104: Viruses & looking into 2023 and when the 33 Days cohorts will be offered

Hello and welcome to Season 2, Episode 104 of the Physician Assistant Exam Review Podcast. This week, we’re going to begin to discuss viral diseases and also give you a tool to maybe improve your outcomes in 2023. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where I’ve been helping PA students get the most out of PA school and ultimately pass the PANCE and land their dream job for over 10 years. That’s right. I’ve been producing this show for over a decade now, which is completely insane. And I appreciate all of you being here and the encouraging emails I get and showing up and sharing the show and everything you do to make the community here amazing.

Now, I do hear from people from time to time that they skipped this introduction and want to get right to the medicine. And what’s funny is I’ve been spending more time this year than I ever have working directly with PA students. And that’s been through the 33 Days to Pass the PANCE program because I do live training live with PA students as they approach their PANCE through that program. It’s something I’ve never done before this year. And I’ve had a fantastic time getting to know people, hearing feedback from people in real time. And it’s been really great. One of the things I hear more often than not during that course is I always listened for the medicine and I skipped over the test-taking tips or I skipped over the beginning part because I just wanted to get to it.

I just wanted to get to it. And now I’m realizing how important those parts are, how much I need to be paying attention to those parts. And I share that with those groups and explain to them that, yeah, that, you know, the medicine is extremely important, but kind of the goal of the 33 Days to Pass Your PANCE program is everything else that goes into studying, test taking, being prepared for an extremely high stakes exam, something that you’ve never experienced before, even how to prepare for that specific day. But there’s so much more that goes into it. Anyway, that’s some of the things that I do cover on this show along with the medicine. Like I said, today we will be covering viral diseases or beginning to cover them as we move through infectious disease. But I did want to take a minute up front here at the beginning just to mention quickly that I’ve been away from the podcast for a while.

I’ve had a little bit of extended absence due to some family issues, some health issues with my immediate family, and just a whole bunch of other things going on. But one of the bigger things has actually been the 33 Days program. I’ve spent a ton of time with the individuals in those cohorts this year. I did four of them. I wasn’t planning on doing one in November, but because people requested it, I went ahead and opened that cohort up and they’ve done amazing. The groups have just been fantastic. The group interaction, the way that the people work together has just been very surprising to me and a whole lot of fun and really helpful for the people inside of those cohorts.

And that’s one of the reasons why I want to stop today and take an extra minute was to discuss with you the upcoming year 2023. Because I know a lot of you are already making your plans and already thinking about what you’re going to be doing in 2023. And I’ve been I know that because I’ve been getting emails asking me specifically, hey, my PANCE is coming up. Hey, I’m doing my PANCE here. When are you going to be offering the 33 Days to Pass the PANCE again? Because I want to sign up for it. And I haven’t been able to respond to these people because I didn’t know exactly what I was going to do.

I wanted to wait till the end of the November cohort and then take some time to think about it. Because it does take a lot of time and energy from me and from other things I’m doing. Obviously, the podcast got delayed a little bit this year because of it. But the 33 Days to Pass Your PANCE program has been such a success for the people in it that I wanted to make sure that I made it completely accessible in the upcoming years. So instead of only doing four cohorts, I’m going to be doing six cohorts. And if that’s a program you’re interested in, I do have some other exciting news for you. I don’t, I’m not going to release what months I’m going to do it on here just now.

I’m still finalizing that. This is going to be released on December 14th, 2022, but tomorrow or Friday, so Thursday or Friday, I am going to release the information as far as what months I’m going to be doing the 33 Days program in 2023 so that you can get yourself ready and set up for that if that’s something that you’re interested in. I will be releasing that to everybody who’s on the email list. So please go over and make sure that you get on that physicianassistantexamreview.com. Once you’re on the website, you will easily be able to figure out how to get on the email list. And I think you’re going to find some amazing things come across there as I do daily study tips, techniques, and ways to get through school and to improve your grades on a daily basis. But in addition to that, like I said, by the end of this week, I’m going to confirm the months for 2023, that I’m going to be doing the 33 Days to pass your PANCE cohorts.

And I’m going to publish that out to that group first.

Now, what’s important about that, if you are so inclined and you are on the move and you are planning for 2023, I’m also going to be doing a a substantial discount next week on the 2023 cohorts. What I wanted to do was give an ability. I know that the cost is not insignificant. So I wanted to give people the ability to get a discount on it. So it’s going to be a 30% discount on the running rate for the 33 Days program. And that’s going to be toward the end of next week. That’s going to run from the 23rd to the 27th of December.

