Whether it’s clinical medicine or studying for the boards, simplification is a part of how I help people. When you can simplify something, your brain latches onto understanding it easier.
It’s kind of like microbiology. I know how important microbiology is, not just for clinical practice, but also for your boards. If you’re like me, microbiology almost seems overwhelming between the different kinds of germs and the different antibiotics. It can be overwhelming and your brain kind of goes, “Oh man, I’ve struggled, it’s too much, I can’t learn it.” So we break it down.
Hey, it’s only about 12 different germs you need to know to be a really good clinician. You have gram-positives and there’s really only three pathological gram-positives: staph, strep and clostridium. There are three atypicals: mycoplasma, chlamydia, legionella and then there’s pseudomonas. Now, if it’s not on that list, it’s going to be a gram-negative. So we teach people what they need to know and then go, “Wait a second, you have a bucket at the bottom that if it’s not on that list, it’s probably going to be gram-negative.” Now, I’m overly simplifying it but still, it’s a very effective way to study.
When studying for the alternative PANRE, as you now know, there are three different levels that you need to understand. Level one, level two, level three. The level one content is the kind of information that we need to go, “Oh man, I got to go get help right away.” Level two, or yellow lights as we call them, are the diseases that you need to identify, know preliminary diagnostic testing and first line treatment. The green lights are the things you need to know everything about.
So, what I’m going to recommend to you is, really know the red lights and the green lights and then everything else is just going to be a yellow light. So don’t worry about studying all three.
Studying Level 3 Diseases
Today’s conversation is going to be about the green light diseases. What are the diseases in the 14 different body systems that are green light that we have to know everything about?
From cardiology, we have to know everything about hypertension. That means all the different meds, which we go into detail about that in our pharmacology curriculum. We need to know everything about hypertension and hyperlipidemia, whether it’s high cholesterol or hypertriglyceridemia.
Atrial fibrillation, that’s important guys, you know why? Because A-fib has two primary presentations. You have to know that atrial fibrillation has two primary presentations. It could be arrhythmogenic or thromboembolic. They could present with an arrhythmia, and that arrhythmia can present in a number of different ways where it could be asymptomatic, they just come in for a routine office visit and you realize they’re in A-fib, or they have symptoms like palpitations, they feel fluttering in their chest or they’re in shock. They could present hypotension with altered mental status because their heart is racing so fast. So we have an arrhythmia presentation and it could be asymptomatic. They could have a stroke, they could have ischemic bowel, they could have an ischemic limb. A-fib is a very tricky disease but we have to know it like the back of our hand because the sequelae is so bad.
Next, is stable angina, which is pretty simple. They have stable angina which means they have coronary disease as determined by some kind of diagnostic test, normally an angiogram. We need to know how to manage them and know if they get worse, then we would have to have an intervention. They would move onto unstable angina and deep venous thrombosis, meaning that we have anybody with an asymmetrical leg finding, we Doppler them and if it’s positive, we put them on anticoagulation.
When it comes to GI, there are only three things. Appendicitis, so we need to know everything about appendicitis and how they present. Typically it’s a gradual onset, radiating down to the right lower quadrant. The mnemonic I teach is P-R-O-M like a prom dress. That’s psoas sign, Rovsing’s sign, obturator sign and the locations of McBirny’s point. Constipation, if someone’s constipated we have to talk about stool softeners and getting them to poop more regularly. We have to, have to, have to be very mindful, “Could it be colon cancer? Could they have OB positive stool?” GERD, please remember, no GERD is GERD until you rule out cardiac.
Four, pulmonary. There are a number of diseases here; our knowledge has got to be deeper than it’s ever been before. With asthma, we need to know everything about asthma. COPD, whether it’s chronic, bronchitis or emphysema. Pneumonia, whether it’s viral or bacterial pneumonia or pulmonary embolism. It is very impressive to me how sinister of a disease DVT and PE are. The NCCPA is saying, we have to know everything about this because it’s such a bad disease, we have to be incredibly understanding and mindful. Now remember, the big, major risk factors for DVT and PE are the venous, thromboembolic risks and that’s damage to a blood vessel that’s classically a broken bone. Stasis, so prolonged plane ride, train ride or immobilization. Or a hypercoagulable state and there are really only three: genetics, high estrogen states or malignancy.
