Podcast Episode 77

Welcome to episode 77 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: Download your copy of the Free Trello Smarty PANCE NCCPA Blueprint Study Plan Follow The Daily PANCE Blueprint on Instagram Follow The Daily PANCE Blueprint on Facebook This week we willbe coveringten general board review questions based on theNCCPA PANCE and PANRE Content Blueprints. Below you will find an interactive exam to complement the podcast. The Audio PANCE and PANRE Physician Assistant Board Review Podcast I hope you enjoy this free audio component to the examination portion of this site. The full boardreview includes over 2,000 interactive board review questions andis available to all members of thePANCE and PANRE AcademyandSmarty PANCE. You can download and listen to pastFREE episodes here,oniTunes, onGoogle Play MusicorStitcherRadio. You can listen to the latest episode, take an interactive quizand download your results below. Listen Carefully Then Take The Practice Exam If you can't see the audio player click here to listen to the full episode. Podcast Episode 77: Ten Question PANCE and PANRE Podcast Quiz 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 10-month-old girl was admitted to the hospital for cardiac catheterization. Her history included cyanosis noted at about 6 weeks of age, increasing over the last 7 months and becoming more severe with crying or physical activity. The chest x-ray demonstrates a "boot-shaped heart." A presumptive diagnosis of tetralogy of Fallot (TOF) was made on admission. TOF has 4 components, which of the following below is NOT PART of the diagnosis? A. Pulmonary valve stenosis B. VSD C. Overriding aorta D. Right ventricular hypertrophy E. ASD Click here to see the answer Answer: E, ASD In 1888, Fallot described a congenital heart defect composed of four characteristics (a) large ventricular septal defect (VSD) (b) right ventricular outflow obstruction (pulmonary valve stenosis) (c) overriding aorta (d) right ventricular hypertrophy. The main characteristic of TOF is cyanosis. Hypercyanotic spells or tet spells are paroxysmal episodes in which the cyanosis acutely worsens. Crying, feeding, or defecating can bring on these episodes. Review NCCPA Blueprint Topic: Tetralogy of Fallot 2. A 65-year-old man presents with pain in his right knee. He says he fell and banged it up fairly bad approximately 6 months ago but that it had since recovered spontaneously and provided no further trouble until now. On examination, his temperature is 37.5 C and his blood pressure is 125/70 mm Hg. He has an inflamed, tender, swollen right knee. No other joints are affected. No other abnormalities are found on physical examination. A plain radiographic examination of the right knee reveals streaking of the surrounding soft tissue with calcium deposits (chondrocalcinosis). What is the definitive diagnostic test of choice for this patient's disease A. A plasma level B. A random urine test C. A 24-hour urine D. A synovial fluid analysis E. Gram stain plus culture and sensitivity Click here to see the answer The answer is D: A synovial fluid analysis A definitive diagnosis of gout is made bydemonstrating negatively birefringent, needle-shaped monosodium urate crystals under a polarizing microscope. Although an elevated serum uric acid concentration is often seen in acute gout, it is neither as sensitive nor as specific a test as the demonstration of uric acid crystals in the synovial fluid under a microscope. Serum uric acid levels can be normal in patients with acute gouty arthritis. The diagnosis of septic arthritis can be ruled out by appropriate Gram stain and culture of the same specimen of synovial fluid obtained for examination with the polarizing microscope. Review NCCPA Blueprint Topic: Gout and pseudogout (Lecture) 3.What is (are) the major difference(s) between polymyalgia rheumatica (PMR) andpolymyositis? A. Marked proximal muscle weakness in polymyositis B. Marked proximal muscle tenderness in polymyositis C. Elevated muscle enzymes such as creatine kinase (CK) in polymyositis D. a, b, and c Click here to see the answer The answer is D:a, b, and c The differences between Polymyalgia Rheumatica (PMR) and polymyositis on clinical examination are as follows: There is marked weakness associated with proximal muscle pain in polymyositis There is often marked muscle tenderness (versus joint pain in PMR) associated with the proximal muscle pain in polymyositis Laboratory examination reveals elevated muscle enzymes only in polymyositis Polymyositis Pearls Polymyositis is an autoimmune-mediated inflammatorydestruction of musclesleading tomuscle weakness Patients with polymyositis experienceproximalsymmetric (bilateral)muscle weakness Theshoulders and hipsare