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/EORs, 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 EOR and 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

Wednesday, August 10, 2016

Antibiotics for PAs - Part I

Antibiotics for Physician Assistants - Part I
Updated: 08/07/2016
  • Empiric therapy is defined as the initiation of treatment prior to firm diagnosis, and knowing the specific organism causing the infection
    • Started only after cultures have been obtained
    • Targets likely pathogens and must use local antibiogram
  • Broad spectrum means covering both gram positive and gram negative bacteria
  • Pharmacokinetics: what the body does to a drug
    • Absorption: described in terms of bioavailability (F)
      • 100% bioavailable drugs (PO = IV): Linezolid, Fluoroquinolones, Tetracyclines, Azithromycin, Metronidazole, Trimethoprim/Sulfamethoxazole (Bactrim), Rifampin
    • Distribution: affected by protein binding, blood flow, molecular size, lipophilicity, inflammation, and fluid status
    • Metabolism: occurs primarily in the liver via multiple mechanisms
      • Phase I: oxidation/reduction (CYP 450), hydrolysis
      • Phase II: glucuronidation, sulfonation, methylation, acetylation, glutathione
    • Elimination: primarily renal (glomerular filtration and tubular secretion)
      • Most antibiotics require dose adjustment for creatinine clearance (CrCl) <50 mL/min
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Cell Wall Synthesis Inhibitors

Sunday, August 7, 2016

Sixth Semester at UTSW

Sixth Semester at UTSW
Updated: 08/07/2016
Below is a schedule taken from our program website detailing the clinical rotation schedule. Each student’s rotations are already set up for them (a huge plus), as I learned at the PAEA conference this year that not all PA programs do this. Some programs require that you setup your own rotations. Additionally, I appreciated an increased level of security that our rotations were quality - something not all programs ensure. Our rotations have been vetted before, dropping sites and preceptors who do not meet a high enough standard for our students. Our clinical coordinators have also done a great job of ensuring preceptors provide feedback to our students and that we get the most experience on each rotation, never being left in the shadows.

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This year our class also joined the many PA programs utilizing PAEAs end-of-rotation (EOR) examinations, streamlining the examination process and unifying rotation evaluation with an enhanced & secure online experience mirroring the PANCE. After each 120-question exam we received feedback about our performance, including a topic list of each type of question we missed and the task area. The content of the exams is provided by PAEA in a blueprint style and topic list format.

During the spring of 2016, I went through internal and family medicine, which were both 8 week long rotations. I was at Parkland and Zale-Lipshy hospital for my internal medicine rotation and I was in Bridgeport, Texas for my rural family medicine rotation. Both presented great opportunities for learning and included lots of 1-on-1 time with my preceptors as well as lots of procedural learning opportunities. Of note, since I was about 1 hour away from home during family medicine, my PA program located, secured, and paid for housing for all 8 weeks. This is something UT Southwestern does for all of its rural family medicine rotations - we are all very fortunate to have this provided for us.

Monday, July 11, 2016

Free Category 1 CME Credit Opportunity

Free Category 1 CME Credit Opportunity
Updated: 07/11/2016

I wanted to take the time to introduce Matt Borges, who has been a PA since 2007.  After graduating from Wake Forest University, Matt spent the majority of his professional career in emergency medicine, where he says every day is an opportunity to encounter the unexpected.  Over the last few years, he has had the pleasure of precepting students, which he claims to serve as a real life reminder that the more you think you know, the more you realize you always have plenty to learn.  

Over the past year, Matt has taken an interest in online educational webinars. While they were initially targeted toward PA students, they spread to an array of health care professionals. Webinars were originally designed to cater to APC's in emergency rooms, urgent cares, and primary care offices, but they also offer exposure to health professionals early in their careers who are still trying to sort what best suits their interests.  

Matt typically teams up with a physician, serving as the expert opinion in their particular field, and walks through cases pertinent to the particular topic. This format has been met with positive reviews, and offers a methodical approach to common issues encountered.  He works to produce webinars every few months, with free registration and opportunity for 1 hour of category 1 CME credit.  

The most current program is on common presentations of pediatric fevers in an ED, happening Tuesday July 12th at 7:30 PM-8:30 PM Eastern Time.  

