The Audio PANCE and PANRE Physician Assistant Board Review Podcast

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:

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

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

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

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

DX: Screening to detect amblyopia in all children younger than 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

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

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:

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

Answer: A. Hepatitis A

Hepatitis A is transmitted via the fecal-oral route

Incorrect Answers:

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

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

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:

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

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

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:

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

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

Answer: B. Selective serotonin reuptake inhibitors

The patient most likely has panic disorder. The DSM V criteria for panic disorder include the following:

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

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

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!

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.

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.

You can also click here to listen to or download this episode.

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.

So, let’s talk about all these three people we’re going to have to interact with.

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.

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.

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.

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.

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

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:

Below you will find an interactive exam to complement the 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.

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

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

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)

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

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

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)

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

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)

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

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)

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

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)

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

Answer: D Grade IV

This is a Grade IV permanently prolapsed hemorrhoid. (Review topic: Hemorrhoids)

Incorrect Answers:

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

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

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

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

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

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

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!

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.

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.

You can also click here to listen to or download this episode.

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.

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. 

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:

And that’s what’s going to happen. Don’t ever say that to the nurses!

What should you say instead?

What you should say to the nurses goes something like this: “hey, so what’s your input?”

It’s that easy!

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. 

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!

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.

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:

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.

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.

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!

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

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).

Special from today’s episode:

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.

Below you will find an interactive exam to complement the 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 the PANCE and PANRE Academy and Smarty PANCE.

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

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?

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.

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?

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:

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?

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:

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?

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:

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?

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:

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?

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:

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?

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:

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?

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:

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?

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

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?

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:

Review NCCPA Blueprint Topic: Infectious Diarrhea (ReelDx + Lecture)

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!

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

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.

Download for PANCE Download for PANRE

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.

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 the PANCE and PANRE Academy and Smarty PANCE.

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

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.

Just search for “The Audio PANCE and PANRE” in your favorite podcasting program or use the following links.

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

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.

Download for PANCE Download for PANRE

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.

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 the PANCE and PANRE Academy and Smarty PANCE.

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

Here are selected audio tips from today’s episode covering the most important points.

In other words, if something carries 51% weight versus 49% weight, the 51% weight wins.

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.

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

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.

Download for PANCE Download for PANRE

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:

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 the PANCE and PANRE Academy and Smarty PANCE.

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

The following questions are linked to NCCPA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website

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?

Steps to answering this question

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?

Steps to answering this 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?

Steps to answering this question:

4. Which of the following patients should be classified as having unstable angina?

Steps to answering this question:

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.

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

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.

Download for PANCE Download for PANRE

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:

Below you will find an interactive exam to complement the 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 the PANCE and PANRE Academy and Smarty PANCE.

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

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

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.

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

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.

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

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.

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

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.

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?

A. Digoxin

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.

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

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.

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

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:

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

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

Diagnosis

Treatment

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

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.

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

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.

Review PAEA EOR Blueprint Pearls With Links to Topic Lesson: Internal Medicine Rotation: Cardiovascular (PEARLS) ⇒ Heart murmurs

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!

Follow this link to download your FREE copy of the PANCE Content Blueprint Checklist

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.

Download for PANCE Download for PANRE

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

Special Links From Today’s Episode:

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

This FREE series is limited to every other episode, you can download and enjoy the complete audio series by joining The PANCE and PANRE Exam Academy + SMARTYPANCE

I will be releasing new episodes every few weeks. Smarty PANCE is discounted, so sign up now.

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

0:00

Welcome, PA, world. My name is Joe Gilboy, PA-C. I work with Stephen Pasquini with the smarty PANCE website.

Today’s podcast is going to be on how to prepare for the PANCE, which is a very big subject and a very important subject to a lot of you guys out there. So come on guys, let’s get this game roll, and let’s learn how to prepare for the PANCE.

0:33

Hello, PA podcast world. My name is Joe Gilbert. I’ve been a PA for about 35 years, with all my time being in the emergency room.

