Richard Snyder

Cheat Sheet / Updated 02-27-2024

The first step to dealing with high blood pressure is understanding your blood pressure measurement — those over and under numbers. When you know what your blood pressure is, you need to know what to do next. The good news is, you may be able to prevent high blood pressure or reduce your blood pressure by making some lifestyle changes. You also need to look for signs of resistant high blood pressure, and if you need high blood pressure medication, consult a physician to find the right medication for you.

Article / Updated 06-20-2023

A lot of pathology and Physician Assistant Exam questions concern the small and large intestines. Here you see conditions such as irritable bowel syndrome (IBS), ischemic bowel, inflammatory bowel disease (IBD), celiac disease, and diverticulitis. Irritable bowel syndrome (IBS) Irritable bowel syndrome (IBS) is a diagnosis of exclusion after other conditions have been ruled out. It’s a clinical diagnosis — you can’t diagnose this condition with endoscopy and biopsy or barium swallow as you can with many other GI conditions, because the findings are often normal. Common symptoms include constipation, diarrhea, or a combination of both. A stereotypical candidate for IBS is someone under a great deal of stress who has problems with either diarrhea or constipation during the day. In a typical PANCE question, you get hints such as “it has been going on for a while,” “both endoscopy and colonoscopy are negative,” “and stool studies, including those for ova and parasites, are negative.” A very common syndrome associated with IBS is fibromyalgia syndrome. The treatment for IBS includes recognizing the triggers, including food, physical stressors, and psychological stressors. Many of the anticholinergic medications, such as dicyclomine (Bentyl), have been tried in treating IBS. Ischemic bowel Ischemic bowel, also known as ischemic colitis, commonly occurs in older individuals. Risk factors and medical conditions associated with ischemic bowel include atherosclerosis of the intestinal vessels, atrial fibrillation or the presence of a left ventricular mural thrombus, and a hypercoagulable state. Low blood pressure can precipitate mesenteric ischemia due to hypoperfusion of these vessels. Here are key points about ischemic bowel: The classic presentation is pain out of proportion to clinical findings. The person (usually with one of the preceding risk factors) can have diffuse midepigastric pain but also have a benign physical examination. The pain worsens after eating a meal. Blood flow to the mesenteric area increases after a meal to aid with digestion, and the timing of the abdominal discomfort in relation to eating can point to ischemic bowel. A person can have mesenteric angina or mesenteric ischemia, which is an acute problem. If a large amount of the bowel is affected, expect to see a lactic acidosis and an anion gap on the CHEM-7. If the affected person’s abdominal pain is just an episode of angina, you may not see a lactic acidosis. If findings suggest an acute mesenteric event, the best way to look at the intestine is an exploratory laparotomy. A CT scan of the abdomen and pelvis with oral contrast may suggest bowel wall thickening, but this is a nonspecific pattern that you also see with other types of colitis. That being said, the CT scan is the best test for looking at the integrity of the bowel wall. Inflammatory bowel disease (IBD) Inflammatory bowel disease (IBD) is a comprehensive term covering two different but overlapping conditions: Crohn’s disease and ulcerative colitis. Both of these conditions confer an increased risk of colon cancer. Crohn’s disease is an inflammatory condition that can involve any area of the GI tract from the mouth to the anus, although it’s usually predominant in the ileum and ileocecal region of the small intestine. When confined to this area, it’s called regional enteritis. Histologically, Crohn’s disease is characterized by noncaseating granulomas on tissue biopsy. The etiology behind the inflammation is unknown. Note that this condition affects all layers of the intestine. When it affects the small intestine, especially the ileum, Crohn’s can cause malabsorption of key nutrients, especially the fat-soluble vitamins A, D, E and K. Here are the key points about Crohn’s disease: It usually occurs in younger people, with an initial onset in the teenage years up to the mid-30s. It’s characterized by the presence of skip lesions as well as what looks like a cobblestoning mucosa on colonoscopy. Crohn’s can affect the anus. If on you’re asked about the presence of anal fissures on the PANCE, think Crohn’s disease. Treatment can involve steroids and salicylate derivatives such as mesalamine. Antibiotics such as metronidazole can be used. In advanced cases that have been refractory to treatment, you can use intravenous infliximab. Surgery is not curative in Crohn’s diseas. Ulcerative colitis (UC) overlaps with Crohn’s disease to some extent, but here are some key differences: Unlike Crohn’s, ulcerative colitis involves only the superficial mucosa, not all layers of the intestine. Ulcerative colitis doesn’t have these skip lesions; the area of inflammation is continuous. Ulcerative colitis is predominantly in the sigmoid-rectal region. In fact, a common presenting symptom of ulcerative colitis is hematochezia and a colonoscopy that demonstrates ulcerative proctitis. Crohn’s, on the other hand, is predominantly in the small intestine, is sometimes in the large intestine, and can affect the anus. Crohn’s disease has a higher rate of strictures than ulcerative colitis. Both are associated with the possible development of obstruction, abscess formation, perforation, and fistula formation. Ulcerative colitis increases the risk of developing sclerosing cholangitis. Remember Charcot’s triad of right upper-quadrant pain, fevers, and jaundice for the diagnosis of cholangitis. Ulcerative colitis treatment can consist of steroids, although it primarily consists of 5-ASA derivatives. They can be given either orally or rectally. Both ulcerative colitis and Crohn’s disease can be associated with extraintestinal manifestations, which makes sense because both conditions are inflammatory. They can be associated with eye disease and certain skin lesions, including pyoderma gangrenosum and erythema nodosum. IBD is also associated with inflammatory arthritis. IBD, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis are examples of the seronegative spondyloarthropathies. All are associated with HLA-B27 expression. The arthritis associated with IBD is thought to affect more of the peripheral joints, especially during an active flare of IBD. Which of the following conditions can be associated with caseating granulomas? (A) Crohn’s disease (B) Sarcoidosis (C) Ulcerative colitis (D) Tuberculosis (E) Silicosis The correct answer is Choice (D). Tuberculosis is associated with caseating granulomas.

