PANCE REVIEW: Train Your Brain

Here are some more Word-Associations for your PANCE studies... I'll add any tricks that I have found or come up with to remember them. Remember, these are meant as a study tool. Read the entire question and use your clinical know-how to determine your final answer. These are in no particular order:

Retinal Artery Occlusion = cherry red spots [When I think artery, I think RED]
Retinal Vein Occlusion = blood and thunder

Hordeloum = Hurt (painful)
Chalazion = painless

Viral conjunctivitis = preauricular lymphadenopathy + bilateral + watery discharge
Bacterial conjunctivitis = purulent discharge

Macular degeneration = drusen deposits/central vision loss

Rinne/Weber - Conduction/Sensorineural 

Epiglottis = thumb print sign/tripod/drooling

Oral white patches
Candidiasis = uncomfortable/Can be scraped off
Leukoplakia = painless/cannot be scraped off (Left on)

HypOparathyroidism = + Chvostek's sign/Trousseau's sign [due to low Ca+]
Hyperparathyroidism = "bones, stones, abdominal groans, psychiatric moans, and fatigue overtones"

Essential tremor = can temporarily gets better with ETOH

Eczema = flexor surfaces
Psoriasis = extensor surfaces

Actinic Keratosis = sun exposure/pre-cancerous!

Seborrheic Keratosis = greasy/ "stuck on"

PANCE REVIEW: Pesky Vertigo

I can never keep these straight. Every practice exam I'm cursing myself when I get these wrong - so I finally decided to make a chart and learn them.

A couple tips to narrow it down:

*Those with the red circle are SUDDEN onset
*Those with blue circle involve hearing loss - so if it is sudden with hearing loss... you're down to Meniere's!

Source: AAPA and PAEA book

My Blog, the Mobile Version (New)

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PANCE: Buzz Words

When studying for the PANCE it is difficult to "know it all" - sometimes you need some helpful hints to jog your memory or lead you in the direction of a likely answer....  The following list contains some word association stuff that may help for which organisms in pneumonia are most common in particular populations. Word association is no substitute for knowing and understanding the clinical scenario, but it may help you narrow down the options.

I will put a list here... quiz yourself (see below for answers):

Which pneumonia organisms would you match with the following patient populations or buzz words?

1. ETOH 
2. COPD
3. Air conditioners/cooling systems
4. Cystic fibrosis
5. Asplenic
6. College
7. Leukemia
8. Kids < 1 yo
9. Kids > 2 yo

 Answers:

1. ETOH = Klebsiella
2. COPD = Haemophilus influenza (H.flu)
3. Air conditioners/cooling systems = Legionella
4. Cystic fibrosis = Pseudomonas
5. Asplenic = encapsulated organisms (strep pneumo/H.flu)
6. College = mycoplasm pneumo or chlamydia pneumo (longer prodrome, sore throat, hoarseness)
7. Leukemia = fungus
8. Kids < 1 yo = RSV
9. Kids > 2 yo = parainfluenza virus

Delirium vs. Dementia

Source: PSYCHIATRY for Medical Students and Residents Nabeel Kouka, MD, DO, MBA (available for free online)

PANCE REVIEW: Jones Criteria

Is it rheumatic fever or not? You need to know the Jones Criteria to make the determination.

Source: AAPA/PAEA Exam Review Book, PANCE review lecture by Janice Herbert-Carter, MD, MGA, FACP

Difference Between OCD and OCPD

What is the difference between Obsessive-Compulisive Disorder (OCD) and Obsessive-Compulsive Personality Disorder? Here is a chart that I found that explains the differences in an easy to understand manner:

Source: PSYCHIATRY for Medical Students and Residents Nabeel Kouka, MD, DO, MBA (available for free online)

Free Ophthalmoscope App

"The Virtual Ophthalmoscope is a free, educational resource for the clinical ophthalmologist. The Virtual Ophthalmoscope features a library of more than 50 clinical cases with high-quality, zoomable images and commentary from a leading consultant ophthalmologist.  Available on iPad and iPhone

