Wednesday, September 19, 2018

The PA Rotation Exam Review

As many of you might have noticed I have been very absent from social media and from my blog. I've taken this temporary 2.5-3 year absence working on the most challenging and taxing project I never thought I'd complete. After many long nights of creating content, revision after revision, sourcing, and final-final-final edits, it is now complete. It's release date was November 27, 2018. 

Below is the front cover for you all. I figured that my biggest fans, my readers, family, and friends, deserve to know first! If you have any questions about the book, I'd love to answer them below. Hopefully this means that I can get back to my blog and update many of my old posts and answer some of the long-overdue questions in the comments section. 

Thank you all for your support and patience. So surreal seeing your name published as the primary author on a text. 

Available for purchase at the following sites:

Wolters Kluwer  (use discount code for 20% off: WJF074EE)
Barnes & Noble Thanks everyone 

Paul Gonzales, PA-C

Monday, February 13, 2017

Update to Readers

Hello everyone,

First off, thank you all for your ongoing support. Writing each of these articles has helped me navigate through the process of becoming the PA I am today. I hope that these articles continue to inspire you and give you hope that you can achieve your dreams if you are willing to work for them. I haven't been as active in the past few months and there is a reason for that - I'm working on big things. I don't want to spoil it all just yet, but keep an eye out for future glimpses at some special work I've got brewing in the pipeline.

As I pursue these projects, I would still like to continue writing articles on the PA profession and update the articles that mean the most to all of you, but with a full time job and learning my new role this is quite challenging. If there are any of you out there who would like to assist me in this process, please comment below leaving your email. I will contact a few of you and ask for your resume and why you'd like to be a part of this project.

My hope is that together we can create the best resource for pre-PA and PA students to go for free information - something that is both current and user friendly. If you have any ideas as to how to improve my blog, I'm open to suggestions.

Thank you once again for reading and I sincerely look forward to writing more posts in the future and jumpstarting my social media accounts to stay in touch with each of you.

All my best,


Wednesday, January 25, 2017

Knee Ligaments Review

Knee Ligaments Review
  • Ottawa knee rules are less sensitive in children; use Pittsburgh rules to determine whether or not to obtain radiographs
  • MRI is 95% and 90% accurate in identifying ACL tears and meniscal injuries, respectively
  • Pain with varus or valgus stress is more suggestive of ligament damage than a meniscus tear
  • The MCL is the primary static stabilizer against valgus stress at the knee
  • The LCL is the primary static stabilizer against varus stress at the knee
  • The ACL is the primary static stabilizer of the knee against anterior translation of the tibia with respect to the femur
  • The PCL is the primary static stabilizer of the knee against posterior translation of the tibia with respect to the femur
  • WB, NWB = weight bearing or non weight bearing
  • Ligament injuries are graded as follows:
    • Grade 1: stretching of the ligament with no detectable instability
    • Grade 2: further stretching of the ligament with detectable instability, but with the fibers in continuity
    • Grade 3: complete disruption of the ligament.

Wednesday, January 4, 2017


Pulmonology makes up 12% of the PANCE and between 10-15% of the End of Rotation Examinations. This means that topics like Asthma, which are found on every topic blueprint, are likely to pop up. This makes it essential for you to know the ins-and-outs of asthma treatment plans, including triggers, signs and symptoms, diagnostic studies, severity index, and stepwise therapy.  

Before we begin, I want to point you in the right direction. Check out the guidelines by the NIH and the National Asthma Education and Prevention Program (NAEPP), which most PA schools teach.
  1. Asthma Action Plan (English) (Spanish)

And don't forget, for more practice questions, visit

Now onto the basics of Asthma...

Friday, December 2, 2016

Comprehensive PANCE Resource Review

Comprehensive PANCE Resource Review
Updated: 12/02/2016
If you are reading this review, please understand that I wrote this with the intention of being informative, not discriminatory, chastising, or undermining. All of these resources have no doubt been the result of many long nights and lots of collaboration amongst writers, editors, and publishers and I fully respect that. That said, I hope that this review provides a comprehensive review of resources available online and print for students to use as a guide during clinical rotations, studying for the PANCE, or reviewing for the PANRE. Best of luck to you all and let me know if you have any comments to add below! Thanks for reading!
Online Vs. Print Reviews

Online Resources
Print (Book) Resources
  • Interactive
  • Provide personal performance feedback
  • Most provide videos, podcasts and other multimedia to enhance experience
  • Most include x-rays, EKGs, and colored images in high definition
  • Easy to take with you “on the go”
  • Never have to worry about internet connection
  • One-time purchase
  • Most contain great outlines, tables, or images
  • Cheaper costs
  • May have to repurchase subscription
  • Can be very costly upfront
  • Could require internet access

  • Info will likely be outdated by the time you recertify
  • Will often lack color images, often helpful for dermatology
  • Low resolution for x-rays

  • PANCE Review Books
    In my personal opinion, all of these resources have their pros and cons. The perfect book would not only follow the NCCPA format but would be in order of highest percentage covered on the PANCE to least. Knowing that there are sections on the rotation exams and PANCE in surgery, emergency medicine, pediatrics, and infectious disease, I would definitely like my review to include these sections - something to consider before you decide on a purchase. No book is perfect and I hope that this review is somewhat comprehensive, giving you better insight into each as you make the decision of where to place your money. Ultimately, my goal is not to praise or critique one book over another, but to offer suggestions for improvement and highlight the best aspects of each.