I’m going to open up all of the cohorts for 2023 and allow you to get in a substantial discount. There’s a couple of reasons for that. One is, like I said, I want to make it a little bit more accessible. But in addition to that, I also want to be able to plan a little bit for the upcoming year and get an idea of how many people I have and what’s coming up and who’s going to be in. So I wanted to get that done early on. And I thought it’d be a great way to do it, to set it up so that you can go ahead and get involved and get yourself set up for 2023 as you come into taking your PANCE. One thing I do want to note is that, you know, some people, it does, it is a 33 day program leading right into the PANCE, but I think it makes more sense to give yourself two, three weeks after you finish the program, before you take your PANCE.

There’s a lot to learn. There’s a lot going on in the program. So I think it gives a better perspective, a better, you get more out of it if you have a little time to practice after you’re done. You can take it. It’s set up to take right after those 33 Days on day 34. But I think most people would say, at least a week or two afterwards makes more sense. And I have some people who have repeated the course.

Actually, a bunch of people who have repeated the course and gotten a lot out of it and waited a couple months after they finished to take their exam. So it really depends on you, but I do want that information to be available so that you have some idea for you to plan out your timeframes. Anyway, all of that information will be available, but only through the email list. So if you’re not on there, you’re going to miss out on this opportunity to plan out 2023 and to get a significant discount on the 33 Days to pass your PANCE program. So go ahead and make sure that you do that again, physicianassistantexamreview.com and you’ll be able to sign up for the email list there without any issues and you will get all that information as it comes out next week or even at the end of this week as I begin to release the months I’ll be running the program.

Alright, I think I’ve talked long enough here at the front end.

Let’s go ahead and get started with our priming questions. What is mononucleosis? What is mononucleosis? Owl bodies on histology should make you think of what two diagnoses? Owl bodies should make you think of what two diagnoses? A sore throat with an enlarged spleen on physical examination should make you think of what diagnosis? A sore throat with an enlarged spleen on physical examination should make you think of what diagnosis.

What age groups are at most risk for severe complications of the flu? What age groups are at the most risk for severe complications of the flu?

All right, let’s go ahead and get started with our discussion of viral diseases. This is going to take a little bit. I’m not sure if there’s going to be two or three shows, but it’s going to take some time to get through these viruses. And I wanted to split them up. They do them in the blueprint a little bit by, well, they do them by alphabetical order, which sometimes makes things easy, but sometimes complicates things, right? If we’re studying things that should be grouped together and they’re not grouped together, then we’re jumping back and forth. Like the childhood exanthems, I’m going to group those together rather than going in order as the blueprint would have it.

So, but because cytomegalovirus is at the top, we’re going to start there. CMV is transmitted by direct contact, either sexual contact or the birthing processes are two possible ways that a person can contract it. We’ll get two viruses that are transmitted during birth in a couple shows from now, but this is one that’s included there. This virus may shed without any symptoms and is found in urine, saliva, blood, tears, semen, and breast milk. It’s also one of the torch infections, so that’s what I was talking about. It is something that can cause complications at birth, can be delivered from, or can be passed from the mother to the child at birth. Those include toxoplasmosis, rubella, CMV, and herpes.

It may remain latent in the body for long periods of time. This is human herpes type 5. And usually we don’t hear too much about CMV unless it’s in a newborn or in someone who is immunocompromised. And this is something in an immunocompromised patient that can become a very serious infection. But generally speaking, in an otherwise healthy person is not. It also causes mononucleosis without a sore throat. And I put that in there intentionally because we’re going to get to Epstein-Barr in a second, which causes mononucleosis with a sore throat.

So they’re similar in how they present. And Epstein-Barr is type 5, human herpes type 4, and CMV is human herpes type 5. So you get a little bit of overlap in how things look here. And they both cause mononucleosis, which I went and looked up because I couldn’t remember what it was. And everything said it is, it’s referred to as the disease, but really it’s a nomenclature that we use because it causes an overproduction of T cells, which are, which happened to only have one nucleus, as opposed to some other white blood cells, right? And it enlarges them, right? So you get a mononucleosis is that shift in a white blood cell count.

So cytomegalovirus can cause it. Epstein-Barr can cause it. So it’s not, we refer to Epstein-Barr a lot of times as mono, right? That’s just to the colloquial way of saying that infection or calling that infection, but it’s not technically accurate. It doesn’t, I guess maybe all this doesn’t really matter, but I like to have a bigger, a better picture, a better understanding of what I’m talking about. So in this case, this helps me to clear it up a little. I’m not necessarily going to retain that for my PANCE, but it is going to help me to separate out the diseases and understand what I’m talking about.

All right, clinical presentation for CMV. Most commonly, there are no symptoms, but you may see a fever, loss of appetite, enlarged lymph nodes, muscle aches, fatigue, diarrhea, ulcers in the digestive tract, possible cause of bleeding, hepatitis, encephalitis, and behavioral changes. In a neonate, things can be much more severe. You can get jaundice, purple skin splotches, or rash, or both. Low birth weight, seizures, enlarged spleen, and poorly functioning liver, and pneumonia. So, how do we diagnose this? It can be cultured, but it’s very difficult.