This app is provided as an educational service by Alcon UK. It is intended for healthcare professionals only. Not for patient use."

iTunes Link

PANCE REVIEW: Dyslipidemia Drugs

Excellent (FREE) Resource for Rotations

I love resources that make my life easier. I love them even more if they are free. The University of Washington put out something called The Turkey Book - which is basically a truncated resource for your clinical rotations as a student. Lots of "need to knows", charts, answers to potential pimping questions, and a good variety and I highly recommend taking a look at it before you begin your rotations.... and keep looking at it during your rotations! It has everything from EKG tips to family medicine to pediatrics to OB/GYN to radiology. It offers help on presenting a patient and writing your notes.

PANCE REVIEW: COPD

I made this chart to study for the PANCE. Thought I would share:

 I was asked to add this to this posting. I should add that I am in no way reimbursed to do so. Just seems like a good cause:

Healthline just launched a campaign for called "You Are Not Your COPD" where COPD patients share their story or advice about living with the disease.  http://www.healthline.com/health/copd/inspirational-stories

They have partnered with the COPD Foundation to promote the campaign and have pledged that for every submitted story, Healthline will donate $10 to the COPD Foundation. (added on 4/20/14)

Asthma Charts

Every PACK-RAT I've taken has had at least 1-2 questions on asthma. During my primary care, pediatrics, and emergency medicine rotations I keep these charts with me because I used them daily.

Source: http://www.rtmagazine.com/issues/articles/2009-05_01.asp, http://www.uspharmacist.com/content/c/10133/?t=men%27s_health,otc_medications

Preceptor Observations or Not?

Re-post found on KevinMD.com - very worthy of a re-post since PA students are often in the same situation. Although awkward and uncomfortable at times, perhaps it IS necessary to have someone watch us directly....

The need to watch medical students interact with patients

by Christopher Johnson, MD | in Education | no responses

I’ve written about this before, but some recent encounters with medical students have me thinking about it again. I went off to medical school thirty-eight years ago. For the era, I went to what folks regarded as a very progressive place. It had a curriculum that was quite revolutionary for the time. Among other things, we started having interactions with actual patients during our first year, rather than the third year, as was traditional then. These days many, probably most, medical schools get their students seeing real patients sooner. That’s good. But do these students get any sort of planned, structured assessments with how they’re doing with those real patients? Does anybody watch them, encourage what they’re doing right and correct what they’re doing wrong?


An editorial in the journal Pediatrics, the official journal of the American Academy of Pediatrics, has an enlightening title: “Oh, what you can see: the role of observation in medical student education.” It turns out that students often don’t get what they need to learn how to do things right.

It turns out that during their pediatric rotation only 57% of students have a faculty member observe them throughout the entire process of meeting a child and family, taking a medical history, and doing a physical examination. In my day I think it was worse than that: I can’t even recall having a teacher watch me go through the entire process; generally, the students would watch the teacher, then go off and try things on their own. Of course we weren’t allowed to do anything involving needles and such without training and supervision (at least at first), but thinking back it is surprising that we were mostly left to ourselves.

The rationale for direct observation is straightforward and obvious. In the words of the authors:

The aim of direct clinical observation is clear — to help preceptors gather accurate information about students’ actual performance in real-life clinical settings rather than inferring performance. Preceptors can then provide effective, timely, and specific feedback on observed skills that can be incorporated into subsequent clinical encounters. With better supervision of learners, both student skills and clinical care improve.

It seems obvious. Our colleagues in internal medicine are doing even worse they we are in pediatrics, though: the survey found that only 22% of students had an in-depth patient encounter observed by one of their teachers. Teachers of surgery, too, evaluated students “primarily on the basis of their own interactions with students rather than on observed clinical interactions with patients.”

