We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management of inflammatory bowel disease, appendicitis, diverticular disease, IBS, and more. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/bowelpart2

We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management of bowel obstruction, intussusception, colon cancer, and Hirschsprung Disease. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/bowelobstruction

We're here to provide you short & sweet PANCE review to help you PASS your exam. Today we'll be covering symptoms, diagnosis, and management PUD, gastritis, gastric neoplasms, and pyloric stenosis. For a complete copy of the show notes including today's take away points, please visit https://pastudysesh.blubrry.net/stomach

As always, we're here to provide you with the key blueprint information to help you PASS your PANCE. For full show notes, including my mnemonics and Take Away Points, please visit: https://pastudysesh.blubrry.net/esophagus

So you're procrastinating studying for the PANCE by scrolling through your Facebook Feed and there it is, another "Happy to announce that I'll be working for ______ as a PA!" post. As graduation inches closer, it seems to be all there is. You want to be happy for your classmates, but what you're really thinking is: why can't I find a job?. I want to share with you my experiencing in finding my first job after graduation and assure you that you are not alone in this feeling and that everything will be ok.

https://pastudysesh.blubrry.net/?p=185&preview=true

As always, we're here to provide you with the key blueprint information to help you PASS your PANCE. For full show notes, including my mnemonics and Take Away Points, please visit: https://pastudysesh.blubrry.net/carditis

Disclaimer: new guidelines as of late 2017

Unlikely to be reflected on PANCE yet.

New BP Guidelines:

Elevated: 120-129/< 80

Stage 1: 130-139/80-89

Stage 2: 140+/90+

Hypertensive crisis: 180+/120+ with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

Medication for Stage 1 only if high ASCVD risk (same calculator used in prescribing statins)

 

Now Back to the PANCE:

Hypertension

*  Definition

* Prehypertension 120-139/80-89

* Stage 1 140-159/90-99

* Stage 2 160+/100+

* Urgency 180+/120+ & NO end organ damage

* Emergency 180+/120+ & end organ damage (HERB)

* ON 2 DIFFERENT READINGS

* Symptoms

* Primary Hypertension is typically asymptomatic

* Hypertensive emergency

* Encephalopathy

* Intracranial hemorrhage

* Nephropathy

* Unstable angina/MI

* Papilledema=malignant hypertension

* Treatment (non-urgent/emergent)

* Lifestyle Modifications 1stALWAYS (Including those with Pre-HTN)

* DASH Diet

* Lower Sodium

* Exercise

* Healthy weight

* Smoking Cessation

* Medication Therapy

* Begin at 140/90 (this is also BP goal)

* Unless

* Over age 60

* Normal Kidneys

* No Diabetes

* Then 150/90

* Which med?

* 4 Main Classes to Choose From

* ACE Inhibitor

* Angiotensin converting Enzyme

* -“pril”

* Side Effects:

* Cough

* Hyperkalemia

* Angioedema

* Contraindications:

* Renal artery stenosis

* Pregnancy

* ARB

* Angiotensin II Receptor Blocker

* -“sartan”

* Side Effects:

* Hyperkalemia

* Angioedema

* Contraindications:

* Renal Artery Stenosis

* Pregnancy

* Calcium Channel Blocker

* -“dipine”

* More effective as vasodilators than verapamil and diltiazem

* Side Effects:

* Cardiac depression

* Still have some cardiac effects

* Thiazide Diuretic (HCTZ)

* Side Effects:

* Hypokalemia

* Gout

* Dyslipidemia

* Contraindication:

* Sulfa Allergy

* How to choose?

* If they have CKD or DM

* ACE/ARB (Renal Protective)

* African American

* TZD or CCB

* None of the above?

* Then just pick one!

* You can max out the dose before adding a 2ndor add a 2ndif goal isn’t met, doesn’t matter

* NEVER MIX AN ACE AND AN ARB

* Both inhibit the RAAS

* Renin angiotensin aldosterone system

* So at most, they’ll be on ACT

* Other possible additions

* Beta blockers “olols”

* fib

* Post MI

* Stable Angina

* Heart failure

* Alpha blockers “zosin”

* Pts with BPH

* Pregnant? Use Methyldopa

* Resistant to medication? Consider secondary hypertension

* Renal artery stenosis

* Coarctation of the Aorta (think Peds)

* Sleep Apnea

* Pheochromocytoma

* Primary Hyperaldosteronism

* Thyroid disease

* Treatment

* Urgency

* Decrease by 25% over 24-48 hours

* Rest in a quiet room

This episode is less about boards, more about being thorough and thinking about how to process an EKG systemically in order to not miss something. For boards, it’s ok to jump to what is glaring at you. No questions or take away points associated with this podcast.