We move down to musculoskeletal, guess what? There aren’t any in that category, which is interesting to me. Orthopedic PAs, the boards are saying you don’t have to know everything about any bone condition.
Now when it comes to ENT, we need to know everything about three diseases: acute pharyngitis, otitis media and thrush. So pharyngitis, you have sore throats and the big thing there is, is it a strep throat or is it a mono throat? Otitis media, just be aware of something folks, is that otitis media is not physiological. Something happened to cause it, meaning something blocked the eustachian tube. Same pathophysiology of sinusitis and the three major irritants to block the eustachian tubes are going to be viruses, allergies or second hand smoke. So once again, ENT is acute pharyngitis, otitis media and thrush.
Now for neuro, we have to know migraine headaches, everything that’s a green light. Stroke and TIAs and then tension headaches. Once again, interesting. The diseases that have really catastrophic sequelae, like PE or stroke, we have to know everything about. Remember migraine headaches, typically in females they’ll have pain that’s severe, unilateral, typically it’s throbbing and typically it’s associated with activities.
Now reproductive, there aren’t any in the category of green light. There are no green light reproductive diseases that we need to know.
For dermatology, we need to know cellulitis and erysipelas. Erysipelas is just cellulitis on the face and it’s typically strep.
For endocrine, now interestingly we need to know diabetes and that’s important because diabetes has such bad sequelae that primary care PAs have to know how to manage the retinopathy, the cardiovascular disease, the renal disease and the neuropathy that will often lead to amputation. So we need to know everything about diabetes, hypothyroidism.
Now interestingly, metabolic syndrome and obesity. Metabolic syndrome, also known as Syndrome X or insulin resistance syndrome, is really important to understand, and we go into detail on this because a lot of people don’t really understand it. This is directly tied into obesity. If you take the skinniest person and you increase their insulin levels, they’re going to have two physiologic phenomenon happen. One is they’re going to gain weight and the second thing is the lipids are going to get bad and there’s nothing that they can do about it. Insulin resistance syndrome means there’s so much insulin that their body can’t use it, so they’re resistant to the insulin. It’s just another name for hyperinsulinemia. If you put someone on a medicine that raises their insulin, they are going to gain weight and their lipids are going to get bad.
The opposite is also true, so if you lower insulin levels, they’re going to lose weight and the lipids are going to get better. We have to always look at what a patient insulin level is. What drives insulin? Well, clearly carbohydrates. High carbohydrates are going to increase insulin levels, leading to obesity.
The last one is osteoporosis. The big one there as we know that using your bones are what stabilizes them, weight bearing exercises.
Now for infectious diseases, only three that we need to know everything about. Chickenpox, herpes zoster and influenza. Interesting, all viral diseases. Now chickenpox is chickenpox, so pediatric rash. There are six pediatric rashes, very contagious. Where herpes zoster is a dermatomal rash, it’s not highly infectious ladies and gentlemen. Lots of people at my conferences seem to think that they are, but just wear gloves. Influenza, that’s a super fast onset of either influenza A or B. Terrible myalgias, high fevers, antivirals can decrease the course.
GU, Psych, Hematology and Renal
Next is GU and there aren’t any in the category. There are no green light GU topics. When it comes to psych, same thing. There are no green light topics, there’s nothing that we need to know everything about in psych. When it comes to hem, again, nothing that we need to know in hematology and the last one is renal. Once again, nothing that we need to know in renal. When we look at all of the diseases that have no green lights, where we don’t have to know everything, we have renal, hem, psych, we have the same thing in GU, we have it also in reproductive and I think that’s interesting. There are a number of categories where there are absolutely no green lights.
Now, I’m going to say what I said earlier in this conversation that you need to know the emergencies, the red lights. The cool thing is guys, it’s kind of intuitive. Green lights are “Oh, I have to know everything about this.” These are the common ones with really bad sequelae that PAs manage all the time.
My advice is, know your red lights and green lights really well and then just leave your yellow lights as, “It’s not a red and a green; it’s got to be a yellow.” You can always have your study resource available to you, you can download it from our website. Remember, when your do your alternative PANRE, it’s an open resource exam where you have five minutes to answer each question.
Good luck studying!