I’m a graduate of the Duke University PA program from 1984. I started helping students prepare for the PANCE and PANRE starting in 1990. So, as you can imagine, I’ve had a lot of students come through my hands. The answer is greater than 10,000. I’ve taught in several schools here in California I teach at several schools in Nevada. I also help in Tennessee. I help in Ohio, I help in Georgia, so I am around in a lot of different places, but for today, let’s get you ready to take the PANCE. So I know a lot of ways to get students prepared. So, let’s start.

1:14

So, today’s podcast is actually going to be on how to prepare for the PANCE. So before we get going into the very specifics, let’s look at so just come some basic guidelines as a student as you’re getting ready to take the PANCE. So, the first thing that we need to actually do is study! I now I know this sounds a little oxymoronic, but you’d be surprised how many students I’ve met along the way, do really well in PA school, you know, they do well in their grades they do well in their End of Rotation Exams, they feel like they don’t need to study. This couldn’t be farther from the truth.

1:44

So usually what I tell most students to do is start preparing for this exam literally about a year before it comes. What you don’t understand and what’s coming is that when you get towards the end of your PA school, you’re going to be so burned out is just amazing how burned out you’ll be, and you’ll see that especially when you go out on rotations and come back for maybe your callback week, or maybe End of Rotation Exam or some kind of maybe specific lecture, and I can guarantee you on that first day back, when you’ve been gone on rotations, it’s like pulling teeth, you’re like, oh, I’m back in this room, again, that I’ve spent so much of my life, I don’t want to be here. And it’s like, your mind’s just not ready for it. So, what I tell my students to do, instead of trying to cram this all in at the end, play it out.

2:28

So basically, about a year before, start getting ready for this. So what I tell most people to do study. Now, one of the questions that commonly comes up is how much do I study? And at most, most people, I tell them, if you can get up to like maybe two hours or three hours a day, that’s great. Max is four. So you’ll see there’s a lot of studies out there that will show that if you take a human being and actually get them studying for more than about three hours, three and a half hours they do not retain and then things get a little frustrating. So two to three hours if you can, no more than four. And of course, you know, always give yourself a day off.

3:13

The other thing about studying is the worst place to study. Yeah, where are you going to study guys home? And so what you have to understand is that when you’re studying, you actually need stimulus free. So your cell phone is off. Now I know this is a big one for most of you young millennials out there; you’re going “what, I have to turn it off?” That’s right. Don’t worry; the world will keep revolving with the cell phone off. But one of the things they’ve done there’s a lot of studies out there showing that when a cell phone is on, literally 15% of your brain is waiting for that thing to go off. I need that 15% of the brain getting ready for the PANCE, and at the end of the day, guys, there’s no cell message or text messages that’s that important. They can always call 911. So again, just make sure your cell phone is off. This is a big thing to really keep in the back your head.

4:00

The other thing sometimes people like to work together and groups. Groups are great. Study groups work well; just the key thing to a study group is that as you’re in the group, you have to teach the other student, maybe about a subject. And you see when you’re a teacher, you have to know a subject twice, once for your own knowledge, but second to be able to present it that knowledge to another person. So study groups do work.

4:09

The other thing I tell people to do is print out the PANCE blueprint. It’s pretty extensive and pretty large if you’ve ever seen it, it’s a very large extensive blueprint. And what I tell people to do, so go the NCCPA website, print out the blueprint.

