Comprehensive PANCE Resource Review

Comprehensive PANCE Resource Review

Updated: 12/02/2016

If you are reading this review, please understand that I wrote this with the intention of being informative, not discriminatory, chastising, or undermining. All of these resources have no doubt been the result of many long nights and lots of collaboration amongst writers, editors, and publishers and I fully respect that. That said, I hope that this review provides a comprehensive review of resources available online and print for students to use as a guide during clinical rotations, studying for the PANCE, or reviewing for the PANRE. Best of luck to you all and let me know if you have any comments to add below! Thanks for reading!

Online Vs. Print Reviews

	Online Resources	Print (Book) Resources
Pros	Interactive Provide personal performance feedback Most provide videos, podcasts and other multimedia to enhance experience Most include x-rays, EKGs, and colored images in high definition	Easy to take with you “on the go” Never have to worry about internet connection One-time purchase Most contain great outlines, tables, or images Cheaper costs
Cons	May have to repurchase subscription Can be very costly upfront Could require internet access	Info will likely be outdated by the time you recertify Will often lack color images, often helpful for dermatology Low resolution for x-rays

PANCE Review Books

In my personal opinion, all of these resources have their pros and cons. The perfect book would not only follow the NCCPA format but would be in order of highest percentage covered on the PANCE to least. Knowing that there are sections on the rotation exams and PANCE in surgery, emergency medicine, pediatrics, and infectious disease, I would definitely like my review to include these sections - something to consider before you decide on a purchase. No book is perfect and I hope that this review is somewhat comprehensive, giving you better insight into each as you make the decision of where to place your money. Ultimately, my goal is not to praise or critique one book over another, but to offer suggestions for improvement and highlight the best aspects of each.

Systemic Lupus Erythematosus

Systemic Lupus Erythematosus

Updated: 11/25/2016

Although Rheumatology falls under the Orthopedics section of the PANCE, which counts for 10% of the test, it isn’t heavily emphasized during PANCE review courses or in PA school, for that matter. I think our program probably spent 1 week or less on Rheumatology. This part of the test doesn’t have to be scary and it doesn’t have to be a bunch of memorization, either. Just remembering the basics can get you the answers you need to a few questions on the PANCE so that you’re not missing the easy “quick and dirty” questions.

A good place to start is with lupus. Lupus is an autoimmune disease that can affect many systems and one of the most challenging aspects about diagnosing it is that many of the symptoms are nonspecific and overlap with other common conditions. You’re almost guaranteed to have a question or two on lupus on your PACKRAT, EOR Exam, PANCE or PANRE. The thing to note about all rheumatological conditions are their overlaps and subtle differences. Lupus has a very characteristic malar rash that is often tested over - keep in mind they can give you a description or photo with a corresponding vignette. Don’t focus too much on all of the manifestations of lupus. It can appear quite vague most times and is often a diagnosis of exclusion.

5 Tips on Taking the PANCE

5 Tips on Taking the PANCE

Updated: 11/25/2016

After studying for the PANCE for about the past month and a half, I will finally be releasing a review of (most) resources for you all - my loyal readers. First off, a huge thank-you to all of you for your interest in the PA profession; whether you’re just starting your journey or close to finishing, I hope that my blog has influenced your life for the better. Thank you all for sticking with my blog even through the past month or so when I’ve been absent from almost all forms of social media.

Second, I’d like to start out by saying that I took my PANCE on a Tuesday and received my results the following Wednesday. Guess what? I passed! I’m now officially a certified physician assistant and am so grateful to have made it this far. My next journey begins as a PA at Children’s Health in Dallas working in Neurology.

Now, let’s get back to why you’re here - the PANCE. This test - while the ultimate determinant of your career - should not be feared. It can be both challenging and deterring, but not impossible. While there are many forums online promoting or demoting the many products, question banks, and review courses, I’m here to give you my own opinion on most of the popular ones out today. Though this review is not intended to be all inclusive, I hope to give you all a starting place no matter your budget or timeline.  