As promised, here is my EKG Cheatsheet!

Evidence of a pacemaker?

* Failure to capture

* Heart doesn’t “capture” signal

* Pacemaker spike, but no P wave

* Failure to Pace/Oversensing

* Pacemaker is over sensing electrical activity

* HR is slow, pacemaker isn’t initiating beats

* Failure to sense

* Pacemaker ISN’T sensing natural heart activity

* sends unnecessary spikes

EKG Interpretation

1 box=0.04s wide x 1mm high

* Rate=how fast

* 6 second strip*10

* can be used for regular or irregular rhythms

* May also use 300-150-100-75-60-50 method

* Refers to # of large boxes in between R waves

* 1 large box=300bpm, 2 large boxes=150bpm

* Rhythm MUST be regular

* Tachycardia is ALWAYS tachycardia (>100bpm)

* regardless of sinus, junctional, or ventricular tachycardia

* Sinus

* Bradycardia >60

* Normal 60-100bpm

* Junctional

* Escape 40-60bpm

* Accelerated Junctional 60-100bpm

* Ventricular

* Idioventricular 20-40bpm

* Accelerated Ventricular 40-100bpm

* Rhythm=pattern

* normal=atria, junction, ventricals

* 1. Should be able to march caliper along R-R intervals without adjustments

* If no, we already know the rhythm is irregular

* 2.  Do we have distinct P waves?

* No?

* Junctional rhythm?

* inverted or absent p waves

* normal QRS complex

* non-compensatory pause

* Ventricular rhythm?

* absent p waves

* wide-bizarre complex

* pre-mature ventricular contraction with compensatory pause

* A fib?

* Yes? Does each P have a QRS?

* No?

* A flutter

* 2nd/3rd degree heart blocks

* 3. Determine if regularly irregular or irregularly irregular.

* P wave

* Normal=2.5×2.5 boxes

* Represents atrial depolarization

* Too wide? (3 boxes)

* Left atrial enlargement

* May also be M shaped

* Left is LONG

* Too tall? (3 boxes)

* Right atrial enlargement

* PR Interval

* Normal= 0.12-0.2s (3-5 boxes)

* Too long?

* Consistent=1st degree heart block

* Inconsistent= 2nd degree heart block (Type 1 or 2)

* Too short? = Pre-Excitation Disorder

* Wolf-Parkinson-White

* Also has delta wave

* Lown-Ganong-Levine

* QRS Complex

* Normal = less than 0.12s (3 boxes)

* Too wide?

* Bundle branch block

* Left

* Deep S in V1 (carrot)

* Broad R in v6

* Right

* RsR’ in v1 (rabbit ears)

* Wide S in v6

* Ventricular rhythm

* Wide, bizarre complex with no p wave

* Height?

* Right ventricular hypertrophy

On this week’s episode, we will be attacking heart failure and finishing off cardiomyopathies. Check out the congenital heart disease episode for information regarding hypertrophic cardiomyopathy here.

Heart Failure

* Systolic vs diastolic

* Systolic #1

* Heart isn’t strong enough to pump blood

* Decreased ejection fraction (aka HFrEF)

* Thin ventricular walls

* Dilated ventricles

* + S3 (passive ventricular filling)

* Etiologies

* s/p MI

* dilated cardiomyopathy

* valvular disorders

* Diastolic

* Heart can’t relax enough to allow chambers to fill

* Normal or increased ejection fraction (HFpEF)

* Thick ventricular walls

* Small VL chamber (small volume)

* + S4 (forced atrial contraction into stiff ventricle)

* Etio:

* HTN

* LVH

* Left vs Right

* Left

* #1 causes are CAD & HTN

* Symptoms

* Remember that left side of the heart takes blood from the lungs and pumps it to the body.

* Slow down that pump=fluid backs into the lungs

* Dyspnea

* Increased pulmonary venous pressure

* Pulmonary congestion

* Rales

* Rhonchi

* Orthopnea (how many pillows??)

