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PANCE Review Questions and the release of my review book

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The Final Step

I wrote the Questions for The Final Step  in July 2013. Due to overwhelming demand I release an awful rough draft version of September 2013. Now, a full year later I finally complete the project.  They’re two different digital versions and audio version and the print version that we’ll all be available in just one week! I can’t wait to share all this with you. Head over to www.physicianassistantexamreview.com/thefinalstep This is the number one resource you can use during the week leading up to your exam.

PANCE Questions

In today’s show I read through a handful of questions from the Final Step.  You’ll just have to listen.

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This is the first shipment of books sitting in my garage!!!

The cover looks amazing!

The cover looks amazing!

 

Ooohh,  I'm so excited!  Packed with PANCE review questions!

Ooohh, I’m so excited! Packed with PANCE review questions!

Finishing Neuro with Seizures

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SeizuresSeizure disorders

Things you should know

  • Epileptic Seizures – abnormal brain activity (affects 5-10% of people)
  • Epilepsy – recurrent seizures (affects 1% of people)
  • Causes
    • Hyponatremia
    • Hypoglycemia
    • Stroke or transient ischemic attack (TIA)
    • Dementia, such as Alzheimer disease
    • Traumatic brain injury
    • Infections, including brain abscess, meningitis, encephalitis, and HIV/AIDS
    • Congenital brain defect
    • Metabolic disorder present at birth ( e.g. phenylketonuria)
    • Brain tumor
    • Abnormal blood vessels in the brain
    • Other illness that damages or destroys brain tissue
  • Types of Seizures
    • Generalized Seizure – involve the entire brain
      • Grand Mal or generalized
      • Absence
      • Clonic
      • Myoclonic
      • Tonic
      • Atonic
    • Partial Seizure – Involve a small area of the brain
      • Simple – awareness is retained
        • Simple Motor
        • Simple Sensory
        • Simple Psychological
      • Complex – impairment of awareness
      • Partial seizure with secondary generalization

I came in to see my physician assistant today because of…

  • Generalized Seizure
    • Grand Mal Seizure
      • Unconsciousness
      • Convulsions
      • Muscle rigidity
    • Absence Seizure
      • Brief loss of consciousness
    • Clonic Seizure
      • Repetitive jerking movements
    • Myoclonic Seizure
      • Sporadic jerking movements
    • Tonic Seizure
      • Muscle stiffness
      • Rigidity
    • Atonic Seizure
      • Loss of muscle tone
  • Partial Seizure
    • Preservation of consciousness and evolves into loss of consciousness and convulsions
    • Jacksonian march – Seizure spreads from distal limb to ipsilateral face.
    • Simple Seizure
      • Jerking, muscle rigidity, spasms, head-turning
      • Unusual sensations affecting vision, hearing, smell, taste or touch
    • Complex
      • Lip smacking, chewing fidgeting, walking and other repetitive, involuntary but coordinated movements
      • An aurora is often present
      • Involves the temporal lobe

Labs, Studies and Physical Exam Findings

  • Electroencephalogram –helps determine the type of seizure
    • Generalized seizures – generalized spikes and slow waves
    • Simple partial seizure – focal rhythmic discharges may be present
    • Complex partial seizure – interictal spikes with slow waves
  • MRI / CT – to rule out other diagnosis
  • Laboratory tests
    • Blood tests
      • Blood Glucose
      • Electrolyte levels (including calcium, magnesium and sodium)
      • Complete blood count
      • Renal and liver function tests
      • Toxicologic screening and anticonvulsant drug levels
      • Arterial blood gas results
      • Blood culture
      • Urinalysis
      • CSF analysis
    • Urine biochemistry (phenylketonuria)
  • Electroencephalogram (ECG) – to rule out heart conditions
  • Lumbar puncture – to diagnose a CNS infection

Treatment

  • First Aid
    • Place in recovery position or roll to one side
  • Treat underlying cause if you can find one
  • In most cases a first time seizure should not be treated medically.
  • Medications – one medication should be used per patient however no one medication is best for every patient.
    • Anticonvulsants
      • Midazolam
      • Phenytoin
      • Carbamazepine
      • Valproate
      • Phenobarbital
  • Surgery in patients who are not controlled with medications and have partial seizures surgery may be an option.
    • Resection of the offending area of the brain

Status epilepticus

Things you should know

  • A life-threatening neurologic disorder defined as 5 minutes or more of a continuous seizure activity or several clinical seizures without return to baseline in between
  • Seizure
  • Causes:
    • Stroke / Hemorrhage
    • Intoxicants or adverse reactions to drugs
    • Insufficient dosage of a medication already prescribed
    • Sudden withdrawal from a seizure medication
    • Consumption of alcoholic beverages while on an anticonvulsant, or alcohol withdrawal
    • Dieting/fasting while on an anticonvulsant
    • Starting on a new medication that reduces the effectiveness of the anticonvulsant or changes drug metabolism
    • Developing a resistance to an anticonvulsant already being used
    • Gastroenteritis while on an anticonvulsant
    • Developing a new, unrelated condition in which seizures are coincidentally also a symptom, but are not controlled by an anticonvulsant already used
    • Metabolic disturbances