Please review the NCCPA Content Blueprint Areas listed by Organ System here. Also, note that the site does mention that “Other content dimensions cross-sect these categories. For example, up to 20 percent of the questions on any exam may also be related to surgery or infectious disease, and up to two percent may also cover legal or ethical issues.” One area that I don’t believe PA programs emphasize heavily is legal issues surrounding healthcare. We do cover a lot of ethical scenarios in PA school - I think most programs do - as it's probably an ARC-PA requirement, but legal issues are not. The Healthcare Handbook is a nationally known text summarizing the basics surrounding healthcare in the U.S. and is a great review that I highly recommend prior to starting PA school.

In my experience with the PANCE, I felt the rotation exams prepared me for the PANCE best by covering topics like surgery, emergency medicine, and pediatrics in great detail. Old PACKRAT questions were great for review as well as they give you a sneak peak into the vignette style questions you may encounter on rotation exams, PACKRAT, and PANCE. You can go here to learn more about the PACKRAT. In addition, PACKRAT files may be found online but the best place to check is Quizlet!

As stated previously, there are many options available to help you review for the exam. During my clinical rotations and month and a half study session, I utilized many of these resources myself to help gauge what I felt was most helpful. While I will not endorse one product over another, I will offer suggestions as to what I think would have been an appropriate study plan. Here are 5 tips on taking the PANCE. Stay tuned for my full review of PANCE resources, coming soon.

5 Tips on Taking the PANCE

Heart Murmurs and Valvular Heart Disease

Heart Murmurs/Valvular Heart Disease*

• Most common causes of mitral/aortic valve disorders are congenital defects; other causes include rheumatic heart disease, connective tissue disorders, infection, sensile conditions
• Most common presenting symptoms: dyspnea, fatigue, decreased exercise tolerance
• Other: Cough, rales, paroxysmal nocturnal dyspnea or hemoptysis, hoarseness
• Physical exam - heart murmur +/- palpable thrill  
• Diagnostic Studies
• EKG - not useful for specific diagnosis → shows chamber hypertrophy
• CXR
• Aortic → left sided atrial enlargement, ventricular hypertrophy
• Mitral → atrial enlargement only
• Echo (transesophageal) and cardiac cath → definitive
• Treatment
• Surgical repair or replacement of defective valve
• Good exercise tolerance → diuretics and vasodilators for pulmonary congestion and digoxin or BB for dysrhythmias
• Anticoagulant therapy for thromboemboli prophylaxis
• Antibiotics to prevent endocarditis and recurrent rheumatic fever

Mitral Valve Prolapse Regurgitant flow across mitral valve

Decreased left ventricular volume results in earlier prolapse and click heard earlier in systole, closer to S1 Increased left ventricular volume results in delayed prolapse, click heard later in systole Thin females with minor chest wall deformities Associated: Ehlers-Danlos, Marfan Syndrome, Mitral Regurgitation

1. Mid-systolic click 2. Followed by a mid-to-late systolic murmur (mitral regurgitation) 3. Loud S2 “Click” is caused by prolapse of leaflets into left atrium and tensing of mitral valve apparatus

1. Maneuvers that increase left ventricular end diastolic volume (preload)/worsen: seated/standing → squatting 2. Maneuvers causing delay in prolapse: handgrip, standing from seated position, valsalva

Health Maintenance 1. Leads to mitral regurgitation 2. Predisposed to infective endocarditis 3. ADA no longer recommends prophylactic antibiotics for MVP

Multiple Sclerosis, Guillain Barre, and Amyotrophic Lateral Sclerosis (ALS)

Multiple Sclerosis, Guillain-Barre, and ALS commonly appear on exams because of their similarities, but its the subtle differences and keywords you should look out for, especially on physical exam. While historically, the PANCE and PACKRAT are only 6% Neurology questions, these are a few that you shouldn’t miss. Do you know multiple sclerosis as well as you think you do? Would you be able to diagnose and work someone up for ALS if you saw their presentation in an ED? Guillain-Barre has its own special findings on lumbar puncture that you don't want to forget. If it's in your differential and you can rule out things like meningitis, make sure you know the things you'd expect on a lumbar puncture. These are all great points to know, though this is not meant to be an all-inclusive review. You'll definitely want to review multiple sclerosis medications before your exam, including which are first line and which are actually long term (disease modifying) vs. acute treatment. Good luck out there!