The authors’ conclusion is self-evident, but at times somebody needs to point out the obvious:

Focused, direct observation of medical students in clinical settings provides valuable information about learners’ skills in history-taking, communication, physical examination, and providing information to children and parents. Observing students’ encounters with patients improves teaching, evaluation, preceptor satisfaction, student satisfaction, and, ultimately, patient care. For the great clinical teacher, direct observation is worth the effort.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

Reading a Chest Xray

You should feel confident reading a chest x-ray (CXR). It is one of the few films that will follow you from rotation to rotation. It doesn't matter if it is pediatrics, internal medicine, or surgery - You need to know how to read a CXR. Below are a couple sources to choose from because not everyone teaches or learns this in the same way. Here are a couple tips that I learned during my rotations from studying, my preceptors, or just plain screwing up!

• The first thing you should check is the name/date/type of film! (On one of my rotations, an intern (1st yr resident) was asked to read a chest X-ray for one of our patients who had just gotten a chest tube placed. He did a great job with lung pathology and describing the fluid - and he was also able to pick out that the chest tube was perfectly placed. I was impressed until the chief resident said "great job, you just harmed your patient." The chief had purposefully put up a CXR from 2 years ago when the pt had rec'd another chest tube. He then pulled up the current CXR to reveal that the tube was improperly placed. )
• Read every film in the same order every time. 
• Learn the anatomy of what you are reading. 

Step by Step Tip for reading CXRs

University of Washington's Method

1. PA or AP, supine or upright

2. Pt rotated? Check for vertebral and clavicle symmetry.

3. Lung volumes

4. Tube & line placement

- ETT 3-5 cm above carina

- NGT in stomach

- FT in stomach/duodenum

- Central line in SVC/R atrium

- Swan in PA

5. Pneumothorax: check apices on upright film, deep sulcus sign at bases

6. Pleural effusion, pleural thickening

7. Mediastinum: normal contour, wide

8. Heart: normal size, cardiomegaly

9. Lung parenchyma: masses, opacites, look for silhouette sign

10. Soft tissues: foreign bodies, SQ air, breast shadows

11. Bones: fractures, osteopenia, abnormalities

Silhouette Sign = obscuring of normal borders on radiograph caused by intrathoracic lesion.

Obscured R heart border = R middle lobe

Obscured L heart border = Lingula

Obscured diaphragm = Lower lobe

Free Medicine Courses

Tufts School of Medicine in Boston, MA offers lots of free classes via their open courseware site:

"For more than 100 years, Tufts University School of Medicine has been a national leader in education and research. It offers one of the most substantive and innovative medical curricula in the country. The school's internationally renowned researchers are closing in on many of humankind's most plaguing diseases with work that ranges from genetics and geriatrics to AIDS and Alzheimer's, from cancer and cystic fibrosis to biotechnical and pharmaceutical breakthroughs."

Lumbar Punctures

LUMBAR PUNCTURES

(Source: http://students.washington.edu/aomega/procedures.shtml#chestTube)

Indications: Suspected CNS infection, SAH, Guillain-Barre syndrome, MS, SLE
Measure intracranial pressure (pseudotumor cerebri)

Contraindications: Increased intracranial pressure (except to dx pseudotumor cerebri), supratentorial mass lesion, thrombocytopenia, bleeding dyscrasia

Complications: Post-LP headache, brain herniation if mass lesion present or increased intracranial pressure, bloody tap if venous plexus punctured.