Labs, Studies and Physical Exam Findings

  • Physical and Neurologic Exam
  • Laboratory Tests
    • Blood Glucose
    • Electrolyte levels (including calcium, magnesium)
    • Complete blood count
    • Renal and liver function tests
    • Toxicologic screening and anticonvulsant drug levels
    • Arterial blood gas results
    • Blood culture
    • Urinalysis
    • CSF analysis
  • Electroencephalogram (EEG) – Continuous seizure activity
  • CT Scan or MRI

Treatment

  • Medications
    • Benzodiazepines are first line- Diazepam, Lorazepam, Midazolam
    • Anticonvulsant agents – Phenytoin, Fosphenytoin
    • Barbiturates – Phenobarbital
    • Anesthetics – Propofol
  • Supportive Therapy

Syncope

Things you should know

  • Global cerebral hypoperfusion
  • Causes
    • Cardiac
      • Arrhythmias
      • Abnormalities of the heart valves
      • Hypertension
      • Aortic Dissection
      • Cardiomyopathy
    • Non-cardiac
      • Postural hypotension
      • Dehydration
      • High altitude
      • TIA
      • Migraine
      • Situational syncope (blood drawing, micturition, defecation, swallowing, coughing)
  • Differential diagnosis
    • Central nervous systems ischemia
    • Vasovagal Syncope
    • Deglutition Syncope
    • Blood pressure

I came in to see my physician assistant today because of…

  • Partial or complete loss of consciousness
  • Skin paleness
  • Lightheadedness
  • Tunnel vision
  • Nausea
  • Cold, clammy skin
  • Blurring of vision

Labs, Studies and Physical Exam Findings

  • Neurologic Exam
  • CT or MRI scan – if with seizure and abnormalities in neurologic exam
  • Carotid ultrasonography – to identify carotid artery disease
  • Hemoglobin count – to identify anemia or blood loss
  • ECG
  • Holter monitoring
  • Tilt table test – to elicit orthostatic syncope secondary to autonomic dysfunction

Treatment

  • Positioning
    • In the event of syncope, position the patient on the ground, with the legs slightly elevated or leaning forward, head between the knees for 10 to 15 minutes
  • Intravenous access
  • Oxygen administration
  • Advanced airway techniques
  • Glucose administration
  • Pharmacologic circulatory support
  • Pharmacologic or mechanical restraints
  • Defibrillation or temporary pacing

Tourette disorder

Things you should know

  • Motor and vocal tics – sudden brief intermittent movements
  • Coprolalia – involuntary swearing
  • Occurs between 2 and 15 years old
  • Causes
    • Genetics – Likely an inherited disorder
    • Brain abnormalities

I came in to see my physician assistant today because of…

  • Motor Tics
    • Eye blinking
    • Head jerking
    • Shoulder shrugging
    • Eye darting
    • Finger flexing
    • Sticking the tongue out
    • Touching the nose
    • Touching other people
    • Smelling objects
    • Obscene gesturing
    • Flapping the arms
    • Hopping
  • Vocal Tics
    • Hiccupping
    • Yelling
    • Throat clearing
    • Barking
    • Using different tones of voice
    • Repeating one’s word or phrases
    • Using vulgar, obscene swear words

Labs, Studies and Physical Exam Findings

  • Physical Exam – Maybe normal or show repetitive movements
  • To rule out other conditions and secondary causes:
    • EEG – if tics and seizure activity exists
    • MRI – to rule out brain abnormalities
    • TSH levels – to rule out hypothyroidism, that cause tics
    • Urine drug screen
    • Serum Copper – to rule out Wilson’s disease

Treatment

  • Deep brain stimulation
  • Behavioral therapy
    • Habit reversal
    • Exposure and response prevention
  • Medication once behavior is interfering with social interactions or activities of daily living
    • Dopamine antagonists – fluphenazine, or pimozide
    • Haloperidol is historically the drug of choice

Study Tip

Parkinson’s law - “work expands, so as to fill the time available for its completion”.

Key Terms and Ideas

  • Which type of seizure is associated with generalized spikes and slow waves?
    • Generalized seizure
  • Does the term tonic refer to jerking movements or muscle stiffness?
    • Muscle stiffness
  • What is the age range for the onset of Tourette syndrome?
    • 2-15 years old
  • What is the first line treatment for a patient in status epilepticus?
    • Barbiturates – Diazepam

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