I hope this review helps you regardless of which avenue you find it useful. Make sure to check out TrueLearn’s free sample questions below! The vignette style questions are exactly what you need to prepare yourself for EOR, PANCE, PACKRAT, and PANRE-related questions.

Strokes, Hemorrhages, and Aneurysms

Strokes

Strokes and TIAs will 100% for sure be on your PANCE/PANRE/PACKRAT, you name it. While historically, the PANCE and PACKRAT are only 6% Neurology questions, these are a few that you shouldn’t miss. After completing my general neurology rotation, I quickly learned that the answers to these complex puzzles was definitely time-dependent. Can you think on your feet and generate a differential diagnosis? Attention to tiny details was crucial for Neurology because that’s how you can tell what part of the brain the ischemia/infarction is coming from.

I hope this review helps you regardless of which avenue you find it useful. Good luck and make sure to check out TrueLearn’s free sample questions below! The vignette style questions are exactly what you need to prepare yourself for PANCE related questions. Good luck!

Transient Ischemic Attack, Cerebrovascular Accidents (CVA) or Stroke, Bell’s Palsy

• Evolving stroke: worsening
• Completed stroke: maximal deficit has occurred
• Duration of symptoms is the determining difference
• Transient Ischemic Attacks (TIA)
• Neurologic deficit that lasts few mins to <24 hours (N: 30 mins)
• Symptoms transient because reperfusion occurs due to collateral circulation or breaking up of embolus
• Blockage in blood flow does not last long enough to cause permanent infarction
• Clinical Pearls
• Triptans are contraindicated in patients with coronary artery disease or peripheral vascular disease and should be avoided in all patients with an increased risk for stroke
• Contraindications to thrombolytic therapy: previous hemorrhagic stroke, stroke within 1 year, a known intracranial neoplasm, active internal bleeding, suspected aortic dissection. Relative contraindications: severe uncontrolled hypertension, use of anticoagulation, active peptic ulcer disease.
• Hypertension is the most common and most important stroke risk factor

Antibiotics for PAs - Part I

Antibiotics for Physician Assistants - Part I

Updated: 08/07/2016

• Empiric therapy is defined as the initiation of treatment prior to firm diagnosis, and knowing the specific organism causing the infection
• Started only after cultures have been obtained
• Targets likely pathogens and must use local antibiogram
• Broad spectrum means covering both gram positive and gram negative bacteria
• Pharmacokinetics: what the body does to a drug
• Absorption: described in terms of bioavailability (F)
• 100% bioavailable drugs (PO = IV): Linezolid, Fluoroquinolones, Tetracyclines, Azithromycin, Metronidazole, Trimethoprim/Sulfamethoxazole (Bactrim), Rifampin
• Distribution: affected by protein binding, blood flow, molecular size, lipophilicity, inflammation, and fluid status
• Metabolism: occurs primarily in the liver via multiple mechanisms
• Phase I: oxidation/reduction (CYP 450), hydrolysis
• Phase II: glucuronidation, sulfonation, methylation, acetylation, glutathione
• Elimination: primarily renal (glomerular filtration and tubular secretion)
• Most antibiotics require dose adjustment for creatinine clearance (CrCl) <50 mL/min

Cell Wall Synthesis Inhibitors

Sixth Semester at UTSW

Sixth Semester at UTSW

Updated: 08/07/2016

Below is a schedule taken from our program website detailing the clinical rotation schedule. Each student’s rotations are already set up for them (a huge plus), as I learned at the PAEA conference this year that not all PA programs do this. Some programs require that you setup your own rotations. Additionally, I appreciated an increased level of security that our rotations were quality - something not all programs ensure. Our rotations have been vetted before, dropping sites and preceptors who do not meet a high enough standard for our students. Our clinical coordinators have also done a great job of ensuring preceptors provide feedback to our students and that we get the most experience on each rotation, never being left in the shadows.