the parts of the body most commonly affected by polymyositis Early fatiguewhile walking andinability to rise from a seated position Diagnosis The three autoantibodiesanti-Jo-1,anti-SRP, andanti-Mi-2, are associated with polymyositis Creatine kinaselevels areincreasedin polymyositis Electromyographycan detect regions of dead muscle cells Muscle biopsycan showendomysial inflammationand various stages of necrosis Treatment Initial treatment of polymyositis involves suppressing the immune response withcorticosteroids Methotrexateis used for long-term immunosuppressive therapy in polymyositis Review NCCPA Blueprint Topic: Polymyositis (ReelDx + Lecture) 4. Clinical features of botulism include all of the following except A. Paresthesia B. Dysphagia C. Diplopia D. Fixed/dilated pupils Click here to see the answer The answer is A: Paresthesia Paresthesia is not a feature of botulism while dysphagia, diplopia, and fixed dilated pupils are. Botulism Pearls Caused by aneurotoxinelaborated byClostridium botulinumagram-positive bacillus, which is ananaerobic, spore-forming bacteria Associated withhome-canned foodproductsandhoney in infants(wait until babies areat least12 monthsbefore introducing honey) Presents withdouble vision,drooping of eyelids,inability to make facial expressions, anddifficulty swallowing Autonomic nervous system effects may causedry mouth, postural hypotension, nausea, vomiting, and constipation Can lead to completeflaccid paralysiswhich is deadly if itinvolves respiratory muscles In infants,symptoms include constipation and generalized weakness, with weak crying, poor feeding, lethargy, and loss of head control(floppy baby syndrome) Diagnosis Diagnosis is bytoxin assays Sometimeselectromyography Treatment Treatment issupportive The greatest threat to life isrespiratory impairmentand its complications IV botulinum immunoglobulin/heptavalentbotulinum antitoxin Correct canningandadequate heatingof home-canned foodbefore serving are essential Canned foods showing evidence of spoilage and swollen or leaking cans should be discarded Review NCCPA Blueprint Topic: Botulism 5. A 59-year-old male complains of "flashing lights behind my eye" followed by a sudden loss of vision, stating that it was "like a curtain across my eye." He denies trauma. He takes Glucophage for his diabetes mellitus and atenolol for his hypertension. He has no other complaints. On the fundoscopic exam, the retina appears to be out of focus. Which of the following is the most likely diagnosis? A. Central retinal vein occlusion B.Retinal artery occlusion C.Retinal detachment D.Hyphema Click here to see the answer The answer is C: Retinal Detachment Patients with retinal detachment frequently complain offlashes of light or floatersthat occur during traction on the retina as it detaches. This isfollowed by loss of vision. In small detachments, the retina may appear out of focus, but with larger detachments, aretinal fold may be identified. Central retinal vein and artery occlusioncausepainless, variable loss of vision.Exam showsretinal hemorrhagesin all quadrants andedema of the optic disk Hyphemais usually associated with trauma and is a collection ofblood in the anterior chamber Retinal Detachment Pearls Retinal detachment is aseparation of the neurosensory retinafrom the underlying retinal pigment epithelium Look forsudden increase or change in floatersalong withcurtain or veil across the visual field Often is spontaneous, but may have an underlying cause example recent cataract surgery Myopia (nearsightedness)is a risk factor for the development of retinal detachment Retinal detachment is usuallyunilateral Retinal detachment usually presents with defects in theperipheral visual field Diagnosis Diagnosis is byfundoscopy retinal detachment is visualized as crinkling of retinal tissue and changes in vessel direction Ultrasonographymay help determine the presence and type of retinal detachment if it cannot be seen with funduscopy Treatment Retinal detachment is anophthalmologic emergency Staysupine(lying face upward)withhead turnedtowards the side of the detached retina Pneumatic retinopexyis a procedure for the management of retinal detachment that involves cryoretinopexy followed by injection of an air bubble in the vitreous Review NCCPA Blueprint Topic: Retinal detachment (Lecture) 6. The first dose of the combined vaccine of measles, mumps, and rubella (MMR) is usually given at age A. 12 months B. 6 weeks C. Birth D. 9 months Click here to see the answer The answer is A: The first dose of MMR is given at age 12 15 months and a second dose at age 4-6 years Mumps Pearls Mumpsis aviral disease that is part of theparamyxovirus family. It presents withparotitis(painfulparotidgland swelling),orchitis, oraseptic