    Saturday, November 26, 2016

    Systemic Lupus Erythematosus

    Systemic Lupus Erythematosus
    Updated: 11/25/2016
    Although Rheumatology falls under the Orthopedics section of the PANCE, which counts for 10% of the test, it isn’t heavily emphasized during PANCE review courses or in PA school, for that matter. I think our program probably spent 1 week or less on Rheumatology. This part of the test doesn’t have to be scary and it doesn’t have to be a bunch of memorization, either. Just remembering the basics can get you the answers you need to a few questions on the PANCE so that you’re not missing the easy “quick and dirty” questions.
    A good place to start is with lupus. Lupus is an autoimmune disease that can affect many systems and one of the most challenging aspects about diagnosing it is that many of the symptoms are nonspecific and overlap with other common conditions. You’re almost guaranteed to have a question or two on lupus on your PACKRAT, EOR Exam, PANCE or PANRE. The thing to note about all rheumatological conditions are their overlaps and subtle differences. Lupus has a very characteristic malar rash that is often tested over - keep in mind they can give you a description or photo with a corresponding vignette. Don’t focus too much on all of the manifestations of lupus. It can appear quite vague most times and is often a diagnosis of exclusion.

    Friday, November 25, 2016

    5 Tips on Taking the PANCE

    5 Tips on Taking the PANCE
    Updated: 11/25/2016
    After studying for the PANCE for about the past month and a half, I will finally be releasing a review of (most) resources for you all - my loyal readers. First off, a huge thank-you to all of you for your interest in the PA profession; whether you’re just starting your journey or close to finishing, I hope that my blog has influenced your life for the better. Thank you all for sticking with my blog even through the past month or so when I’ve been absent from almost all forms of social media.

    Second, I’d like to start out by saying that I took my PANCE on a Tuesday and received my results the following Wednesday. Guess what? I passed! I’m now officially a certified physician assistant and am so grateful to have made it this far. My next journey begins as a PA at Children’s Health in Dallas working in Neurology.

    Now, let’s get back to why you’re here - the PANCE. This test - while the ultimate determinant of your career - should not be feared. It can be both challenging and deterring, but not impossible. While there are many forums online promoting or demoting the many products, question banks, and review courses, I’m here to give you my own opinion on most of the popular ones out today. Though this review is not intended to be all inclusive, I hope to give you all a starting place no matter your budget or timeline.  

    Please review the NCCPA Content Blueprint Areas listed by Organ System here. Also, note that the site does mention that “Other content dimensions cross-sect these categories. For example, up to 20 percent of the questions on any exam may also be related to surgery or infectious disease, and up to two percent may also cover legal or ethical issues.” One area that I don’t believe PA programs emphasize heavily is legal issues surrounding healthcare. We do cover a lot of ethical scenarios in PA school - I think most programs do - as it's probably an ARC-PA requirement, but legal issues are not. The Healthcare Handbook is a nationally known text summarizing the basics surrounding healthcare in the U.S. and is a great review that I highly recommend prior to starting PA school.

    In my experience with the PANCE, I felt the rotation exams prepared me for the PANCE best by covering topics like surgery, emergency medicine, and pediatrics in great detail. Old PACKRAT questions were great for review as well as they give you a sneak peak into the vignette style questions you may encounter on rotation exams, PACKRAT, and PANCE. You can go here to learn more about the PACKRAT. In addition, PACKRAT files may be found online but the best place to check is Quizlet!

    As stated previously, there are many options available to help you review for the exam. During my clinical rotations and month and a half study session, I utilized many of these resources myself to help gauge what I felt was most helpful. While I will not endorse one product over another, I will offer suggestions as to what I think would have been an appropriate study plan. Here are 5 tips on taking the PANCE. Stay tuned for my full review of PANCE resources, coming soon.