Technique
1. Obtain informed consent
2. Position patient with back near edge of bed in lateral recumbent position. Have patient flex hips and draw knees up to chest to increase curvature of spine.
3. Palpate iliac crests and identify L3 and L4 interspaces.
4. Open tray, wear sterile gloves, and set up tubes in order, 1-4.
5. Prep and drape skin in sterile fashion
6. Infiltrate skin with 1% lidocaine
7. Use 20-22 gauge spinal needle. Insert at interspace with needle angled slightly toward umbilicus (cephalad). Keep level of needle in line with horizontal plane.
8. A course resistance can be felt as the needle passes through the paraspinous ligaments and a “pop” may be felt when needle passes through the dura.
9. Withdraw stylus fully to check for fluid.
10. Once fluid is obtained, place stopcock and manometer on hub of needle to obtain opening pressure.
11. Fill tubes in order, 2-3cc per tube
12. Once fluid has been collected, replace stylus and withdraw needle.
13. Cover site with sterile dressing and have patient remain lying down in supine position for 2 hours.
14. Observe tubes for occult blood. Decreasing amounts of blood in tubes 1-4 suggests a bloody tap, while increasing or steady amounts suggests an CNS bleed.
15. Send fluid for analysis:
Tube #1: glucose, protein, protein electrophoresis
Tube #2: Gram stain, culture, bacteria, fungal, TB, viral
Tube #3: cell count, differential
Tube #4: VDRL, India ink, cytology

PANCE REVIEW: Get the Most Out of Studying

How do you get the most bang for your buck when studying for the PANCE? Below is a break down of the % of questions for each subject on the PANCE. If you are cramped for time to study - pick the categories with the highest yield. As you can see, CV + GI + Musculoskel + Pulm account for 48% of the questions on the PANCE! If you add Reproductive and EENT to the mix you are up to 65% of your exam.

Organ System             % of Exam Content

*Cardiovascular                      16

Dermatologic                            5

EENT                                        9

Endocrine                                  6

*Gastrointestinal/Nutritional  10

Genitourinary                            6
Hematologic                              3
Infectious Diseases                   3

*Musculoskeletal                     10

Neurologic System                    6
Psychiatry/Behavioral               6

*Pulmonary                              12

Reproductive                             8 

Total: 100%

Negotiations 101

Negotiations are awkward. No one likes to talk money deals with a complete stranger, nor does anyone like to ask for more than what is offered... but if you want to get up to your financial earning potential... I say, "Get over it." You won't always get everything you ask for - in fact - sometimes you may get nothing, but the point is... if you don't ask, you'll never know. A few of my classmates negotiated their contracts - some successful, some not. To me, a successful negotiation means that you gained something that you didn't have before- even if it is only $1000 more or 1-2 extra vacation days- it is something extra that you didn't have before. They aren't going to take back your offer if you ask for more money (at least I've never heard of it) - they expect a negotiation.

As a new graduate, it is sometimes difficult to negotiate - but its not impossible. Below are some basic tips that I've learned through research and experience that should help you negotiate your first salary:

1. Do your research. You wouldn't dream of walking into your cardiology final without having studied up! Why walking into a negotiation without studying either?? Know what the going rate for new PAs in your geographic/specialty area are. How do you find out? AAPA and NP&PA Advance Mag (website) has some salary information, but I got the most helpful information by just asking. Many of my classmates were open about their base salary offers which was very helpful. I suggest that you are the same way with your classmates. It only helps everyone to know the playing field.
2. Know the going benefits packages. You should ask around to see which hospitals cover what as far as paying for CMEs, licensing costs, re-cert exam costs, etc. These things add up very quickly and are worth knowing. If your hospital is not covering any of your licensing or DEA fees, you are looking at approx $1500 of additional costs that you have to cover.
3. Know the demands of the position. CT surgery is notorious for having a crazy schedule, but that is one of the reasons that they are some of the best paid PAs. Will your job include nights/weekends/holidays/call? If so, think of if the salary they are offering you is taking that into consideration. Do you get paid extra for call? Night/weekend differential pay? Think about what is important to you by way of "work-life" balance. Some people are willing to work 80hrs a week to make money to help pay loans, others want an 8-5p type job with no call/wkends/holidays knowing that they will likely make less money. It is a personal decision.
4. Know the pay structure. Are you salary? Are you hourly? It makes a huge difference if you are scheduled for 40hr wks but are working 50hrs.
5. Know your worth. What can you offer to this position that perhaps some of the other new grad applicants couldn't? (aka, why did they pick you?!) If you are negotiating for an orthopedic position and you spent 5 yrs as an athletic trainer - use that in your negotiations! You are bringing several skills to the table that other new grads likely aren't. Do you have another degree in public health or business? Incorporate into negotiations how those extra skills may help advance the practice.
6. Never, and I mean NEVER, take the first offer. (Even if it is $10K more than you had expected!) When I had a negotiations discussion with some friends that work in business they all said they were taught never to accept the 1st offer. Why? Because businesses/hospitals almost never offer the ceiling salary upfront. Why would they? Healthcare providers aren't taught anything about negotiations. I have asked med school students, PA students, and nursing students - almost none of them have been truly taught how to negotiate.
7. Think in LONG term, not SHORT term. Your starting salary will dictate your next salary and your next salary when you switch jobs and start the negotiation process all over.
8. Be prepared. Have a list of "wants" and rank them in order of importance. This list is for your eyes only. It is not something you hand to the HR negotiator! For example, write down a salary that you plan on asking for - then ask - "Thank you for the generous offer... blah, blah... I was wondering if there was any room for negotiation on the salary?" If they say yes, give them a range. Based on their response you can move on from there, but what happens if they say "No"? Then you say, "Ok, then I was wondering if other aspect of the benefits package are negotiable such as _____." You can ask for whatever is next on your list of "wants" - more vacation time, more CME $, etc.
9. Know your limits. You are a professional, but in many cases you are also a mother/father, husband/wife, T-ball coach, etc - the point is that you wear many hats and have other time and financial responsibilities. Keep this in mind during negotiations. Most times you can come to an agreement and it all works out. Sometimes they just might not be willing or able to meet your wants/needs - know when to walk away. Don't take a job that is going to make you miserable or force you to eat Ramen noodles every night. You many not find the perfect job out of school - and that's ok - but you should at least enjoy it and get paid well to do it. Before walking into a negotiation, sit down with your finances (rent, loan repayments, bills, etc) and figure out what is the least amount that you could live on and then account for the fun things in life that you'd like to do - this should help you at least find a minimum salary that you could work for.
10. Ask for time to make a decision. Don't let any institution strong arm you into making a decision on the spot. It isn't standard practice and you shouldn't make such a large decision without some time to ponder. I asked for "48 hrs to consider this very important decision" - and most places are very amenable to that. Ultimately, the decision is yours but you should discuss with your significant other/family as your new job will likely affect them.

Good luck with the process. Don't be afraid of a little awkward conversation. It could pay off hugely in the end.

PANCE REVIEW: Thyroiditis

So today's topic hits close to home because I was diagnosed with Hashimoto's thyroiditis this year after complaining of incredible fatigue. It was getting to the point that I was having difficulty getting through the day past 2p without napping. I was wiped out. So for today's PANCE review we will discuss Hashimoto's specifically - but you should also be familiar with the other forms such as subacute, post-partum, and infectious.

Hashimoto's Thyroiditis, Noteworthy Stuff Only

• Most common form
• Autoimmune or polyglandular syndrome
• More common in women than me
• Familial
• Frequency increases with 1) iodine supp and 2) certain meds
• Diffuse, enlarged, firm nodules (often asymmetric)
• NOT painful*
• Can see depression/chronic fatigue
• Tests: serum antithyroid peroxidase and antithyroid globulin antibodies
• Tx: lifelong thyroid hormone replacement (levothyroxine) for hypothyroidism, watchful waiting if goiter is present

*In contrast to subacute which is PAINFUL!

NOTE: Don't forget - for the PANCE... the single best screening test for thyroid dz is TSH!

Source: AAPA, PAEA Exam Review Book
Pic: http://www.nature.com/nm/journal/v10/n9/fig_tab/nm0904-895_F1.html