meningitis. It is transmitted throughrespiratory dropletsand has anincubation period of 12-14 days Prodrome offever,malaise, andanorexia Parotid enlargement(usually bilateral but not always synchronous) 24 h later Swelling ofsubmaxillaryandsubmandibular glands Orchitis(usually unilateral) withtesticular enlargementtwo to three times normal size Mumps is the most common cause ofpancreatitis in children Diagnosis During an outbreak, a diagnosis can be made by determining recent exposure and parotitis.Usually, the disease is diagnosed on clinical grounds, and no confirmatory laboratory testing is needed If there is uncertainty about the diagnosis, a test of saliva or blood may be carried out; a newer diagnostic confirmation, usingreal-time nested (PCR) technology, has also been developed As with any inflammation of the salivary glands, the serum level of the enzymeamylaseis oftenelevated CSFdemonstratesincreased lymphocytesanddecreased glucose Treatment There is no available cure for mumps andtreatment is supportive Symptoms usually last for 7-10 days and patients are contagious for up to 9 days after onset May need to providescrotal supportif painful or swollen testicle (as in case presentation) MMR vaccine is given at 12-15 monthsthen again at4-6 years of age Review NCCPA Blueprint Topic: Mumps 7. A 28-year old sub-fertile woman presents to you on account of dysmenorrhea, deep dyspareunia, dyschezia, and pelvic pain of a few months duration. Physical examination revealed nodularity of the uterosacral ligaments, tenderness in the pouch of Douglas, and a fixed retroverted uterus with positive cervical excitation tenderness. What is the most likely diagnosis? A. Endometriosis B. Pelvic inflammatory disease C. Adenomyosis D. Uterine leiomyoma The diagnosis is generally made by A. Detection of increased estrogen levels B. Endometrial biopsy C. Pelvic ultrasound D. Laparoscopy E. CT of the pelvis Click here to see the answer Answer: A, endometriosis, and D Laparoscopy Endometriosis, which is the presence ofbenign endometrial tissue outside of the uterine cavity typicallypresents as described in this clinical vignette. Remember the three ds Dyspareunia, dyschezia (difficulty in defecating) and dysmenorrhea Definitive diagnosis is made bylaparoscopy and confirmed with a biopsy Imaging tests(eg, ultrasonography, barium enema, IV urography, CT, MRI)are not specific or adequate for diagnosis.However, they sometimes show the extent of endometriosis and thus can be used to monitor the disorder once it is diagnosed. Incorrect Answers: Patients with PID may have similar symptoms with endometriosis, but also presents with fever and vaginal discharge Patients with adenomyosis (acondition in which endometrial tissue exists within and grows into the uterine wall) present with uterine mass with or without pressure symptoms and menorrhagia Uterine leiomyomas cause chronic painful bleeding and are common in women in their late thirties and early forties. Review NCCPA Blueprint Topic: Endometriosis (Lecture) 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 B. Add niacin 100 mg three times daily C. Add ezetimibe (Zetia) 10 mg daily D. Add a PCSK9 inhibitor E. Refer to a lipid specialist Click here to see the answer 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 offamilial hypercholesterolemiais to addezetimibe 10 mg dailyand check again in 6-12 weeks. If at that time the patients LDL is still not at goal (ideally 150) refer to lipid specialist to consider adding a PCSK9 inhibitor. Pearls Familial hypercholesterolemia (FH)is the most common autosomal dominant genetic disease. The clinical syndrome (phenotype) is characterized by extremely elevated levels of low-density lipoprotein cholesterol (LDL-C) and a propensity to early-onset atherosclerotic cardiovascular disease. In general,homozygotes manifest the disease at a much earlier age than heterozygotes and the disease is more severe. HomozygousFH patients are rare and have an estimated prevalence of approximately 1:300,000 to 1:400,000 HeterozygousFH is estimated to occur in 1 in 200 to 250 individuals in the United States. It is estimated that about 7 percent of American adults have an untreated lipoprotein cholesterol 190 mg/dL but only 1.7 percent carry an FH mutation Patients withundiagnosed homozygous familialhypercholesterolemia (FH)develop severe, premature, atherosclerotic cardiovascular disease anddie before age 20 in many cases. In patients with a negative or unknown family history, an untreated LDL-C level of 190 mg/dL (4.9 mmol/L) suggests FH. This value is greater than the 90th percentile for age and sex. Diagnosis The diagnosis ofheterozygous familial hypercholesterolemia (FH)is made withgenetic testing or clinical criteria.A