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Stroke, TIA and CP

Play

StrokeStroke

Things you should know

  • Stroke is the third most common cause of death in the USA
  • Ischemic event in the central nervous system
  • Risk Factors
    • Increasing age
    • African American, American Indian & Hispanics are at increased risk
    • HTN
    • Smoking
    • Diabetes
    • Oral contraception
    • ETOH
    • Afib
    • Heart valve issues
    • Endocarditis
  • Classification:
    • Ischemic Stroke – 80-85%% of strokes – result of a blockage of a blood vessel or cerebral hypoperfusion.
      • Thrombotic Stroke
        • Thrombotic vs embolic
    • Hemorrhagic Stroke a blood vessel in the brain ruptures
      • Intracerebral Hemorrhage

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

In the majority of stroke cases, the symptoms are unilateral, affecting only one-side of the body.  Motor symptoms typically occur on the contralateral side in relation to the lesion Symptoms also depend on which part of the brain is affected.

  • Hemiplegia and facial muscle weakness
  • Numbness
  • Reduced sensory or vibratory sensation
  • Initial flaccidity followed by spasticity and hyperreflexia
  • Altered sense of smell, taste, vision and hearing
  • Ptosis and weakness of ocular muscles
  • Decreased reflexes such as gaga, swallowing, pupil reactivity to the light
  • Facial muscle weakness
  • Nystagmus
  • Balance problems
  • Altered respiratory rate, heart rate and breathing pattern
  • Inability to turn head to one side
  • Inability of the tongue to protrude and move from side to side
  • Aphasia
  • Dysarthria – motor speech disorder  due to neurological injury
  • Apraxia – altered voluntary movements
  • Visual field defect
  • Memory deficits
  • Disorganized thinking, confusion
  • Altered walking gait
  • Altered movement coordination
  • Vertigo/Disequilibrium
  • Loss of consciousness
  • Headache
  • Nausea and vomiting – often occurs in hemorrhagic stroke due to increased intracranial pressure.

Labs, Studies and Physical Exam Findings

  • Physical Examination / Medical History – helps identify location and severity of a stroke.
    • “FAST”
      • Face – One side of the face droops when asked to smile.
      • Arms – When both arms are raised, one arm drift downward
      • Speech – Presence of slurring of speech when asked to repeat a simple phrase
      • Time. Seek immediate medical attention if these cardinal signs are present.
  • Carotid Bruit
  • Heart Murmur
  • Radiology
    • Non contrast CT
    • MRI – detect chronic hemorrhages
    • Ultrasound Doppler of carotid arteries
    • ECG
    • Echocardiogram
    • Holter Monitor Study
  • Angiogram – for the cerebral vasculature.  This is done if an aneurysm or arteriovenous malformation is suspected.
  • Nuclear Medicine
    • SPECT – documents cerebral blood flow
    • PET/CT – identify metabolic activity of the neurons
  • Blood Tests – to identify hypercholesterolemia, bleeding disorder and homocystinuria.

Treatment

  • Ischemic Stroke – restoration of blood flow to the brain is the most important thing
    • Medications –  Chances of survival depends on the urgency of treatment provided
      • Aspirin – Prevents the formation of blood clot.  Immediate treatment to reduce the possibility of another stroke.
      • TPA (Tissue Plasminogen Activator) – Administered through intravenous injection and should be done within 4.5 hours.
        • Contraindications are important to consider
          • Any possibility of intracranial bleeding
          • Recent major surgery
          • Recent head trauma
          • Active bleeding
          • Intracranial neoplasm
          • HTN > 185/110
    • Endarterectomy
    • Angioplasty and stents
  • Hemorrhagic Stroke – emergency treatment is all about controlling the bleeding and reducing intracranial pressure.
    • Surgical
      • Clipping
      • Coiling
      • Hemicraniectomy
    • Medical
      • Mannitol
      • Corticosteroids

Transient Ischemic Attack

Things you should know

  • A TIA is a neurologic dysfunction caused by a disruption in cerebral blood flow without the death of brain tissue.
  • Symptoms typically resolve in less than a day.
  • Risk Factors
    • Family History of stroke or TIA
    • People aging 55 years old and above
    • Males are more prone than females
    • High blood pressure
    • Diabetes Mellitus
    • Smoking
    • Atherosclerosis
    • Increased blood viscosity
    • Migraine
    • Hypercholesterolemia
    • Afib
    • Heart valve issues
    • Etc

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

  • Symptoms vary depending on the area of the brain involved.  Symptoms may usually last a few seconds to a few minutes and mostly disappear after an hour.
  • Amaurosis fugax – temporary loss of vision
  • Diplopia
  • Aphasia – difficulty speaking
  • Contralateral hemiparesis
  • Paresthesia
  • Change in mental status
  • Dizziness
  • Lack of coordination
  • Poor balance

Labs, Studies and Physical Exam Findings

  • Medical History
  • Complete neurologic exam
  • Carotid bruit
  • Carotid ultrasound
  • CT
  • MRI
  • ECG
  • Holter monitor
  • CBC
  • PT/PTT

Treatment

Treatment usually depends on the underlying cause of TIA.  Treatments may include:

  • Blood pressure control
  • Surgery
    • Carotid endarterectomy – removal of atherosclerotic plaque where the stenosis of the carotid artery is more than 70%
  • Medication
    • Anticoagulant – If source is cardiac
      • Heparin
      • Warfarin
    • Antiplatelet – If non cardiac source
      • Aspirin
      • Clopidogrel (Plavix)
      • Ticlopidine
  • Lifestyle Changes
    • Quitting smoking
    • Losing weight
    • Regular exercise

Altered Level of Consciousness

Things you should know

  • Causes:
    • Insufficient blood or oxygen to the brain
    • Excessive intracranial pressure
    • Dehydration
    • Changes in pH
    • Uremia
    • Hyperthermia / hypothermia
    • Infection – Meningitis
    • Stroke
    • Concussion / brain injury
    • Low blood sugar (think insulin overdose)
    • Medications / Drugs / alcohol

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

  • Change in mental status
  • Seizures
  • Loss of bowel or bladder function
  • Poor Balance
  • Falling
  • Difficulty walking
  • Fainting
  • Lightheadedness
  • Weakness in the face, arms and legs

Labs, Studies and Physical Exam Findings

  • Medical History – diabetes, epilepsy, depression, intake of insulin and anticonvulsants
  • Neurological Examination
    • AAOx3
    • Levels of consciousness
      • Conscious – Normal
      • Confused – Disoriented / Impaired
      • Delirious – Disoriented, restless, hallucinations, and delusions may occur
      • Somnolent – Sleepy
      • Obtunded – Decreased alertness and slowed response
      • Stuporous –Respond only to severe pain
      • Comatose – Non-arousable, Non-responsive to stimuli
    • Glasgow Coma Scale
      • Eye movement response 1-4
      • Verbal response 1-5
      • Motor response 1-6
    • Decreased in reflexes, such as gag and cough reflexes
  • Pulse Oximetry – to determine hypoxia
  • Serum glucose levels – to rule out hypoglycemia
  • Radiology
    • CT Scan of the head
    • MRI of the head
  • EEG (electroencephalogram)
  • ECG
  • Complete Blood Count (CBC): a low hemoglobin level indicates anemia and an elevated white blood cell count indicates infections, such as meningitis or pneumonia
  • Toxicology screen
  • CMP
    • Liver function tests
    • Kidney function test

Treatment

  • Maintain patent airway and monitor circulatory status
  • Medications
    • Dextrose – for hypoglycemia
    • Naloxone
    • Thiamine
  • Lumbar puncture – if meningitis is suspected

Cerebral Palsy

Things you should know

  • Lifelong physical disability due to damage of the developing brain.  This is not progressive.
  • Evident in the first 12 to 18 months
  • Risk Factors
    • About 50% of CP patients are born premature
    • Low birth weight
    • Infection of the mother in early pregnancy
    • Prolonged loss of oxygen during the pregnancy or birthing process

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

  • Speech and language issues
    • Dysarthria – difficulty saying words
    • Language delay – Inability to speak simple sentences by 24 months
  • Musculoskeletal
    • Low muscle tone
    • Unable to hold head up
    • 75% of patients present with spasticity and contractures.  This is often found on one side of the body.
    • Poor muscle control
    • Unable to walk at 12 to 18 month
  • Delayed development
  • Feeding or swallowing difficulties

Labs, Studies and Physical Exam Findings

  • Physical Exam:
    • Slow motor movement
    • Tight or floppy muscle tone
    • Contractures & spasticity
    • Missed developmental milestones
  • CT or MRI – may show injury to the brain

Treatment

  • Cannot be “cured”
  • Preventative measures
    • Carry baby to term
    • Magnesium Sulphate – Is used to help prevent preterm labor
  • Medical treatment
    • Benzodiazepines -help with muscle spasms
      • Diazepam
    • Botulinum toxin type A injection – administered IM for muscles with spasticity
    • Antiepileptic medication – to minimize seizures
  • Surgery
    • Fasciotomy
    • Muscle lengthening
    • Joint replacement
  • Physical and  Occupational Therapy
  • Massage
  • Special education and learning strategies
  • Behavior therapy and counselling

Study Tip

Focus at will is an amazing system for using music to study.  Check it out totally free.  I got the paid version after about 5 minutes. https://www.focusatwill.com

Key terms and Ideas

  • Do you use antiplatelet therapy for a TIA with a non cardiac source?
    • Yes
  • Give two contraindications for giving TPA
    • Any possibility of intracranial bleeding
    • Recent major surgery
    • Recent head trauma
    • Active bleeding
    • Intracranial neoplasm
  • Which are more common ischemic or hemorrhagic strokes
    • Ischemic events make up about 85% of strokes
  • A patient has been diagnosed with a TIA.  You have good reason to believe there is a cardiogenic cause.  What medication do you start the patient on immediately?
    • Heparin
  • What is the #1 risk factor for a child having CP?
    • Prematurity

If you are preparing for the PANRE or PANCE check back for weekly   Bookmark this site or add it to your feed reader and never miss an update.   You can also subscribe by clicking here and receive my top 54 Study Tips!  Spend a few minutes a week with us and never have to cram again.

Parkinsons and Intracranial hemorrhages

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300px brain bleedParkinson’s Disease

Things you should know

  • Degenerative disorder of the central nervous system
  • There is an imbalance between acetylcholine and dopamine due to the death of cells in the substantia nigra which normally produce dopamine
  • in the motor symptoms associated with Parkinson’s disease known as parkinsonism

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

  • Motor function
    • Resting or pill rolling tremor – begins in one limb or on one side but will spread
    • Bradykinesia (slow movements) – reduced arm swing, mask like facies
    • Rigidity – Lead-pipe or cogwheel
    • Postural Instability
      • Festination (rapid shuffling gait)
      • Difficulty getting up from a chair, difficulty with stairs
  • Psychiatric
    • Loss of executive function
      • problem solving
      • planning
      • Inhibition of inappropriate actions
    • Speech disorders
    • Behavior and mood alterations
      • Depression
      • Anxiety
    • Dementia
  • Sleep disturbances
  • Autonomic Nervous System
    • Urinary Incontinence
    • Orthostatic Hypotension
    • Excessive sweating
    • Constipation or gastric motility
    • Eye and vision abnormalities

Labs, Studies and Physical Exam Findings

  • Medical History
  • Motor function
    • Resting or pill rolling tremor – begins in one limb or on one side but will spread
    • Bradykinesia (slow movements) -reduced arm swing, mask like facies
    • Rigidity – Lead-pipe or cogwheel
    • Postural Instability
      • Festination (rapid shuffling gate)
      • Difficulty getting up from a chair
      • Increased risk of falls
      • Difficulty with stairs
  • Neuropsychiatric
    • Loss of executive function
      • problem solving
      • planning
      • Inhibition of inappropriate actions
  • CT or MRI are normal in Parkinson’s, but used to rule out other causes of neurologic symptoms
  • Lewy Bodies may be seen on an autopsy of the brain in…
    • Parkinson’s disease
    • Dementia with Lewy bodies
    • Multiple system atrophy
    • Alzheimer’s disease

[click to continue…]

Your first physician assistant job search

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What specialty should your physician assistant job search include

  • It is important to remember lifestyle as you make this decision.  Consider shifts versus long term patient care.
    • Surgery
      • Orthopedics

        The most important step in the physician assistant job search is the phone call

        The most important step in the physician assistant job search is the phone call!

      • Cardiac
      • Plastics
      • Neuro
      • etc.
    • Medicine
      • Family care
      • Hospitalist
      • Peds
      • ER
      • Cardiology
      • etc

Choose private office or hospital

 

Choose the location where you want to work

 

Web searches for available jobs are not a good method of doing a job search.  You can use them, but don’t make them 100% of your search.  25% would be more reasonable.

Dan Millers’s job search plan at www.48days.com

  • Pick several offices and or hospitals you would like to work in. 10 – 15 will give you a good chance of finding something.
  • Find the name of the an actual person you are trying to reach.  Do not send correspondence to human resources, to whom it may concern or anything else.  Find a real person.  Most frequently there is an office manager.  The easiest way to get the name of the office manager is to call the office and ask the person who picks up the phone.  “I’d like to send in a resume and I’m trying to find out who to send it to.  Can you please give me the name of the office manager for your practice?”
  • Send a letter of introduction including: your current situation and goals, why you’re an interesting candidate, and that you will be sending in your resume in a few days.
  • One week later send in your cover letter and resume.
  • Four to five days later – follow up with a PHONE CALL.   This is extremely important and will make a huge difference in your search.  “I’m following up on a recent letter and resume I sent to you.  I understand that your practice provides great care for patients and I really think I can add a lot to the team as well as free up some time for you doctors.  When can we get together and and talk?
  • http://www.48days.com/wp-content/worksheets/job-search-process.pdf

Your first physician assistant job search should be all about finding what you want to do.  Searching for a job should not be about sitting and waiting for an opportunity.  It should be about going out and making opportunities.  Find the place you want to be and let them know your an excellent candidate and your interested.

 

 


If you are preparing for the PANRE or PANCE check back for weekly   Bookmark this site or add it to your feed reader and never miss an update.   You can also subscribe by clicking here and receive my top 54 Study Tips!  Spend a few minutes a week with us and never have to cram again.

Neurology: infections and movement disorders

Play

300px Brain and spinal cordInfections

Encephalitis

Things you should know

  • Acute brain inflammation
  • Causes
    • Viral
      • Rabies
      • Herpes
      • Polio
      • Measles
      • West Nile
      • Eastern Equine
      • St Louis encephalitis
      • etc
    • Bacterial
      • Secondary syphilis
      • Toxoplasmosis
      • Malaria
      • Cryptococcus
      • Strep and staph

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

  • Headache
  • Confusion
  • Changes in mental status
  • Fever
  • Drowsiness
  • Fatigue
  • Seizures
  • Tremors
  • Hallucinations
  • Vomiting
  • Stiff neck

Labs, Studies and Physical Exam Findings

  • CT is done to rule out brain swelling
  • Lumbar puncture
    • Elevated protein
    • Elevated WBCs
    • Normal glucose
    • Antibody assays are positive
    • Positive cultures and gram stain

Treatment

  • Symptomatic
  • Acyclovir to treat herpes
  • Appropriate antibiotic therapy
  • Steroids to reduce inflammation

Meningitis (Bacterial)

Things you should know

  • Membrane inflammation
  • Cause tends to vary with age
    • Newborns – Group B Strep
    • Infants – E. coli
    • Toddler to 6 years old – Haemophilus influenzae
    • Teenagers and young adults – Neisseria meningitidis
    • Adults – Streptococcus pneumoniae (70% of all cases are caused by  Strep pneumo)

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

  • Fever
  • Headache
  • Vomiting
  • Stiff neck
  • Confusion
  • Petechial rash is associated with a Neisseria infection

Labs, Studies and Physical Exam Findings

  • Meningeal signs
    • Kernig’s sign – Patient is supine with hips and knees flexed to 90 degrees.  A positive sign is pain while extending the knee with the hip flexed.
    • Brudzinski’s sign – Patient is supine.  A positive sign is when a the patient’s neck is flexed he will involuntarily flex the hips and knees.
  • CT to look for  a space occupying lesion
  • Lumbar puncture
    • Cloudy fluid.  Normal is clear and colorless
    • Elevated pressure
    • Elevated WBCs from about a normal of 5 up to 10,000 during infection
    • Protein is elevated. Normal is 15-60.  During infection the range is 100-500
    • Glucose is decreased.  Normal is about 60% of serum glucose.  During infection it may be below 40
    • Cultures and Gram stain

Treatment

  • Vaccination
    • H. Flu
    • Neisseria meningitidis
    • Strep pneumonia
  • Testing pregnant woman at 35-37 weeks for group B strep.  Treat GBS positive moms with penicillin during labor.
  • Empiric antibiotics may be given according to the patient’s age
    • Newborns & infants- ampicillin and gentamicin
    • Young children into early adulthood – Third generation cephalosporin and either chloramphenicol or vancomycin due to increased resistance
    • Adults – penicillin
  • Follow treatment with serial lumbar punctures

Movement disorders

Essential Tremor

Things you should know

  • Often called familial tremor because it may follow an autosomal dominant pattern.
  • Most common movement disorder

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

  • Uncontrollable rhythmic movement typically involving the hands, tongue or head.
  • The tremor may occur at rest, but is more commonly seen when the patient attempts to use the affected muscles.
  • The tremors get worse with fatigue, stress, caffeine as well as many other triggers.

Labs, Studies and Physical Exam Findings

  • Diagnosis is based on clinical exam

Treatment

  • Avoidance of fatigue, stress, caffeine etc
  • First line medical treatment is with Beta blockers
    • propranolol
  • Second line include anti epileptics
    • topiramate
    • gabapentin
  • Second line also includes benzodiazepines
    • alprazolam
  • Patients may self medicate with alcohol as is it provides dramatic relief.

Huntington’s disease

Things you should know

  • Autosomal dominant inheritance pattern
  • Offspring have a 50% chance of inheriting the gene for Huntington’s found on chromosome 4
  • Symptoms typically do not appear until age 30
  • This is a progressive neurodegenerative disease

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

  • Changes in mental status
    • Irritability
    • Moodiness
    • Dementia
  • Movement issues
    • Fidgetiness
    • Restlessness
    • Chorea – jerky random uncontrolled movements
    • Rigidity
    • Writhing
    • Abnormal posturing
    • Difficulty swallowing
    • Difficulty speaking

Labs, Studies and Physical Exam Findings

  • Changes in mental status
    • Irritability
    • Moodiness
    • Dementia
  • Movement issues
    • Fidgetiness
    • Restlessness
    • Chorea – jerky random uncontrolled movements
    • Rigidity
    • Writhing
    • Abnormal posturing
    • Difficulty swallowing
    • Difficulty speaking
  • Brain CT may show cerebral atrophy and atrophy of the caudate nucleus
  • Genetic testing (including presymptomatic test and prenatal testing)

Treatment

  • There is no cure and the disease is progressive.  Life expectancy is typically 20 years following onset of symptoms.
  • Supportive care
    • Counseling
    • Speech therapy
    • Occupational therapy etc
  • Treatment for chorea
    • Typical and atypical neuroleptics -olanzapine, risperidone, haloperidol
    • Dopamine depleting agents – tetrabenazine

 

Study Tip

Distraction free study time.  No kids, no cooking diner, no cell phone, no twitter.  Turn it all off and study.  It takes 18 minutes to become completely focused on a task.  How often are you interrupted?

 

Key terms and ideas

  • A patient presents complaining of a tremor in his right hand that seems to go away after two beers.  What is the likely diagnosis?
    • Essential Tremor
  • What is the most likely bacteria causing meningitis in a 17 year old?
    • Neisseria
  • What vaccination has greatly reduced the cases of meningitis in infants.
    • H flu
  • Symptoms for Huntington’s disease typically begin after what age?
    • 30 years old

If you are preparing for the PANRE or PANCE check back for weekly   Bookmark this site or add it to your feed reader and never miss an update.   You can also subscribe by clicking here and receive my top 54 Study Tips!  Spend a few minutes a week with us and never have to cram again.

Headaches

Play

HeadachesCluster Headache

Things you should know

  • Extremely painful unilateral headaches which occur in clusters throughout the day and may continue for months.

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

  • Sudden onset of unilateral, extremely painful,  headaches which come and go but usually last between 15 minutes and 3 hours.
  • They usually come in “clusters” and occur on schedule each day
  • The pain is usually around the eye
  • Along with the headaches
    • Runny nose
    • Watery eyes
    • Drooping eyelid
    • Blushing

Labs, Studies and Physical Exam Findings

  • Just a good history

Treatment

  • Acute attacks
    • Oxygen
    • Triptans
      • Sumatriptan
      • Zolmitriptan
    • Opioids are just as likely to make things worse
  • Preventive therapy
    • Calcium channel blockers – Verapamil
    • Steroids may be used in the first few days.

Migraine Headache

Things you should know

  • Typically unilateral headache of moderately severe pulsating pain.
  • Auro occurs in about 30% of patients
    • Classic migraine = aura
    • Common migraine = no auro
  • Usually lasts between 2 and 72 hours
  • There is often a family history of migraines
  • Before puberty more boys than girls.  After puberty more women than men.

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

  • Recurrent severe headaches
  • They become worse if I move at all
  • Nausea/vomiting
  • Sensitivity to light and sound

Labs, Studies and Physical Exam Findings

  • Imaging is not necessary

Treatment

  • Acute migraine or abortive therapy
    • NSAIDs – Ibuprofen
    • Aspirin
    • Caffeine
    • Triptans – serotonin receptor agonists
      • Sumatriptan
    • Ergotamine
    • Dexamethasone
  • Prophylactic treatment
    • Beta blockers – metoprolol, propranolol
    • Calcium Channel blockers – verapamil
    • ACE inhibitors
    • Tricyclic antidepressants

Tension Headache

Things you should know

  • Most common type of headache making up about 90% of all headaches
  • Causes include
    • Stress
    • Lack of sleep
    • Hunger
    • Minor head and neck trauma

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

  • Constant pain like my head is in a vice

Labs, Studies and Physical Exam Findings

  • No neurologic deficits

Treatment

  • Analgesics
    • NSAIDs
    • Aspirin
    • Acetaminophen

Study Tip

Use a timer.  A timer can be used in several places to make your preparation much more efficient and effective.  You should set a time for all of your study sessions.  This will help you keep track of how long things actually take and it will keep you focused.  When that timer is counting down I won’t check email because I only have another 15 minutes left on my timer.  Then I can check email.  I usually set mine for between 45 and 90 minutes depending on what I’m working on.  It is nice to use one during all study sessions.  It is imperative that you use one when you are doing test questions.

I constantly hear from people that they ran out of time on the exam.  Thats why I think key words are so important and that’s why I think you have to practice with a timer.  One minute per questions because that is what you get on the test.  Running out of time causes panic.  The most likely place you will run out time if don’t practice is on the first section.  If you panic at the end of the first section the rest of your day will be very very stressful.  Practice with a timer.

Key terms and ideas

  • Unilateral headache with a runny nose that occurs at 1:30 everyday for the past week?
    • Cluster headache
  • Oxygen therapy is used in the acute setting of which headache?
    • Cluster headache
  • Which type of headache is associated with an aura?
    • Migraine
  • Which is the most common type of headache?
    • Tension headache

Peripheral neuropathy and a negative iTunes review

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Survey results and negative iTunes comment

  • 60% are getting ready for the PANCE
  • 20 minute podcasts are preferred
  • Can you cover more detail?
  • You talk too much versus you don’t talk enough
  • Questions at the end

Complex regional pain syndrome (CRPS) or Reflex sympathetic dystrophy (RSD)

Things you should knowobject on white - tool sewing pin

  • Chronic disease
  • Usually begins with a surgery or trauma.  It is an inappropriate response of the nervous system to injury
  • It is a systemic disease affecting both the central and peripheral nervous system
  • The average age of diagnosis is 42 though it may occur at any age
  • Females are more likely to be affected than males

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

  • I had surgery/trauma and now I’m having severe pain all the time and even with just light touch.  “Even having a sheet on at night hurts”
    • Burning
    • Throbbing
    • Searing
  • Muscle spasms
  • Red or reddish violet skin color
  • Swelling

Labs, Studies and Physical Exam Findings

  • Pain out of proportion to injury
  • Changes in temperature in a limb either warm or cold
  • Reddish violet skin color
  • Normal EMG

Treatment

  • Physical therapy
  • Occupational therapy
  • Medic ations
    • NSAIDS
    • Steroids
    • Gabapentin
    • Beta blockers
    • Bisphosphonates
  • Local anesthesia and nerve blocks
  • Amputation

Guillain-Barre’s syndrome

Things you should know

  • Autoimmune disease that often occurs after an infection or surgical procedure
  • May become life threatening if respiratory muscles become involved

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

  • **Ascending paralysis –  weakness in hands and feet and now my whole legs feel weak (rubbery legs)
  • Muscle pain
  • Progression is rapid taking hours to days

Labs, Studies and Physical Exam Findings

  • Rapidly ascending muscle weakness
  • Absence of deep tendon reflexes
  • Change in temperature and pain sensation
  • No fever
  • Lumbar puncture – elevated protein
  • Electromyography – slow nerve conduction velocities

Treatment

  • Supportive care
  • Plasmapheresis to filter antibodies
  • IV immunoglobulins
  • In most cases improvement begins at about 4 weeks and they go on to a complete recovery

Diabetic peripheral neuropathy

Things you should know

  • Neuropathy is secondary to vascular insufficiency.
  • There is a direct relationship between degree of hyperglycemia and nerve damage

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

  • Painful numbness and tingling in my feet
  • Loss of bowel or bladder function
  • Erectile dysfunction
  • Indigestion (slow gastric emptying)
  • I get light headed when I stand up (postural hypotension)
  • I’m sweating a lot (poor thermoregulation)

Labs, Studies and Physical Exam Findings

  • Decreased vibratory sensation
  • Electromyography

Treatment

  • Control hyperglycemia
  • Symptomatic treatment

Bell’s Palsy

Things you should know

  • Unilateral facial muscles weakness without cause
  • Most commonly seen in patients who are pregnant or have diabetes
  • ** Affects Cranial nerve VII

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

  • Sudden onset of a one sided facial droop

Labs, Studies and Physical Exam Findings

  • Clinical diagnoses based on exclusion

Treatment

  • Early use of prednisone has helped the most

Key terms and ideas

  • What is the best way to avoid diabetic neuropathy
    • Tight glycemic control
  • A 52 year old overweight male presents complaining of erectile dysfunction.  What metabolic disorders should you be thinking of?
    • DM
    • Atherosclerosis
  • When you read “ascending paralysis” you should immediately consider what disease process?
    • Guillain-Barre’s syndrome
  • Clinically you suspect a patient may have RSD based on the severity of their pain 2 months post-op.  What simple physical exam finding will help your diagnosis?
    • Check the temperature of the skin

If you are preparing for the PANRE or PANCE check back for weekly   Bookmark this site or add it to your feed reader and never miss an update.   You can also subscribe by clicking here and receive my top 54 Study Tips!  Spend a few minutes a week with us and never have to cram again.

Rheumatologic conditions part 2

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Reactive arthritis (Reiter syndrome)

Joint painThings you should know

  • This is a cross reactive autoimmune response.  The immune system responds to an   infection and then continues the fight after the infection is cleared.
  • Typically begins with a GI or GU infection.  Most commonly Chlamydia
  • Typically affects ages 20-40
  • Men more frequently than women

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

  • I can’t see, I can’t pee and I can’t climb a tree
    • Conjunctivitis
    • Nongonococcal urethritis
    • Asymmetric oligoarthritis – typically large joints
    • Lesions on hands and feet

Labs, Studies and Physical Exam Findings

  • Culture the urethra/cervix
  • Rheumatoid factor will be negative
  • Elevated C-reactive protein
  • 75% of patients will have HLA-B27 (?)

Treatment

  • Treat underlying infection
  • NSAIDS
  • Steroids

Rheumatoid arthritis

Things you should know

  • Autoimmune disease which can affect any tissue in the body, but mainly affects the joints
  • Affects women more frequently than men

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

  • Joints
    • Typically affects the small joints of the hands and feet
    • Stiffness – most prominently in the morning.
    • Pain in the affected joints
    • Deformities in the hands and feet.

[click to continue…]

Rheumatologic Conditions Part 1

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300px Joint pain 2Fibromyalgia 

Things you should know

  • Muscle and connective tissue pain
  • Frequently associated with depression, anxiety and posttraumatic stress disorder

I came in to see my physician assistant because of…

  • Widespread pain
  • Bowel and bladder issues
  • Fatigue
  • Weakness
  • Palpitations
  • Sleep issues

Labs, studies and physical exam studies

  • This is a diagnosis of exclusion
  • Widespread pain in all four quadrants of the body
  • Trigger points

Treatment

  • Cognitive behavioural therapy
  • Antidepressants
  • Excercise

Gout (Podagra)

Things you should know

  • Uric acid crystallizes in the joints
  • Occurs in men more than women

I came in to see my physician assistant because of…

  • I woke up with a really really painful, hot, red joint.

Labs, studies and physical exam studies

  • Red, hot, tender joint with decreased ROM
  • Most commonly this affects the metatarsal phalangeal joint of the great toe
  • It may be found in any joint but the feet, ankles and knees are most common
  • Hyperuricemia or uric acid levels > 8 is diagnostic however half of patients with gout will have levels below this
  • X-rays will be negative until end stage arthritis
  • Joint fluid – showing negatively birefringent crystals

Treatment

  • Prevention
    • Diet
      • Limit alcohol
      • Limit organ meats
      • Limit animal protein
      • Drink lots of water
  • NSAIDS – indomethacin is the drug of choice
  • Steroid injection to reduce inflammation
  • Colchicine – decrease inflammation in acute attacks
  • Allopurinol – decreases production of uric acid and is used for long term treatment

Pseudogout 

Things you should know

  • Due to deposits of calcium pyrophosphate into the joint
  • May be acute or chronic

I came in to see my physician assistant because of…

  • Joint pain

Labs, studies and physical exam studies

  • Most often affects large joints
  • X-ray may show fine linear calcifications
  • Joint fluid – calcium pyrophosphate crystals in the joint.

Treatment

  • NSAIDS
  • Steroid injection
  • Surgical joint replacement

Juvenile rheumatoid arthritis 

Things you should know

  • Girls more often than boys
  • Age of onset is before 16
  • Systemic JRA may include
    • Rash
    • Hepatosplenomegaly
    • Hepatitis
  • Oligoarticular or pauciarticular
    • Involves fewer than 5 joints
    • Typically involves larger joints
    • Eye issues are most common with this subtype
  • Polyarticular
    • More than 5 joints are involved

I came in to see my physician assistant because of…

  • Poor appetite
  • Fatigue
  • Lethargy
  • Fever
  • Limping
  • Pain
  • Morning stiffness
  • Systemic JRA has a characteristic rash and fever which come an go

Labs, studies and physical exam studies

  • Joint pain
  • Rash fever
  • X-rays will likely be negative
  • There is no specific blood work that is diagnostic
    • ESR is elevated
    • Rheumatoid factor may be positive

Treatment

  • NSAIDS
  • Physical Therapy
  • Occupational therapy

Polyarteritis nodosa 

Things you should know

  • Vasculitis of medium and small vessels
  • Affects males are  3x more likely to get this disease
  • Typically occurs between 40 and 60 year old

I came in to see my physician assistant because of…

  • Constitutional symptoms -fever, weight loss, fatigue
  • Abdominal pain
  • Neuropathy
  • Skin issues
    • Rashes
    • Ulcers
    • Livedo reticularis – a mottled purple skin discoloration

Labs, studies and physical exam studies

  • Skin issues
    • Rashes
    • Ulcers
    • Livedo reticularis
  • Kidney issues
    • Hypertension
    • Edemia
    • Oliguria
    • Elevated BUN
    • Creatinine Elevated
  • WBCs may be elevated
  • Erythrocyte sedimentation rate may be elevated
  • C-reactive protein may be elevated
  • Tissue biopsy will show vasculitis
  • Angiography

Treatment

  • High dose steroids

Polymyositis

Things you should know

  • Inflammation of the muscle – most frequently affecting the proximal limbs and neck
  • Women are affected more frequently than men

I came in to see my physician assistant because of…

  • Insidious onset of proximal muscle weakness
    • Difficulty going up stairs
    • Difficulty getting up from a chair
  • Dysphagia
  • Butterfly facial rash

Labs, studies and physical exam studies

  • Enzymes that may be elevated but are not specific
    • Creatinine phosphokinase (CPK)
    • Aspartate aminotransferase (AST)
    • Alanine aminotransferase (ALT)
    • Lactate dehydrogenase (LDH)
    • Myoglobin
  • Muscle biopsy

Treatment

  • High dose steroids

Polymyalgia rheumatica (PMR)

Things you should know

  • Pain in many muscles
  • Women are more commonly affected
  • Typically occurs in people older than 50.
  • Associated with temporal arteritis
    • 15% of patients with PMR will have temporal arteritis
    • 50% of patients with temporal arteritis will have PMR

I came in to see my physician assistant because of…

  • My muscles hurt and ar are stiff when I wake up in the morning
  • Muscle pain most commonly in the neck, shoulders and hips.
  • Symptoms tend to be symmetrical
  • Fatigue
  • Fever
  • Weightloss

Labs, studies and physical exam studies

  • Erythrocyte sedimentation rate is elevated

Treatment

  • Low dose corticosteroids (10-20 mg of oral prednisone) for several years
  • Excercise

Key terms and Ideas

  • A question includes the term negatively birefringent crystals.  What disease must be in your differential?
    • Gout
  • What medication do you use to control uric acid in a patient with a history of gout?
    • Allopurinol
  • Aside from lupus what is another disease which may have a butterfly facial rash?
    • Polymyositis
  • Which is used to treat polyarteritis nodosa, high or low dose steroids?
    • High

Study Tips

  • Discuss your study schedule with the people it will affect.  Be sure that before you begin study session that everyone else understands what you are planning to do and how long you will be.

If you are preparing for the PANRE or PANCE check back for weekly updates and PA review questions which are typically posted on Thursdays.   Bookmark this site or add it to your feed reader and never miss an update.   You can also subscribe by clicking here and receive my top 54 Study Tips!  Spend a few minutes a week with us and never have to cram again.

Orthopedics osteoarthritis, tumors and more.

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Knee replacementAcute/chronic osteomyelitis

Things you should know

  • An infection in the bone
  • Hematogenous- spread through the blood. 90% of these cases are found in children and long bones are most commonly affected
  • Exogenous – Typically from an open wound or surgery
  • Staph Aureus the most common pathogen
  • Salmonella is the most common cause of osteomyelitis in a patient with sickle cell anemia
  • Chronic osteo comes and goes. It is treated with antibiotics and then it comes back months or years later.

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

  • Pain, warm, red, tender
  • Open oozing wound
  • Foul smelling wound
  • Difficulty using limb

Labs, Studies and Physical Exam Findings

  • Warm, red, tender area
  • Swelling
  • X-ray will only show advance stages
  • MRI
  • Bone scan
  • Bone biopsy

Treatment

  • At least 6 weeks of antibiotics
  • Surgical debridement
  • Remove hardware if there is any. (plates, screws etc)

[click to continue…]

The Lower Extremity

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femur fracture surgical intervention in orthopedics techniqueGeneral fracture care

Things to know

  • X-ray is initial study of choice and is usually enough to diagnose the fracture
  • CT scan may be used for interarticular fractures or fractures which are difficult to see on plain film
  • MRI may be used in the case of an occult fracture
  • Open fractures should undergo irrigation and debridement within 8 hours of injury.  They should also receive a first generation cephalosporin empirically.  You may also add an aminoglycoside.
  • Treatment for fractures
    • Anatomical reduction either open or closed
    • Immobilization
    • Internal fixation with plates and screws or other hardware may be required if reduction is unstable or fracture is interarticular.

Disorders of the Hip

Avascular necrosis of the femoral head

Things you should know

  • Avascular = no blood, necrosis = death
  • This is the death of the femoral head leading to destruction of the joint surface
  • Risk factors
    • Long term steroid use
    • Alcoholism
    • Trauma
    • Arterial embolism
    • Sickle cell anemia
    • Autoimmune disorders like lupus or rheumatoid arthritis

I came in to see my physician assistant because of…

  • Groin pain
  • Difficulty walking

Labs, Studies and Physical Exam Findings

  • X-ray
  • MRI

Treatment

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