Download for PANCE Download for PANRE

4:33

Then what you do, it’s like, let’s say you get to your cardiovascular and let’s say it says mitral stenosis. So, what I tell my students to do is actually physically write down the word mitral stenosis, and then just jog down some quick notes about things that you memorize in school, and you’re like, I think I remember opening snap. I think I remember rheumatic fever. I think I remember somebody Jones, Jone’s criteria. Jones something, I remember and then stop. And then at that moment, what you do is you start reading up on other things about the Jones criteria. So, in other words, you write more notes to help you out and stuff like that. And this is one of the things that I tell a lot of students to do. Because believe it or not, when you write something down, you know, it’s twice, once for thought, second for motor. For example, just to show you how your brain works, and I know you did this in PA school, you wrote down a note, maybe like, on your one note on your computer, or maybe you wrote it down on a handout that you’re given. You took the test. There you were on the test going. What was it again? I wrote about Jone’s criteria? God, I can’t remember this question. I know I wrote it down somewhere, but I can’t remember. And as soon as the test is over, you walk outside, and you know exactly where it is on your notes. It is in the upper right-hand corner of circle than pink. Welcome to your Brain, you wrote it down once for thought and then second for motor. So when we do this, we actually locking it. I’m not saying that we need to write a dissertation on mitral stenosis, what I’m really saying to you is that just write down some quick notes and try to make this more kind of like thought friendly, like, hey, this is what I remember. And this is what makes sense. And then you read up on the Jones criteria like That’s right. Fevers, minor, even though I want to make it major and things like that. So that tends to work out really well with my students.

6:28

The other thing that we’re going to do, and I’ll try to help you guys out, is with the ambiguous questions. Who got into a test, you’re taking the test? And you were choosing between A and B. And you were like, I think it’s A I think it’s B thing? It’s A I think it’s B. And so, there was this ambiguous question, and you couldn’t figure out which was the right answer. So you felt like you’re in this what I call ambiguous 50/50 game. So when we play the ambiguous 50/50 game, there are a couple things you need to do. Just a little test-taking technique that works all the time. One, keep it simple. The simple answer is usually the correct answer one more time; the simple answer is usually the correct answer.

7:06

If one answer outweighs the other, even if it’s to a 51/49 edge. In other words, 51% of the time is right here. 49% of the time, it’s right there. What do I take? The 51! So, it only takes 1% to push me over. So one more time. Keep it simple. And the one that weighs just a little bit more than the other? That’s your answer.

7:30

Every now and then, what you’ll see is that student’s kind of miss like a little, like a little piece of the word up in the question. In other words, most likely, at least likely first line, second line. So again, as we go through test questions, we have to be really alert about all the various words they use. And remember at the end of the question is what I call the hook. So sometimes what students will do is they’ll read the last line of the question, so we’ll just say, you know, there’s a question, and it says, What’s the most likely treatment. So as you go to the question, you realize this is what it’s asking for is a treatment. So the whole time you read the question like, so what’s going to be the treatment for this patient? Maybe it’s a CHF, pneumonia, whatever it may be. So again, another test-taking technique that kind of works pretty well. Yeah, try saying that five times fast.

8:21

The other thing that I tell students to do, and hopefully this, this handout will also be up there on the smarty PANCE website on how to prepare the seven major points, which is what we’re going over is to control your x-factors. This is huge. Guys. If I had to put my 30 years of teaching students into a paragraph, oh, this is it. So when I say control your x-factors, what I’m saying to you is this is that as you get ready to take this PANCE, don’t change your emotional or social wellbeing at all. Now granted, you can’t prevent certain things from coming like a death in the family and illness, things like that. But don’t create chaos is what I always tell my students because PA school is chaotic enough; the last thing you need to do is create more chaos. So don’t try to change your relationships during PA school, just play them out. Don’t try to change your surroundings, don’t buy anything big. I mean, come on, guys, every single one of you guys is in debt. So, going out and buying a Tesla is not the smartest thing to do before the PANCE because now you’re kind of worried about how am I going to pay for this Tesla. And I always tell people, this is you know, in other words, don’t add stress to your life. This is what I’m really trying to get at. Try to make this as stress-free as possible.

9:34

The last thing, the number seven-point that I’m always trying to make to my students, practice your questions in tutor mode. This is big. This is huge. And if all this thing in the podcast I hope remember is this point, you see guys; our brain is much more like a dog than you know. In other words, we need to be corrected in real-time. For example, there’s this world called neuroplasticity, just type it in enjoy the ride, guys. Okay, and it pretty much goes like this. you fire it, I wire it. That’s how your brain works. If you fire it, I’ll wire it. But if it’s fired the wrong way, you need to wire it the correct way, in real-time. For example, when your dog pees on the bed, what do you do? You scold him at that moment, but you don’t scold him three hours later. He’s like, going, what do you hit me for? I’m over here chewing my bone, and in other words, you have to correct them in real-time. As humans, we’re the same way.