Cheat Sheet / Updated 04-13-2022

When you're preparing to take the PANCE or PANRE, you may feel like you have to know an endless amount of information. How will you ever remember all the details of so many diseases and conditions? Here, you can review some useful mnemonics that will not only help your recall as you prepare for your physician assistant exam but also improve your clinical acumen.

Cheat Sheet / Updated 03-10-2022

Treating adrenal fatigue includes improving nutrition, replacing key nutrients, supplementing with antioxidants, reducing stress, and beginning a controlled exercise program. Before you can treat the condition, though, you need to recognize the symptoms that suggest you have adrenal fatigue.

Cheat Sheet / Updated 01-20-2022

No matter what initials you have after your name (RN, CNA, PA, and so on), you can bet you’ll see math on a daily basis if you’re going into (or are already in) a career in the medical field. Grasping some medical math basics — such as how to break down medical dosage problems into steps and use conversion factors — can simplify everyday situations all health care professionals face. In addition to just knowing math, you’re going to need to know how to read and interpret doctors’ orders, and spot when there’s potential trouble.

Article / Updated 06-16-2016

Rheumatoid arthritis (RA) is a debilitating inflammatory arthritis that can cause adrenal fatigue and typically occurs in middle-aged individuals, but it can occur in people as young as their 20s and 30s. This deforming type of arthritis needs to be actively treated because, when full blown, it causes erosion of the joints. An article published in 2008 in the medical journal Best Practice and Research: Clinical Rheumatology reviewed the interactions of the endocrine system, the nervous system, and inflammation with respect to the development of arthritis. With respect to the adrenal glands, the article noted two important points: Rheumatoid arthritis is associated with a significant amount of chronic inflammation, which should lead to high levels of cortisol. However, the authors noted decreased production of cortisol, given the significant amount of inflammation present. The authors also noted that the hypothalamus and pituitary gland, both of which produce hormones that affect adrenal glands, also demonstrated reduced levels of functioning. If you've been diagnosed with rheumatoid arthritis or you strongly suspect that you have it, you may have experienced one or more of the following symptoms: Morning stiffness lasting for more than one hour: This stiffness is dramatically different from just being a little stiff in the morning. This is a prolonged stiffness in many joints that can take over an hour to loosen up. Arthritis that is bilateral and symmetric (affecting both sides of the body equally): Common areas affected include the hands, especially the fingers. Characteristic findings on X-rays: Your healthcare provider can order X-rays to confirm the presence of rheumatoid arthritis. Examples of typical radiographic findings include narrowing of the joint spaces and erosion of the joints themselves. Characteristic lab findings: Your healthcare provider can order certain blood tests to aid in the diagnosis of rheumatoid arthritis. In rheumatoid arthritis, you may see an elevated sed rate. Other labs that can be elevated include a rheumatoid factor as well as a specific antibody for rheumatoid arthritis alone called the anti-cyclic citrullinated peptide (or anti-CCP ) antibody. The traditional treatment for rheumatoid arthritis involves medications that suppress the immune system as a means of stopping the inflammation and joint swelling. These medications can include prednisone, methotrexate, and/or biologic agents, such as adalimumab (Humira). Alternative options for the treatment of rheumatoid arthritis include tart cherry extract (cherries are a potent natural inflammatory) and natural anti-inflammatory agents such as turmeric and bromelain.

