Strokes, Hemorrhages, and Aneurysms

Strokes

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

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

Cell Wall Synthesis Inhibitors

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

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

Pancreatitis and Pancreatic Cancer

Pancreatitis and Pancreatic Cancer

I can’t even stress to you how frequently PA students are tested over pancreatitis (acute and chronic) and pancreatic cancer. It seems to be one of those vague presentations that test writers take advantage of by placing in distractors (answers that seem right, but are in fact incorrect). This is meant to be a short, but hopefully helpful review of each of them, so that you are better prepared to tackle questions on these topics regardless of if they’re your in house exams during didactic, rotation exams, the PACKRAT, the PANCE, or the PANRE. I hope this helps you regardless of which avenue you find it useful. Good luck and make sure to check out TrueLearn’s free sample questions below! I’ll say, I loved their gastroenterology section the most. The vignettes were on point and difficulty wise - they were spot on with the rotation exams and PANCE-style questions.

Acute and Chronic Pancreatitis

Introduction to Behavioral Health

Introduction to Behavioral Health

Updated: 04/22/2016

The Multiaxial System - used previously in DSM 4 (now DSM 5 is used, but we should still understand and recognize the importance of these axes).

1. Axis I – serious mental illnesses (mood, anxiety, eating, sleep, impulse-control, adjustment)
2. Axis II – personality disorders +/- mental retardation
3. Axis II – general medical conditions (neoplasms, injury, poisoning)
4. Axis IV – psychosocial and environmental problems (educational problems, economic, housing, access to healthcare)
5. Axis V – GAF (1-100) = global assessment of functioning

Terminology

AFFECT - The patient’s present emotional responsiveness, inferred from patient’s facial expression, including amount and range of expressive behavior [objective: what you observe about pt]

Appropriate	Inappropriate	Congruent	Incongruent
Appropriate amount of eye contact, facial expression, responsiveness, etc.	Incongruent with content or social norms	Psychotic content consistent with patient's mood	Psychotic content inappropriate to patient's mood

Restricted	Constricted	Blunted
Reduced intensity of affect – lesser degree than blunted	Restricted affect	Severe reduction in intensity of affect

Flat	Exaggerated	Labile
Virtually no signs of affective expression, no facial expression, monotonous voice	Dramatic, overly expressive	Fluctuating, rapid changes in emotion unrelated to external stimuli

Seizures, Headaches, and Migraines

Seizures, Headaches, and Migraines

Updated: 04/18/2016

Seizures, headaches and migraines are some of the most commonly occurring questions on the PACKRAT, rotation exams, PANCE, and PANRE. Since they also occur commonly in practice, you’ll definitely want to cover these topics thoroughly. Knowing the subtleties between each and the questions to ask is important not only for your understanding, but so you can treat the patient accordingly with the most appropriate therapy.

While Neurology only makes up 6% of the PANCE, knowing topics like this well can mean the difference between passing and not passing. As I have stated before, one of the best ways to prepare for your exams is through quality question banks and study guides. TrueLearn has introduced an incredible opportunity to work with the PA-student and PA community to help us excel in our didactic education and clinicals, and on our boards. See below for our second post discussing Seizure Disorders and Headaches and Migraines.

Remember from last month that TrueLearn’s SmartBanks include specialized medical content crafted to mirror rotation exams, the PACKRAT, the PANCE and the PANRE. This means that the best test writers have come together to write questions that not only get your juices flowing, but challenge you to think critically - the most important characteristic of great PAs.

Visit TrueLearn.com/Physician-Assistant/ today to learn more about their physician assistant products.  

Disclosure: I am not an employee of TrueLearn.

Seizure Disorders - sudden abnormal discharge of electrical activity

• Epilepsy - syndrome of recurrent, idiopathic seizures

• In seizures, duration of unconsciousness tends to be longer than in syncope (momentary)
• In syncope, bladder control is retained, but lost in seizures
• Causes: four Ms and four Is
• Metabolic and electrolyte disturbances - hyponatremia, water intoxication, hypoglycemia and hyperglycemia, hypocalcemia, uremia, thyroid storm, hyperthermia
• Mass lesions - brain mets, primary brain tumors, hemorrhage
• Missing drugs
• Non-compliance with anticonvulsants (most common reason)
• Acute withdrawal from alcohol, benzos, barbituates
• Miscellaneous
• Pseudoseizures - psychiatric in origin
• Eclampsia
• Hypertensive encephalopathy
• Intoxication - cocaine, lithium
• Infection - septic shock, bacterial or viral meningitis, brain abscess
• Ischemia - stroke, TIA (common in elderly)
• Increased ICP due to trauma
• Diagnosis
• If known epileptic → check anticonvulsant levels
• If first seizure
• CBC, CMP (LFTs), blood glucose, renal function tests, serum calcium, urinalysis
• EEG: most helpful diagnostic test, abnormal pattern is not diagnostic alone
• CT scan of head: r/o structural lesions
• MRI of brain with and without gadolinium: more sensitive than CT for structural changes
• LP/blood cultures if febrile
• Pregnancy test - before initiating anticonvulsants!!!
• Treatment
• ABCs first, secure airway and roll patient to side
• Known epileptics
• Check for non-compliance of anticonvulsant, check levels
• If persistent with monotherapy, increase dose of first anticonvulsant until signs of toxicity appear → add second drug if seizures uncontrolled
• If controlled → continue regimen x 2 years, then taper
• First seizure
• EEG with neurology consult
• Anticonvulsant therapy
• If normal EEG, recurrence low (15%) compared to abnormal EEG (41%)
• Do not treat patients with single seizure - start antiepileptics if EEG abnormal, MRI abnormal or status epilepticus

Introduction to Medically Important Bacteria

Introduction to Medically Important Bacteria

Updated: 08/07/2016

Types of Therapy

• Prophylactic Therapy – treatment initiated to prevent an infection that has not yet developed
• Ex. Antibiotic “prophy” to prevent opportunistic bacterial infections
• Ex. Antibiotics while on a trip to Mexico
• Ex. Antibiotics before surgery or dental procedures to prevent bacterial endocarditis
• Empiric Therapy
• Empiric – relies solely on observation or practical experience.
• Therapy initiated to treat serious infections until test results are available; or therapy for minor infections (URI’s, UTI’s) because causative organisms are predictable and their susceptibility to available antibiotics is known
• Definitive Therapy
• Start broad spectrum antibiotics before the culture and sensitivity results are reported. When they become reported, you know what will kill the bug in vitro and can tailor the therapy making it less broad and more definitive.
• The hospital antibiogram can assist with empiric or definitive therapies.
• Antibiogram
• The cumulative results of hospital performed bacterial susceptibility testing organized into a summary table which may be used by clinicians, pharmacists, infection control personnel and microbiologists as a reference guide to community or hospital-specific resistance patterns.