10:30

We need to be corrected in real-time. And so, there’s a lot of studies that have come out here in the world of neuroplasticity and how our brain works like this. So, I kept telling my students to keep it in Tudor mode. Let’s say you get the question wrong. We’re back to mitral stenosis, and for whatever reason, you forget the left lateral decubitus position is the best way to listen to the murmur. So what you do is you stop at that moment. You read up on it, you correct yourself in real-time, and then you go back to the question again. So again, it’s correcting yourself in real-time. This is huge. You have no idea how big this is. But it’s always in Tudor mode

11:05

Only towards the end, and I’m talking about the last month before you take the exam, you start timing yourself.

The other thing to do high-quality questions, one more time, high-quality questions. One of the biggest mistakes students will make they’ll tell you like, yeah, I’m doing 150 questions today. Wrong. What you’re doing is you’re probably going through these questions so fast, you’re probably developing a lot of bad habits.

So I tell students to do is 20-25 a day, Max, no, Max, but I want you to do them in a high-quality fashion. I want you to pick apart every single word on that question. I want you to go beyond the question. So they’re asking the question, you know, aortic stenosis. Like I got this. I know the left ventricular hypertrophy, I know It’s a split S2 to I want you to go past the answer. In other words, you got the answer. And you went through it nice and slow. You peeled it apart. It was ambiguous, and you chose 51 verses 49. Practice these good habits because come the day the test, these good habits will rear up and they will help you. Because one of the things I see all the time with my high-risk students, the ones that fail, it’s always the same story. They’re always telling me that they are doing anywhere between the one to 200 questions a day, and I’m like I need you to do 25 high-quality questions a day. In other words, practice good test habits. So when you get to the day of the test, this will help you out the most.

12:42

So now, our next topic we’re going to talk about is what are the best textbooks to get ready for the PANCE. About five years ago, I went out and actually bought all the PANCE and PANRE review booklets. I’m a big fan. If I’m going to talk the talk, I’m going to walk the walk, and what I did is it went out to and took a look at all these booklets that you guys are being introduced to. And what I did is I came up with the list of the booklets that I thought was best. Let me frame this statement quite clearly. There is no great book one more time; there is no great book; you will be piecemealing this. They’re all good. Nobody’s great. Each one is good, but each one has its flaws. So there are a lot of good ones out there, but nobody’s Great. So what were the better booklets that I saw out there when I was kind of doing my little research on how to get ready for the PANCE? First, one I came by is the AAPA book. That’s a Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants that you see. It’s good. It’s not great. Some of the information is pretty good, but as you read through it, it’s really hard to find the nugget. Go ahead, look up meningitis, and osteomyelitis. You’ll be spending minutes trying to find out what your most common cause, which IV anabolic do I use? Things like that. So it’s good. It’s not great. Then there’s the Physician Assistant Board Review: Certification and Recertification by James Van Rhee, which is also a good book, but it’s not great. The Davis PA Exam Review book is good. There’s a Kaplan medical PANCE review book that’s good. Lange has gotten really good. So Lange, if you go back in time, 10 years ago, Lange was definitely not the best book that out there. But they got new editors, and they’ve done much, much better and I can only tell you the book is very good and this is the one that’s the Lange Q&A Physician Assistant Examination, Seventh Edition by Rachel Carlson and Albert Simon. It’s gotten very, very good. So highly recommend that one as well.