Article / Updated 05-13-2016

A common scenario you deal with clinically and for the Physician Assistant Exam (PANCE) is inadvertently finding a lung lesion on a chest radiograph. You’re looking for something, and bam! There it is. What do you do about it? You assess the lesion on the radiograph: Check the other lung findings to make sure that you’re just dealing with a pulmonary nodule. Other lung findings should be normal. Examples of abnormal findings include the presence of atelectasis or a recurrent pneumonia that won’t go away despite repeated treatment with antibiotics. The presence of adenopathy, especially hilar adenopathy, should be inspected on the chest radiograph. Know the size of the lung lesion. The number 3 is the key. If the lung lesion is < 3 cm, you likely have a lung nodule. If it’s > 3 cm, you’re likely dealing with a lung mass. The larger the lung lesion, the more likely that you’re dealing with a malignancy. Look at the edges of the lesion. A lung malignancy has irregular or spiculated borders. Benign lesions tend to have smooth edges. See whether the lesion contains calcium. More often than not, calcification suggests a benign lesion. In fact, calcification has many benign causes, including old, healed infections or reaction to a foreign body. Granulomas are a perfect example of a nonmalignant calcified lung lesion. However, if the calcification is irregular or eccentric, there’s a higher chance that you’re dealing with a malignancy. If all else fails and you need a better assessment of the solitary nodule, obtain a CT scan. This step may or may not be necessary. After you’ve looked at the characteristics of the lesion, look at the characteristics of the person. Is he or she old or young? A smoker? An older person who smokes has a higher chance of malignancy. You can watch people who are at lower risk with serial imaging, but for those who are at higher risk, you may need to get a biopsy to find out what you’re dealing with. You’re evaluating a 55-year-old man who presents to the ER with hemoptysis. He hasn’t been feeling well for a while. He says he has intermittent episodes of dizziness and diarrhea that comes on for no reason. He feels flushed. This has been occurring for a few weeks. You obtain a chest radiograph, and it shows a tumor located on the right mainstem bronchus. What does this lung mass likely represent? (A) Small-cell lung cancer (B) Legionellosis (C) Tuberculosis (D) Carcinoid tumor (E) Pulmonary embolus The correct answer is Choice (D). Carcinoid tumor is a neuroendocrine tumor that, although not aggressive, is treated like a lung mass. Some patients can have the symptoms mentioned in the question, including dizziness, diarrhea, and flushing, because the tumor secretes serotonin. A CT scan is used for staging, because the most common place of spread is to the liver. The treatment is surgery.

Article / Updated 03-26-2016

Whenever you’re administering intravenous (IV) infusions, you need to know the flow rate, infusion time, and total volume. Fortunately, calculating any one of these three variables is easy to do when you know the other two variables. Use the following equations: flow rate (mL/hr) = total volume (mL) ÷ infusion time (hr) infusion time (hr) = total volume (mL) ÷ flow rate (mL/hr) total volume (mL) = flow rate (mL/hr) × infusion time (hr) For example, if you must administer 1 L (1,000 mL) of fluid over 4 hours, use the first formula to calculate the flow rate, like so: flow rate (mL/hr) = total volume (mL) ÷ infusion time (hr) flow rate (mL/hr) = 1,000 ÷ 4 flow rate (mL/hr) = 250 The flow rate is 250 mL/hr.

Article / Updated 03-26-2016

Making sure that you correctly calculate a dose doesn’t matter much if the medication itself is incorrect or the dosing instructions are unclear. Some abbreviations in prescriptions are unacceptable because they cause ambiguity and confusion (the enemies of patient safety and quality healthcare!). For this reason, you don’t want to see these abbreviations on any medical orders you work with. Abbreviation Mistaken Meanings Better Choice DC or D/C Does it mean “discontinue” or “discharge”? Write discontinue or discharge. HS Does it mean “half-strength” or “at bedtime”? Write at bedtime or a designated time. Also write out the specific dosing strength and/or quantity QD Does it mean “every day” or “right eye”? QD looks like OD, which means “right eye.” (OS means “left eye.”) Write every day. QOD Does it mean “every other day” or “daily”? Write every other day or daily, according to patient’s needs. MSO4 Does it mean “magnesium sulfate” or “morphine sulfate”? Write magnesium sulfate or morphine sulfate. U or IU Does it mean “unit” or “zero”? Could it be mistaken for “0” or “10”? Write units. IV Does it mean “intravenous,” “international units,” or “4”? IV is an acceptable abbreviation for “intravenous,” but the doc could write international units or intravenous to be clearer. Or “4” SQ or SC Does it mean “subcutaneous” or could it be mistaken for “5Q” (“5 every”)? Write Subq, subcut, subcutaneous, or 5 every. TIW Does it mean “twice a week” or “three times a week” (the real meaning)? Write twice a week or three times a week. cc Does it mean “cubic centimeter” or “milliliter”? Could it be mistaken for “00”? Write milliliter or mL. Ug or g Does it mean “microgram” or “Ugh”? Could it be mistaken for mg? Write microgram or mcg. OD Does it mean “once daily” or “right eye”? Write once daily or right eye. Source: The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). http://www.nccmerp.org/

Article / Updated 03-26-2016

As a healthcare professional, you have to convert patient weights, fluid volumes, medication weights, and more. Conversion math isn’t hard to do as long as you know the basic conversion factors. Here are the most useful ones: Converting lb to kg and kg to lb lb = kg × 2.2 kg = lb ÷ 2.2 Converting mL to L and L to mL mL = L × 1,000 L = mL ÷ 1,000 Converting mg to g, g to mg, mg to mcg, and mcg to mg mg = g × 1,000 g = mg ÷ 1,000 mcg = mg × 1,000 mg = mcg ÷ 1,000