    5 Tips on Taking the PANCE

    Tuesday, October 11, 2016

    Heart Murmurs and Valvular Heart Disease

    Heart Murmurs/Valvular Heart Disease*
    • Most common causes of mitral/aortic valve disorders are congenital defects; other causes include rheumatic heart disease, connective tissue disorders, infection, sensile conditions
    • Most common presenting symptoms: dyspnea, fatigue, decreased exercise tolerance
      • Other: Cough, rales, paroxysmal nocturnal dyspnea or hemoptysis, hoarseness
      • Physical exam - heart murmur +/- palpable thrill  
    • Diagnostic Studies
      • EKG - not useful for specific diagnosis → shows chamber hypertrophy
      • CXR
        • Aortic → left sided atrial enlargement, ventricular hypertrophy
        • Mitral → atrial enlargement only
      • Echo (transesophageal) and cardiac cath → definitive
    • Treatment
      • Surgical repair or replacement of defective valve
      • Good exercise tolerance → diuretics and vasodilators for pulmonary congestion and digoxin or BB for dysrhythmias
      • Anticoagulant therapy for thromboemboli prophylaxis
      • Antibiotics to prevent endocarditis and recurrent rheumatic fever

    Mitral Valve Prolapse

    Regurgitant flow across mitral valve
    Decreased left ventricular volume results in earlier prolapse and click heard earlier in systole, closer to S1

    Increased left ventricular volume results in delayed prolapse, click heard later in systole

    Thin females with minor chest wall deformities

    Associated: Ehlers-Danlos, Marfan Syndrome, Mitral Regurgitation
    1. Mid-systolic click
    2. Followed by a mid-to-late systolic murmur (mitral regurgitation)
    3. Loud S2

    “Click” is caused by prolapse of leaflets into left atrium and tensing of mitral valve apparatus
    1. Maneuvers that increase left ventricular end diastolic volume (preload)/worsen: seated/standing → squatting
    2. Maneuvers causing delay in prolapse: handgrip, standing from seated position, valsalva

    Health Maintenance
    1. Leads to mitral regurgitation
    2. Predisposed to infective endocarditis
    3. ADA no longer recommends prophylactic antibiotics for MVP

    Saturday, September 17, 2016

    Multiple Sclerosis, Guillain Barre, and Amyotrophic Lateral Sclerosis (ALS)

    Multiple Sclerosis, Guillain-Barre, and ALS commonly appear on exams because of their similarities, but its the subtle differences and keywords you should look out for, especially on physical exam. While historically, the PANCE and PACKRAT are only 6% Neurology questions, these are a few that you shouldn’t miss. Do you know multiple sclerosis as well as you think you do? Would you be able to diagnose and work someone up for ALS if you saw their presentation in an ED? Guillain-Barre has its own special findings on lumbar puncture that you don't want to forget. If it's in your differential and you can rule out things like meningitis, make sure you know the things you'd expect on a lumbar puncture. These are all great points to know, though this is not meant to be an all-inclusive review. You'll definitely want to review multiple sclerosis medications before your exam, including which are first line and which are actually long term (disease modifying) vs. acute treatment. Good luck out there!

    I hope this review helps you regardless of which avenue you find it useful. Make sure to check out TrueLearn’s free sample questions below! The vignette style questions are exactly what you need to prepare yourself for EOR, PANCE, PACKRAT, and PANRE-related questions.

    Monday, August 15, 2016

    Strokes, Hemorrhages, and Aneurysms

    Strokes and TIAs will 100% for sure be on your PANCE/PANRE/PACKRAT, you name it. While historically, the PANCE and PACKRAT are only 6% Neurology questions, these are a few that you shouldn’t miss. After completing my general neurology rotation, I quickly learned that the answers to these complex puzzles was definitely time-dependent. Can you think on your feet and generate a differential diagnosis? Attention to tiny details was crucial for Neurology because that’s how you can tell what part of the brain the ischemia/infarction is coming from.

    I hope this review helps you regardless of which avenue you find it useful. Good luck and make sure to check out TrueLearn’s free sample questions below! The vignette style questions are exactly what you need to prepare yourself for PANCE related questions. Good luck!

    Transient Ischemic Attack, Cerebrovascular Accidents (CVA) or Stroke, Bell’s Palsy
    • Evolving stroke: worsening
    • Completed stroke: maximal deficit has occurred
    • Duration of symptoms is the determining difference
    • Transient Ischemic Attacks (TIA)
      • Neurologic deficit that lasts few mins to <24 hours (N: 30 mins)
      • Symptoms transient because reperfusion occurs due to collateral circulation or breaking up of embolus
      • Blockage in blood flow does not last long enough to cause permanent infarction
    • Clinical Pearls
      • Triptans are contraindicated in patients with coronary artery disease or peripheral vascular disease and should be avoided in all patients with an increased risk for stroke
      • Contraindications to thrombolytic therapy: previous hemorrhagic stroke, stroke within 1 year, a known intracranial neoplasm, active internal bleeding, suspected aortic dissection. Relative contraindications: severe uncontrolled hypertension, use of anticoagulation, active peptic ulcer disease.
      • Hypertension is the most common and most important stroke risk factor