many cases.
In patients with a negative or unknown family history, an untreated LDL-C level of ≥190 mg/dL (4.9 mmol/L) suggests FH. This value is greater than the 90th percentile for age and sex.

Diagnosis

The diagnosis of heterozygous familial hypercholesterolemia (FH) is made with genetic testing or clinical criteria. A causative mutation in the LDLR, APOB, or PCSK9 gene(s) secures this diagnosis
When genetic testing is not available or not felt to be necessary, you can use the Dutch Lipid Clinic Network criteria, which assigns points based on low-density lipoprotein cholesterol (LDL-C) levels, personal history of early atherosclerotic cardiovascular disease (ASCVD), family history of early ASCVD, or high cholesterol in a first-degree relative, and personal and physical examination finding

Treatment

Patients with homozygous familial hypercholesterolemia (FH) – intensive LDL-C lowering, which targets a minimal value of <150 mg/dL (3.9 mmol/L)
In addition to a high-dose statin (atorvastatin 80 mg daily or rosuvastatin 40 mg daily), most homozygous patients will require additional therapies such as ezetimibe, a PCSK9 inhibitor, or potentially LDL-C apheresis

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Hyperlipidemia

9. A 65-year-old man comes to the emergency department because of progressive dyspnea, coughing, and orthopnea. The patient says that over the past 2 months he has been feeling fatigued with ordinary physical activity. His medical history is relevant for dyslipidemia, type II diabetes mellitus, and a posterior myocardial infarction 4 months ago. Auscultatory findings reveal a pansystolic murmur over the mitral area. His temperature is 37.5°C (99.5°F), pulse is 90/min, respirations are 17/min, blood pressure is 120/90 mm Hg, and pulse oximetry on room air shows an oxygen saturation of 95%. This patient most likely has which of the following conditions?

A. Aortic stenosis
B. Aortic valve regurgitation
C. Mitral valve regurgitation
D. Mitral valve stenosis
E. Pulmonary stenosis

Click here to see the answer

The answer is C. Mitral valve regurgitation

Mitral valve regurgitation is defined as an incompetent closure of the mitral valve. Classically patients will present with a pansystolic heart murmur over the mitral area. Posterior myocardial infarction is the second most common cause of mitral valve regurgitation. Mitral valve regurgitation is characterized by an incompetent closure of the mitral valve. This condition causes retrograde blood flow into the left atrium during systole. The most common cause of mitral regurgitation is mitral valve prolapse, followed by a dysfunction of the posteromedial papillary muscle due to posterior myocardial infarction. Other causes may include, endocarditis or stretching of the mitral valve ring.

Aortic stenosis is the reduction of the valvular orifice (<2 cm) with left ventricular outflow obstruction. Patients with aortic stenosis present with chest pain, syncopal episodes, and dyspnea. Here, the patient has progressive dyspnea (NYHA II), and a pansystolic murmur (mitral area), which relates to mitral valve regurgitation
Aortic valve regurgitation (AOR) is described as an inefficient closure of the aortic valve leading to a retrograde blood flow into the left ventricle during diastole. Patients will present with a wide pulse pressure (Corrigan hammer pulse) or an Austin-Flint murmur (severe), none of which are present in this case.
Mitral valve stenosis (MVS) is the reduction of the mitral valve orifice (<2.5cm). The left atrium becomes dilated and hypertrophied because of increased work of the left atrium. Patients with MVS present with dyspnea, rust-colored sputum, atrial fibrillation, and a diastolic heart murmur (diastolic rumble and opening snap).
Pulmonary stenosis is an uncommon valvular lesion. It is commonly associated with congenital heart disease and carcinoid heart disease. Patients present a systolic ejection murmur in the left second intercostal space.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Valvular heart disease

10. A 43-year-old man with a history of rheumatic fever comes to the primary care clinic for a check up. Cardiac examination reveals a late systolic crescendo murmur with midsystolic click best heard over the apex and loudest just before S2. Which of the following maneuvers will cause an earlier onset of the click/murmur?

A. Inspiration
B. Rapid squatting
C. Standing
D. Hand grip
E. Left lateral cubital position

Click here to see the answer

The answer is C. Standing

The ‘click’ of mitral valve prolapse, caused by the tightening of the chordae tendinae, moves closer to S2 with increased preload. Increased preload causes the left ventricle to stretch, as a result, the chordae tendinae are stretched as well. This makes it harder for the mitral valve to prolapse until the ventricles shrink enough to allow the chordae tendinae to let the mitral valve prolapse. Since there is more blood in the ventricles, it takes them longer to pump it out and shrink to a point at which MVP can occur, hence it occurs later in systole. Thus, the click will get closer to S2 with increased preload. Hand grip, rapid squatting, and inspiration all increase preload. Standing decreases preload and will cause an earlier onset of the click.

The click of mitral valve prolapse is heard closer to S2 in the event of increased preload. Preload is increased by hand grip, squatting and inspiration.
Placing the patient in the left lateral cubitus position will not affect preload and will have no effect on the timing of the click in mitral valve prolapse.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Heart murmurs

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The post Podcast Episode 81: Internal Medicine EOR Cardiology Questions appeared first on The Audio PANCE and PANRE.

How to Study for Your PANCE: Podcast Episode 79

Mon, 02 Mar 2020 21:41:53 +0000

Podcast Episode 79: How to Study for Your PANCE

Welcome to episode 79 of the Audio PANCE and PANRE PA Board Review Podcast.

In this episode 35-year PA veteran and PANCE/PANRE board review expert Joe Gilboy PA-C shares his top tips on how to best prepare for the Physician Assistant National Certification Exam

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