causative mutation in the LDLR, APOB, or PCSK9 gene(s) secures this diagnosis When genetic testing is not available or not felt to be necessary, you can use theDutch Lipid Clinic Network criteria, which assigns points based on low-density lipoprotein cholesterol (LDL-C) levels, personal history of early atherosclerotic cardiovascular disease (ASCVD), family history of early ASCVD, or high cholesterol in a first-degree relative, and personal and physical examination finding Treatment Patients withhomozygous familial hypercholesterolemia (FH) intensive LDL-C lowering, whichtargets a minimal value of 150 mg/dL(3.9 mmol/L) In addition to a high-dose statin (atorvastatin 80 mg daily or rosuvastatin 40 mg daily), most homozygous patients will require additional therapies such asezetimibe, a PCSK9 inhibitor, or potentially LDL-C apheresis Review NCCPA Blueprint Topic: Hypercholesterolemia 9.What best describes the time that preeclampsia is commonly seen? A. Before 18 weeks of pregnancy B. After 18 weeks of pregnancy C. After 16 weeks of pregnancy D. After 20 weeks of pregnancy E. Before 12 weeks of pregnancy Click here to see the answer The answer is D, after 20 weeks of pregnancy Preeclampsia is a systemic disease characterized by hypertension that is accompanied by proteinuria.Preeclampsia usually begins after the 20th week of gestation;however, it can appear at any time during pregnancy. It occurs most frequently in the final trimester. Pearls Preeclampsiais a systemic disease characterized byhypertensionthat is accompanied byproteinuriaafter the20th week of gestation. If left untreated, preeclampsia can lead to serious, and even fatal, complications. Risk factors include nulliparity, age younger than 19 or older than 35, obesity, multiple gestations, positive family history, pre-existing hypertension or renal disease, and diabetes mellitus. Eclampsiais defined as thedevelopment of seizuresin awoman with preeclampsia. Diagnosis Hypertensionwithproteinuria Mild Preeclampsia BP 140/90 160/110 Proteinuria 300 mg/24 hours or +1 on dipstick BP 160/110 Proteinuria 5g in 24 hours or no urine or 3 +on dipstick ***HELLPSYNDROME Hemolysis, elevated liver enzymes, and low platelets Treatment Delivery is the only cure for preeclampsia. The decision to induce depends on the stage of pregnancy and the severity of the disease Patients with preeclampsia without severe symptoms are generally induced into laborafter 37 weeksgestation in severe preeclampsia delivery is performed at 24-26 weeks If less than 34 weeks antenatal steroidspromote fetal lung development Intravenousmagnesium sulfate as seizure prophylaxis) Review NCCPA Blueprint Topic: PANCE Blueprint Reproductive System (7%) Hypertension disorders in pregnancy 10. A 36-year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops a rapid onset of profound dyspnea. The initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. A follow-up chest x-ray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient? A. Tracheal intubation B. Bilateral chest tube insertion C. Type-specific packed cells D. Colloid solutions E. Provide supplemental oxygen Click here to see the answer The answer is A Tracheal intubation Tracheal intubation with the lowest level of PEEP is required to maintain the PaO2 above 60 mmHg or SaO2 above 90% in a patient with ARDS Pearls Acute respiratory distress syndrome (ARDS)is a type ofrespiratory failurecharacterized byfluid collecting in the lungsdepriving organs of oxygen The underlying abnormality in ARDS is Permeability of alveolar-capillary membranes development of protein-rich pulmonary edema(non-cardiogenic pulmonary edema) ARDS can occur in those who arecritically illor who havesignificant injuries Three clinical settingsaccount for75% of ARDS cases: Sepsis syndrome (most common cause) Severe multiple trauma Aspiration of gastric contents (alcoholics), toxic inhalation, near-drowning People with ARDS havesevere shortness of breathand often are unable to breathe on their own without support from a ventilator Occurring12-24 hours after the precipitating event Tachypnea,pink frothy sputum,crackles Diagnosis Chest radiographshowsairbronchogramsandbilaterally fluffy infiltrate Normal BNP, pulmonary wedge pressure, left ventricle function and echocardiogram Treatment Treatment involvesidentifying and managing underlying precipitation and secondary conditions Tracheal intubationwith the lowest level PEEP to maintain PaO2 60 mmHg or SaO2 90 ARDS isoften fatal, the risk increases with age and severity of illness Review NCCPA Blueprint Topic: PANCE Blueprint Pulmonary (10%)Acute respiratory distress syndrome (Lecture) [spoiler title=C Looking for all the podcast episodes? 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