* Paroxysmal nocturnal dyspnea (wake up gasping for air)

* Chronic, non-productive cough

* PINK, FROTHY SPUTUM

* CHF=#1 cause of transudative pleural effusions

* HTN

* Cheyne-Stokes breathing

* Deep/fast breathing with periods of apnea

* S3/S4 depending on systolic or diastolic

* Picmonic

* Right

* #1 cause =left

* Right side is the “gentler” side of the heart

* Right side of the heart can’t work against the increased pressure created in the lungs

* Right side takes blood from body to lungs

* Slow it down=fluid backs into body

* Peripheral edema

* Pitting edema

* JVD

* GI/hepatic congestion

* Hepatosplenomegaly

* Many other GI symptoms

* Imagine you’re full.

* Picmonic

* Diagnosis

* Echocardiogram #1

* Measures ventricular function & EF

* Normal EF =55-60%

* <35% need for defibrillator placement

* CXR

* Pleural Effusions (#1 cause of transudative effusion)

* Kerley B lines

* Butterfly pattern infiltrates

* B-type natriuretic peptide or brain natriuretic peptide (BNP)

* Released by ventricles during volume overload

* >100=CHF likely

* Management

* Acute (aka decompensated or congestive)

* LMNOP

* Lasix (loop diuretic)

* Morphine

* Nitrates

* Oxygen

* Position (upright decreases venous return)

* Maybe digoxin

* Chronic Systolic

* SWABD

* Sodium <2g/d

* Water <2L

* ACE/ARB 1stLine!

On this week’s episode, we’ll be discussing vascular disorders. Please note that we’ll be discussing arteriovenous malformations in the neurology chapter.

Peripheral artery disease

PAD Picmonic Here!

* Pain in lower extremities increased with exercise, relieved with rest

* Called claudication

* Imagine angina for the legs

* Most commonly in the calf

* Physical exam

* Decreased pulses

* Decreased cap refill

* Atrophic skin changes

* Thin/shiny skin

* Hair loss

* Cool limbs

* Pale on elevation, dusky red with dependency (dependent rubor)

* Lateral malleolar ulcers with well-defined borders

* No artery on the lateral side

* Diagnosis

* Ankle-Brachial Index

* Ratio of BP at ankle compared to arm

* Lower BP in ankle=less blood flow=lower index

* Screening tool

* + if ABI <0.9

* Arteriography

* Gold Standard (because it SHOWS us occlusion)

* Usually only done in practice if revascularization planned

* Management

* Platelet inhibitors

* Cilostazol

* Useful for intermittent claudication

* ASA

* Clodpidogrel

* Exercise!

* Revascularization

* Angioplasty

* Fem-pop bypass

Acute Arterial Embolism

* Can be a complication of PAD

* Thrombus=originates at that spot embolus=originates elsewhere, then lodges

* 6Ps

* Paresthesias

* Pain

* Pallor

* Pulselessness

* Paralysis

* Poikilothermia

* Same as the 6Ps of compartment syndrome!

* Except these patients complain of paresthesias first (and different risk factors)

* “Cut off your circulation”=numb and tingly

* Compartment syndrome=squeeze tightly (like with a cast)=painful

* Tx: Heparin, Thrombolytics if thrombus, embolectomy if needed.

AAA

* >3.0cm

* Most often occurs infrarenally

* Risk Factors:

* Atherosclerosis #1

* Age >60

* Smoking!

* Male

* Connective tissue disorders

* Laplace’s law: larger aneurysms expand more quickly

* Symptoms:

* Often none

* Tender, pulsatile abdominal mass

* Rupture: severe back/abdominal pain, syncope, hypotension

* Diagnosis:

* Abdominal ultrasound

* Initial study of choice

* Used for monitoring (discussing in a minute)

* CT:

* thoracic aneurysms

* pre-surgical planning

* Angiography

* Gold standard (again, shows us a picture)

* Management:

* Beta blockers to decrease rupture risk

* 3-4cm: ultrasound Q1year

* 4-4.5cm: u/s Q6months

* >4.5cm: referral to vascular surgeon

* >5.5 cm or >0.5cm growth in 6 months: immediate surgical repair

Aortic Dissection

* Tear in the intima layer of the aorta

* Creates a false lumen

* Most often ascending (aortic highsections)

* Most fatal

* Risk Factors

* Hypertension

* Age 50-60

* Connective tissue disorders may present younger

* Symptoms: