Physician Assistant Exam Review

A review of uterine disorders for the Physician Assistant preparing for the PANCE or PANRE

An overview of the menstrual cycle for the physician assistant reviewing for the PANCE or the PANRE

Osteomalacia abnormal mineralization of bones after the closing of the epiphyseal plates Rickets – abnormal mineralization of bones before the closing of the epiphyseal plates Causes Vitamin D deficiency Low sun exposure Nutritional Malabsorption Billroth type II gastrectomy Jejunoileal bypass Sprue Chronic renal failure Calcium deficiency Phosphate deficiency Decreased alkaline phosphatase Phenytoin – seizure medication […]

A PANRE review of acromegaly and diabetes insipidus

A review for the physician assistant preparing for the PANCE/PANRE on metabolic syndrome and hypoglycemia

A review of diabetes type 2 for the physician assistant preparing for the PANRE or PANCE.

A Review of diabetes type 1 for the physician assistant preparing for the PANCE or PANRE. Podcast episode number 12

The Hypothalamic Pituitary Adrenal Axis In response to low serum cortisol or stress the hypothalamus secretes corticotropin releasing factor (CRF). In response to CRF the pituitary releases adrenocorticotropic hormone (ACTH).  In response to In response to ACTH the adrenal glands secrete cortisol In response to elevated cortisol levels the hypothalamus decreases production of CRF. If […]

Chronic Adrenocortical Insufficiency or Addison’s Disease Your physician assistant program no doubt had an excellent anatomy department, so you are aware that the adrenal glands sit atop the kidneys.  In addition to that I am certain that physiology being one of your favorite classes still remains fresh in your mind today (I’m joking of course). […]

Thyroid Cancer I realized after getting halfway into the parathyroid gland that I hadn’t covered thyroid cancer.  This is not a big section, but I do think that it’s important.  I’m not sure what you think, but memorizing all the tumor markers and the dosages of the medications seems a little more than I can […]

I still have not registered for my PANRE.  I am in the fifth year of my cycle, and like I recommend to all of you, I should take it at least once this year.  I don’t know if I will, but I should.  I will say studying for this one has been so much more fun than I had studying for the PANCE.  In the short time I’ve been putting this together and launched the podcast I have had a great response.  I really appreciate the feedback. Since we covered hyperparathyroidism last week, this week we will cover hypoparathyroidism and pseudohypoparathyroidism.  If hyperparathyroidismis characterized by elevated calcium in the blood stream then hypoparathyroidism can be characterized by decreased calcium in the blood stream.  Parathyroid hormone Hypoparathyroidism Acquired hypoparathyroidism Post thyroidectomy is the most common Post parathyroidectomy Heavy metal damage Low Mg Granulomas Tumors Infection Reidel’s thyroiditis Autoimmune hypoparathyroidism may occur alone in combination with other autoimmune disorders like lupus or Addison’s disease. Congenital DiGeroge Syndrome There are several different genetic disorders which can contribute to hypoparathyroidism that I am not going to go into here Clinical Presentation Acute disease symptoms irritability tetany  -- the involuntary contraction of muscles carpopedal spasms cramping convulsions tingling circumoral distal extremities Chronic disease symptoms Lethargy parkinsonism mental retardation anxiety changes in personality cataracts → blurred vision dry skin decreased eyebrow hair Nail and teeth defects -- brittle nails hyperreflexia (possible) Signs Chvostek’s sign Trousseau’s sign Labs and Studies Lab work Ca low Corrected Ca will be low  (Ca is mostly bound to albumin so if albumin is low you need a corrected Ca) Urinary Ca low Parathyroid hormone is low Mg low Other studies CT or x-ray may show dense bones cutaneous calcifications, calcifications of basal ganglia EKG prolonged QT T wave abnormalities Slit-lamp early cataract formation Treatment Emergently airway maintenance IV calcium gluconate Followed by Mg if appropriate Ca supplement Vitamin D supplement Close monitoring of Ca Psuedohypoparathyrodism Pseudohypoparathyroidism and hypoparathyroidism are like Diabetes type 1 and Diabetes type 2.  In DM 1 you don’t make insulin.  In DM 2 you make insulin, but your insulin receptors do not respond to it.  In pseudohypoparathyroidism you make parathyroid hormone, but the receptors don't respond to it.  There are two types, but I think as a physician assistant it studying for your PANRE or PANCE it is enough to know that pseudohypoparathyroidism exists for now.   Clinical Presentation Similar to hypoparathyroidism tetany seizures cataracts dental problems Labs and studies Blood work Ca will be low Parathyroid hormone is elevated Treatment Cases are typically not as severe as true hypoparathyroidism Ca supplement Vitamin D supplement    

This week I thought we would move into disorders of the parathyroid as we just finished up the thyroid.  If you are interested in a more detailed review of the parathyroid glands I would visit parathyroid.com.  They do an excellent job over there. The parathyroid produces parathyroid hormone  (PTH).  The parathyroid glands act to increase calcium levels in the blood.  As you are no doubt aware, calcium plays a major role in physiology.  Keep this in mind as you go through the symptoms of hyper and hypoparathyroidism.  One example is the importance of calcium in muscle contractions. Hyperparathyroidism Like thyroid conditions hyperparathyroidism is three times as likely in women as in men. Primary disease is typically this is caused by an adenoma in one of the four parathyroid glands although could be from hyperplasia or carcinoma.   An adenoma leads to excessive secretion of parathyroid hormone. Secondary disease may be associated with Chronic renal failure and poor production of vitamin D which will decrease Calcium, thereby stimulating the parathyroid glands malignant tumor -- breast, lung, pancreas Calcium deficiency Clinical Presentation “moans, groans, stones, and bones” patients will not usually come in complaining of any particular symptom.  Hyperparathyroidism is usually an incidental finding. Muscles paresthesias muscle weakness decreased deep tendon reflexes Mental changes (Moans) general malaise depression cognitive impairment psychosis Heart HTN Prolonged P-R interval Shortened Q-T interval heart block GI (Abdominal Groans) constipation nausea/vomiting anorexia abdominal pain weight loss Kidney (Stones) hypercalcemia induced nephrogenic diabetes insipidous polyuria polydipsia Kidney stones Bone (Bones) bone pain arthralgia increased risk of pathologic fractures Skin pruritus Labs and Studies Blood work Ca > 10.5 elevated PTH is diagnostic phosphate low less  calcimimetic Vitamin D Estrogen decreases serum Ca in a postmenopausal hyperparathyroidism Propranolol may be used to protect the heart against elevated Ca There will not be any questions on Thursday.  We are going to cover hypoparathyroidism next week.  I am going to combine those two topics into one set of questions.  Check back next week for those.    

The NCCPA has officially stated that they are changing the PANRE from a six year cycle to a ten year cycle!  Recertification was first introduced in 1981 and since that time it has always been on a six year cycle.  This is amazing news!  These are huge changes to our profession that many of us have been asking for.  I think most people accept the idea of recertification.  I for one like knowing that my provider is still expected to maintain some level of core knowledge regardless the area he practices in.  A lot of the complaints I hear about the PANRE is that we have to take it every six years.  The majority of physician assistants will be much happier with having ten years between exams. Of course, there will still be complaints.  Initially the biggest complaints will be from you and me.  Those of us whose six year cycle ends in 2012 and 2013.  The new ten year plan goes into effect for those PA’s whose cycle ends in 2014.  As an example, the sixth year of my cycle is 2013.  I graduated in 2007, and  I can take my exam in 2012 or 2013.  I will have to take my PANRE again six years later in  2018 or 2019  The lucky SOB’s who graduated the year after me will take their PANRE in 2013 or 2014 and then be on the ten year recertification plan and not have to take it until 2023 or 2024. In addition to the ten year cycle there are some changes to CME going forward. The good news here is that they are keeping it at 100 hours of CME for every two year cycle.  There will still be a mandatory minimum of fifty category one CMEs during each two year period.  The difference is that now there will be subcategories of category one CME . Self assessment CME This is a more active type of CME.  No more snoozing in the back of grand rounds and getting CME for it.  The details have not completely come out on this yet, but the idea here is pretty straight forward.  I’ve already done this for some of my CME.  You take a short exam on a topic of your choice and get credit for it.  The big question I have is who grades these assessments?  I have always graded my own, but I know that some have the company you bought the exam from grade it for you.  At this point I’m not sure what will be acceptable for the NCCPA, but I am hoping to hear soon. Performance Improvement CME This is where things change a little more.  The idea here is simple it’s the implementation I’m not so sure about.  To earn these CME, you create project for improving your practice.  You find an area you would like to work on.  You compare what your facility/practice is doing against national benchmarks, and then you put into place a plan to improve in this area.  You then follow up by comparing your initial results with the results after your improvement plan has been in place. The ten year cycle like the six year cycle is composed of two year cycles.  You now have five of these cycles rather than three.  You still must log 100 CMEs during each two year cycle.  The difference here comes in with the self assessment and performance improvement CME.  You can do them in any order you like, but you must do them both.  You must complete at least 20 hours of either self assessment or performance improvement in each of the first four cycles.  You must complete at least two self assessment activities and two performance improvement activities during the first four cycles.  Although they introduced these two new requirements they did not add to the total of CME needed.  In addition, during your fifth cycle, while you are preparing for your PANRE, you do not have to do the self assessment or performance improvement CME.  You are free to complete any category one CME.  This is so you can focus your attention on passing the PANRE. 1st 2 year cycle Complete 100 CME with a minimum of 50 category one CME.

Hypothyroidism Causes of Hypothyroidism Thyroiditis (see complete listing below) Hashimoto’s thyroiditis - the most common thyroid condition in the U.S. Patient has no thyroid Radioactive iodine ablation Surgical removal of the thyroid Congenital Medications Amiodarone which is structurally similar to thyroxine Lithium Propylthiouracil (PTU) and Methimazole - used to control hyperthyroidism Clinical Presentation And you thought the hyperthyroid symptom list was long and vague.... cold intolerance puffy face fatigue changes in menstrual cycle, typically heavier pale, cool, dry skin thin brittle nails and hair poor memory depression psychosis dementia weakness muscle stiffness anorexia constipation weight gain edema bradycardia hyporeflexia Labs and studies TSH -- elevated in primary hypothyroidism. total T4 -- decreased free T4 -- decreased T3 -- may be normal Antithyroid peroxidase Antithyroglobulin antibodies CBC -- may show anemia BMP -- low sodium CT or MRI can be done but not typically necessary Treatment Thyroid hormone replacement Levothyroxine is the most commonly used medication.  It is a synthetic T4. Patients are started with the lowest dose and it is slowly moved up while monitoring symptoms and TSH levels. Once the dose is set yearly levels should be checked Treatment is forever Watch for symptoms of hyperthyroidism Myxedema This is the mirror of thyroid storm.   This is extremely severe hypothyroid and a true life threatening emergency   Clinical Presentation Patients with myxedema will have symptoms of hypothyroid as well as mental changes from confusion to coma convulsions hypotension hypothermia hypoventilation rhabdomyolysis and acute kidney damage hyponatremia Treatment IV levothyroxine intubation if necassary slow warming with warm blankets if necessary Thyroiditis All are far more common in females.  For the PANRE I would focus on Hashimoto’s and really have a good understanding of it. Categories of thyroiditis Hashimoto’s thyroiditis This is also known as chronic lymphocytic thyroiditis. Subacute thyroiditis also known as granulomatous thyroiditis, de Quervain’s thyroiditis and giant cell thyroiditis.   It is thought to be caused by a virus. Postpartum thyroiditis believed to be autoimmune in nature occurs in 7.2% of women post delivery Suppurative Thyroiditis nonviral infection of the thyroid rare Reidel thyroiditis invasive fibrous, woody, ligneous are all terms used to describe this typically as part of a systemic fibrosis rarest form of thyroiditis Clinical Presentation Hashimoto’s thyroiditis -- symptoms of hypothyroidism, these patients have a high rate of other autoimmune problems like Sjogren’s, myasthenia gravis, celiac disease, addison’s disease etc. thyroid enlarged, firm, nodular neck tightness mental changes depression chronic fatigue Autoimmune about 33% have Sjogren’s syndrome xerostomia -- dry mouth keratoconjuctivitis -- dry eyes myasthenia gravis is often a concomitant autoimmune problem Subacute Thyroiditis acute pain (really? this seems like a bit of an oxymoron) painless is called silent thyroiditis glandular enlargement → dysphagia low grade fever fatigue 50% will have thyrotoxicosis followed by hypothyroid followed by euthyroid Postpartum Thyroiditis beings 1-6 months postpartum hyperthyroid followed by hypothyroid painless palpable goiter Suppurative Thyroiditis  (remember this is typically a bacterial infection) painful tender red fluctuant Reidel thyroiditis hypothyroid symptoms the thyroid becomes enlarged and  hard dysphagia hoarseness pain dyspnea typically goes along with systemic fibrosis

For the those of you who are following along on weekly basis we are going to start a review of the endocrine system.  I am going to continue to work through each section in it’s entirety rather than bouncing from topic to topic.  I think that adds some continuity to the review and it is easier for you to follow along.  At some point I would also like to create a short review test for each section and doing them together will better facilitate this.  Anyway, lets get started Thyroid - Hyperthyroidism Primary vs Secondary Primary hyperthyroidism is when the problem is within the thyroid. Secondary hyperthyroidism is when the problem is with something else in the body which is affecting the thyroid like the pituitary or hypothalamus Graves disease is the most common cause of hyperthyroidism.  It is an auto immune disease in which the body creates antibodies that bond to the TSH receptor thereby forcing the thyroid into excessive production. Amiodarone may cause thyrotoxicosis   Clinical Presentation As a physician assistant with acute clinical skills you will of course be keeping an eye out for symptoms of hyperthyroidism.  It is quite a list!  If you picture someone who has had a lot caffeine for a long period of time a good number of the symptoms will come easy to  you.  So here’s the list. Eyes stare lid lag with downward gaze upper eyelid retraction diplopia Ophthalmopathy -- which means any eye disease Grave’s disease  20-40% of pts will have chemosis conjunctivitis exophthalmos or proptosis Heart Tachycardia AFib Palpitations Chest pain Skin Fine hair warm moist onycholysis myxedema Mental changes irritability nervousness fatigue heat intolerance sweating changes in weight increase in appetite loose stool frequent urination muscle cramps changes in menstruation fine resting tremor hyperreflexia goiter bruit hypokalemic periodic paralysis lasting 7-72 hours typically in Asian and Native American Men following oral or IV carbohydrates or excessive exercise Chronic symptoms include osteoporosis clubbing finger swelling hypercalcemia decreased libido Thyroid storm very rare but severe risk factors stressful illness thyroid surgery radioactive iodine treatment symptoms fever tachycardia vomiting/diarrhea dehydration muscle weakness confusion Believe it or not this is where I decided to stop listing symptoms.  It could still continue quite a ways. Labs & Studies Being a good physician assistant you will want to understand the relationships between the hypothalamus, pituitary and the thyroid in order to understand what the lab work should look like.  At this point I am not branching out into video or graphic design so here is a link to a decent review of the the hypthalmic pituitary thyroid axis. Hyperthyroid blood work TSH (thyroid stimulating hormone) decreased (almost all the time) T4 (thyroxine) elevated T3 (triiodothyronine ) elevated Free T4 elevated Free T4 index elevated ESR elevated TSH receptor antibody elevated in Graves disease hypercalcemia Radioactive iodine uptake scan will be elevated in Graves disease U/S may be helpful   Treatment Beta blockers are the first line of treatment and propranolol is the one you will hear about with hyperthyroidism and thyroid storm Methimazole and propylthiourcial (PTU) will actually control hyperthyroidism and is used to prepare patients for surgery or as treatment in someone who can not do either iodine ablation or have surgery. Radioactive Iodine ablation Surgical removal Digoxin to treat AFib Warfarin to treat clotting with AFib   ------------------------------------------------------------------------------------------------------------------------- If you are preparing for the PANRE/PANCE check back for weekly updates.