Read my post: 

https://www.thepalife.com/the-4-best-pance-and-panre-study-guides-review-books/

15:16

So let’s stop right here right now. I can guarantee you, if you’re listening to this podcast, you have this booklet. Make no mistake. It’s a great book, but it’s a reference book, not a study book. One more time, PANCE Prep Pearls. Wonderful reference book, not a good study book. If you don’t believe me, I know you already did this. What did you do? And I’m not begrudging anybody out there in the podcast world, but as students would you do? Okay, so let’s just say you had a GI test on a Monday, and you had a pulmonary test on Wednesday, and you had an ENT test on Friday. What do you do? You pulled out your PANCE Prep Pearls. You looked at the subjects or the objectives you had to do and you just brutally memorize the stuff, did you not you brutally memorize all the stuff at the pulmonary exam, the ENT exam, so you really memorized it off the reference book. Then what happened? I don’t know. By Friday afternoon, I could walk up to you and say, Hey, what is the first-line treatment of choice for pneumonia? Like I have no idea. I don’t even know where I parked. So in other words, you memorized it. It’s in it’s out. So again, it’s a great reference book, but not a good study book. If I had to paint, the student who is going to fail the boards. How would I paint on this one? I know I have your attention now. So who are my high-risk students? Oh, let me tell you what they all have in common. One. They live off a PANCE Prep Pearls. No, that’s the only book they have. They live off a Rosh review. That’s the only database and questions they use, period. And then what ends up happening to them because they had all the stuff memorized. They get a concept question. Some type of concept question shows up, and oh my god, they’re flat-footed. They have no idea which way to go. Because you see if it doesn’t show up as a trigger word of something they memorize and PANCE Prep Pearls. They’re done. And we’ll get to talk about Rosh in a second here about why I think Rosh is good, but again, it’s not great. So again, PANCE Prep Pearls is a wonderful, wonderful reference book. I think it’s great. It’s wonderful. I think Dwayne Williams did a wonderful job on this. But to use it specifically to study for the PANCE. Oh no, not at all. You’re going to get yourself lost.

Cost: $34.70 on Amazon – Version 3 is now divided into two books: part A / part B

17:00

When it comes to the website question. There are some database questions out there that are pretty good, and again, I went out there bought them all and there are some good ones some of them can get pretty pricey there’s no doubt about they can get pretty expensive.

So the first one I came across was PA Easy. I like PA Easy; it is quite good on the databank questions with the Lange references was really good, and again, you can put it in tutor mode. And again, I really enjoyed that a lot.

www.paexamprep.com

Kaplan is good, alright, so let’s stop right here. I love Kaplan Don’t get me wrong, but Kaplan, you know, I will say with Kaplan, take it with a grain of salt. Do you ever see some of those questions on Kaplan? They are hard so if you score above 60% or Kaplan, you’re doing great. And I know as students that suddenly you take some you know, cardiovascular exam, you score 62% and you swear that you’re going to you know, not pass the PANCE. That’s not true. Kaplan is a very, very difficult exam bank, but again, just take it with a grain of salt and just understand that some of these questions can be very tough.

www.kaptest.com

If you’re listening to this podcast, I’d say about 80% of you guys use Rosh Review. Rosh is good, but it’s not great. Let me explain to you why. Who out there in podcast world took a question on Rosh Review, you swore you got it, right? You’re like I know this, this is what I learned in school. And then you went to Rosh Review, and they said no. And then if you look to the right, there is this thing called peer comparison, and you’re gonna find out that wait a second 70% that people got the question wrong. So as a teacher, just let you know that peer comparison over there. So when you do peer comparison, one of the things you should do if you’re a good teacher, your test question should sit around 70/30. This is really what’s called the discretion of a question in the education world. In other words, if a question is presented correctly, 70% of your class should get it right, 30% should get it wrong. That’s pretty much the ballpark. That’s the sweet spot anything hire is obviously good, but anything lower, ends up being a context problem. So when you get below 70%, getting it right. This is context. This isn’t a knowledge base issue with the students. This is a context of the question and otherwise, the question is worded poorly or incorrectly? Who on Rosh, if you have seen peer comparisons below 70/30? Yeah, you’re all shaking your head. Aren’t you going? Yeah, I’ve seen it all the time, Joe. Exactly. That’s my whole point. The other problem with Rosh, some of those questions aren’t even on the blueprint. That’s right. Look it up. You’ll see some of these questions going, who’s this disease? And it’s not even on your blueprint? So again, it’s like, I always tell people stick to the blueprint. This is what you’re going to be held accountable for. You’re not going to be held accountable for some, you know, chemo drug from breast cancer and some crazy side effects. But knowing the breast guidelines and what kind of cell type breast cancer is. Yes, that will be there. But not this other craziness that sometimes you’ll see on Rosh. So again, Rosh, it’s good. It’s not great. Of course, I’m going to push out my personal bias, Smarty PANCE. I think it’s a great website.