This year our class also joined the many PA programs utilizing PAEAs end-of-rotation (EOR) examinations, streamlining the examination process and unifying rotation evaluation with an enhanced & secure online experience mirroring the PANCE. After each 120-question exam we received feedback about our performance, including a topic list of each type of question we missed and the task area. The content of the exams is provided by PAEA in a blueprint style and topic list format.

During the spring of 2016, I went through internal and family medicine, which were both 8 week long rotations. I was at Parkland and Zale-Lipshy hospital for my internal medicine rotation and I was in Bridgeport, Texas for my rural family medicine rotation. Both presented great opportunities for learning and included lots of 1-on-1 time with my preceptors as well as lots of procedural learning opportunities. Of note, since I was about 1 hour away from home during family medicine, my PA program located, secured, and paid for housing for all 8 weeks. This is something UT Southwestern does for all of its rural family medicine rotations - we are all very fortunate to have this provided for us.

Free Category 1 CME Credit Opportunity

Free Category 1 CME Credit Opportunity

Updated: 07/11/2016

I wanted to take the time to introduce Matt Borges, who has been a PA since 2007.  After graduating from Wake Forest University, Matt spent the majority of his professional career in emergency medicine, where he says every day is an opportunity to encounter the unexpected.  Over the last few years, he has had the pleasure of precepting students, which he claims to serve as a real life reminder that the more you think you know, the more you realize you always have plenty to learn.  

Over the past year, Matt has taken an interest in online educational webinars. While they were initially targeted toward PA students, they spread to an array of health care professionals. Webinars were originally designed to cater to APC's in emergency rooms, urgent cares, and primary care offices, but they also offer exposure to health professionals early in their careers who are still trying to sort what best suits their interests.  

Matt typically teams up with a physician, serving as the expert opinion in their particular field, and walks through cases pertinent to the particular topic. This format has been met with positive reviews, and offers a methodical approach to common issues encountered.  He works to produce webinars every few months, with free registration and opportunity for 1 hour of category 1 CME credit.  

The most current program is on common presentations of pediatric fevers in an ED, happening Tuesday July 12th at 7:30 PM-8:30 PM Eastern Time.  

Registration Here

I hope you'll find a topic that interests you, and check one out, soon!

--

Matthew M. Borges, PA-C, MMS

APC Director, Virginia Emergency Medicine Associates

www.vemadocs.com

Introduction to EKGs for Physician Assistants

Intro to Electrocardiograms for Physician Assistants

Updated: 07/08/2016

Electrocardiocardiograms can be difficult to tackle and I know that this is a topic that I repeatedly visit, both for simple things like delineating PVCs (premature ventricular contractions) from PACs (premature atrial contractions) and denoting what defines a second degree type 1 versus a second degree type 2 heart block. But there’s so much more than just that - there’s right and left bundle branch blocks, right and left ventricular hypertrophy, ischemia, infarction, axis deviation, atrial hypertrophy, etc. While this is a very limited approach to EKGs and while there is still much to learn about them, this is a great introduction to EKGs for any student, whether you are pre-med, pre-PA, pre-NP, pre-nursing, or pre any other health profession. At the end of the review are a few helpful questions provided by TrueLearn you can use after you’ve studied the review, which offer you some insight into the type of questions and degree of exam preparation offered. I hope that you find them as useful as I have. Good luck and let me know if there are any errors or questions!

Electrocardiogram (ECG): records the electrical activity of the heart and information about the heart’s function and structure