Registration Here

I hope you'll find a topic that interests you, and check one out, soon!

Matthew M. Borges, PA-C, MMS
APC Director, Virginia Emergency Medicine Associates

Friday, July 8, 2016

Introduction to EKGs for Physician Assistants

Intro to Electrocardiograms for Physician Assistants
Updated: 07/08/2016

Electrocardiocardiograms can be difficult to tackle and I know that this is a topic that I repeatedly visit, both for simple things like delineating PVCs (premature ventricular contractions) from PACs (premature atrial contractions) and denoting what defines a second degree type 1 versus a second degree type 2 heart block. But there’s so much more than just that - there’s right and left bundle branch blocks, right and left ventricular hypertrophy, ischemia, infarction, axis deviation, atrial hypertrophy, etc. While this is a very limited approach to EKGs and while there is still much to learn about them, this is a great introduction to EKGs for any student, whether you are pre-med, pre-PA, pre-NP, pre-nursing, or pre any other health profession. At the end of the review are a few helpful questions provided by TrueLearn you can use after you’ve studied the review, which offer you some insight into the type of questions and degree of exam preparation offered. I hope that you find them as useful as I have. Good luck and let me know if there are any errors or questions!

Electrocardiogram (ECG): records the electrical activity of the heart and information about the heart’s function and structure
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Tuesday, July 5, 2016

First Rounds Call For Articles

My Plans After Graduation
The flexibility of the PA profession allows us all to practice medicine in various specialties, subspecialties, primary care, population health, public policy, internationally, and beyond. Do you have any fascinating plans after PA school? Planning to work or volunteer abroad? Working for the Peace Corps? Applying for postgraduate fellowships, residencies, or other post-graduate training? First Rounds - PA Professional's student news section - is looking for stories about unique opportunities after PA school.

Tell us how your plans after PA school are unique. We ask that articles be no longer than 600 words and written in a conversational manner. For more information or to submit a proposal, contact First Rounds at FirstRoundsSubmission@gmail.com. First drafts are due by July 30th, 2016.

Monday, July 4, 2016

The PA Foundation Reception

The PA Foundation Reception
Updated on: 07/04/2016
A few months ago I was asked to speak at the PA Foundation’s Donor Recognition Breakfast at the 2016 AAPA Conference, which I was eager to accept especially after all that they had done for me in the preceding months. [Insert: I was previously accepted as one of the 18 recipients and the 2015 Bristol-Myers Squibb Endowed Scholarship Recipient]. More on Bristol Myers Squibb here.

I don’t say, ‘Thank You’ often enough for the hard work others put in, but it is definitely deserved. So, ‘thank you’ to everyone at AAPA and the PA Foundation who work tirelessly to ensure that students like myself can achieve their dreams of becoming a PA on top of making other milestones for our profession. Special thanks to Caroline Pierce and Key Ideas for working on my ‘impromptu nonsense of a speech’ and creating this incredible video to promote the PA Foundation Scholarships for future PA students.


Thursday, June 9, 2016

Introduction to Radiology for Physician Assistants

Introduction to Radiology for Physician Assistants
Updated: 06/09/2016
In this post, I hope to introduce you all to the differences between imaging modalities, including indications and contraindications. My goal is also to provide a basic understanding of the concepts surrounding density and normal x-ray findings. Future posts will investigate the findings for pneumonia, pneumothoraces, effusions, atelectasis, fractures/dislocations, arthritis, intracranial, GI and hepatic pathology, bowel, lines/tubes, and heart disease.

Conventional Radiography (Plain Films)
  • Images produced through use of ionizing radiation
  • No contrast material (barium or iodine)
    • Why it’s important: Large doses of radiation can produce cell mutations leading to cancer or anomalies. Even low levels of radiation are teratogenic (avoid in pregnancy).
  • Relatively inexpensive, obtained easily (portable, mobile), most widely used
  • Common uses: chest x-ray (CXR), abdominal x-ray, and for fractures or arthritis

Computed Tomography (CT or CAT Scans)
  • Uses a gantry with a rotating x-ray beam and multiple detectors with sophisticated algorithms to process the data
  • Expensive equipment, lots of space, and high computer processing power required