www.roshreview.com

20:03

It’s just a treasure trove of information that takes a while to get through, but it’s a treasure trove of information. Wonderful website. And it follows the blueprint. So what I tell people to do is open up your smarty PANCE. There’s your blueprint, right, so let’s just say we’re back to aortic stenosis or mitral stenosis. So there it is, on the smarty PANCE blueprint there it is, you’re like, Okay, I gotta know, mitral stenosis. You open it up there’s an opening snap. Maybe you use another reference to study, and maybe you use the Merck manual? Maybe you’re using Lang, but in other words, you’re using other references to pull this all together? I keep trying to tell you guys; this is piecemeal, nobody’s great. Everybody’s good. So now, with all the information that you have, what would I recommend? Oh, this is what I would tell people to do.

www.smartypance.com

20:50

One, start studying a year before, keep the stress out of your life. What I’d start doing is start studying. Yes, I would buy smarty PANCE ASAP use the blueprint; there’s my blueprint. This is the information I will be held accountable for, then I’m I looked at other references about maybe a or cynicism or look at PANCE pro tips. Maybe here’s some stuff that I forgot that and maybe I’ll read up on Merck manual or maybe I’ll read up on Lang and I’m going to do my questions how tutor mode? Because what do I need to correct myself in real-time? And that’s exactly what you need to do. So again, tutor mode, correct myself from real-time have all these references, my cell phone is off. I got no stress in my life. And I’m starting to go at it. That’s how you do it guys. That’s the secret sauce. That’s how it goes about. You see, where people go wrong, is they start not studying till the very end, they start memorizing things. They start doing things in test mode, not tutor mode. They’re doing 100 questions a day, not high-quality questions. But if we could just do high-quality questions, start them out a year before, it’s in tutor mode. I got smarty PANCE up and on one side, I’m looking at my blueprint. I got her other resources. Maybe I’m going to spend the afternoon on aortic stenosis. That’s all I’m doing. Sounds good to me. And then the next day, maybe another murmur and start trying to make sense of it all. Not memorize, because you see guys, just as my last little parting comment to you see, guys, the reason the board scores have dropped, and they have nationwide, and for some of these schools, they have dropped like a rock.

22:40

What happened? Well, what they did is a couple of things. One, they took away the buzzwords. So all these little buzzwords that you were used to writing, you know, you know, frothy green discharge, you know, purulent those kinds of things, right? They’re all gone. And now what they did is they made some of these questions, kind of concept questions. Do you know the concept of this issue and that is what I’m really trying to get at and see if you see something and you’ve got a big broad look at it? Now you understand the concept. You didn’t memorize it off PANCE Prep Pearls. You kept to the blueprint. You didn’t go way off base on some crazy Rosh Review that had nothing to do with the blueprint. And you stuck to it. You stick to that and I guarantee you you’re going to do great guys. So in the end of the day, high-quality questions, tutor mode, stick to the blueprint. Keep the stress out of my life. You do that guys, nine times out of 10 you’re going to end up in a very very good area guys. You really will.

So I hope this helps you guys out there in the podcast world. It was really great talking to everybody and I will be talking to you guys real soon. Take care.

Follow this link to download your FREE copy of the Content Blueprint Checklist

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.

Download for PANCE Download for PANRE