A tissue biopsy with an H&e stain will show owl eye inclusion bodies. You may also see these with Reed-Sternberg, but it’s a little bit different setup, but it is the description. PCR may be used on body fluids. I was reading where they do that for the urine on newborns as a way to test for it. And antibody serology is also used. Treatment. Well, if we have no symptoms and usually people do just fine, treatment is usually not necessary or supportive care.

But you can use antivirals like ganciclovir, valganciclovir, foscarnet, and cidofovir. And there’s also a CMV immune globulin for people who are having some serious issues. And again, all of this stuff depends on how people are handling it, right? How we treat these things. If people are relatively healthy, you may not even know they have it, and they do just fine. Other people may wind up hospitalized with much more serious effects and much more serious treatments. And we’ll see that as we go through in all of these cases.

Epstein-Barr is next. Like I said, this is human herpes virus number four. This can cause a few different types of infections. So we can get infectious mononucleosis with a sore throat. So that’s that T cell, enlarged T cells. You can get nasopharyngeal carcinoma and Burkitt’s lymphoma, where Epstein-Barr virus has found in 100% of patients with Burkitt’s lymphoma. But really, the bulk of what we’re going to be talking about as far as the PANCE is concerned, is more than infectious mononucleosis.

The mode of transmission here is also direct contact. Clinical presentation. This is one I would absolutely be aware of. The clinical presentation for Epstein-Barr is fever, sore throat, significant fatigue that may last for weeks. That’s a major part of Epstein-Barr, right? Of mononucleosis. You get teenagers who are wiped out and exhausted for weeks.

You can get swollen and large lymph nodes, lack of appetite, rash, weakness, and sore muscles. Physical exam findings. So one of the ways I think about this is strep throat plus. So it’s going to be all of the symptoms like strep throat. You’re going to get lymphadenopathy. The difference here is that strep is anterior chain, mono is anterior, posterior, and cervical chain. But you get a much more exudative pharyngitis and an enlarged spleen.

Diagnosis. You can do a monospot, which is a heterophile antibody test. False positives and negatives may occur, and you’re going to want to retest a few weeks later to confirm results, if necessary. You can also do an EBV antibody test. Treatment here, again, generally going to be supportive. A lot of fluids, Tylenol, ibuprofen for pain relief and to bring the fevers down, that kind of thing, but mostly supportive care.

All right, then we have herpes simplex one and two. These are transmitted through direct contact. Transmission may occur without any visual signs of disease. So you can get a couple of different types of infections. You can get a skin infection, you can get an eye infection, you can get a central nervous infection, and there’s a few others, but we’re not going to go too deep down that rabbit hole. Generally speaking, it’s thought of that herpes simplex virus type 1 would have been oral herpes, and herpes simplex type 2 would have been genital herpes. Obviously, these are overlapping and mixed, but historically, that’s kind of how we think about them, and it’s still probably true on a percentage basis.

When we talk about oral herpes, we’re talking about what would be referred to in the public as a cold sore, right? That blister along the vermilion border. The virus for herpes, as you know, can become latent within a neuron and is never fully cleared, and it can be reactivated. So, the easiest way to talk about this is what was with through the idea of the cold sore, right? That fluid-filled, painful blister people can get on their vermilion border. This gets reactivated when there’s stress on the system. So if you have someone who is, it’s called a, you know, I thought this, but I wasn’t sure.

So I went ahead and looked it up. And what I did find was it’s called a cold sore because they typically follow some other infection. Some other illness like a cold. And the idea is that you become a little bit immune compromised as you are fighting off these other issues. So an illness can result in a flare-up of the herpes infection. Stress, either physical, emotional, whatever, can result in a herpes re-inflammation. If a person is immunosuppressed for some reason, that can result in a flare-up.

Overexposure to sunlight can cause it too. And I assume that’s similar in the fact that it’s causing damage to the area and stress to the area, which then allows that flare up to occur. Clinical presentation. So you get these. So the one we’ve been talking about is that cold sore, that fluid filled blister. You can get tingling, itching, and burning, which occurs before the blister appears, right? You get that nerve pain that comes before you actually see the blister.

You can get flu-like symptoms, fever, muscle aches, and swollen glands. And genital herpes can cause those same blistering, but can also cause painful or difficult urination. And then obviously, if this involves the eye, you have severe conjunctivitis. Lab studies and physical exam findings, again, typically blisters around the mouth, around the vermilion border, or in the genitals. A Tzanck test can show multi-nucleated giant cells. You can do a PCR. And then if there’s eye involvement, you’re going to do a slit lamp examination with fluorescein stain.

And that classic dendritic lesion is going to be diagnostic and you’ve all seen pictures of that. And if not, you should look them up because they’re pretty cool looking. Treatment. Number one is going to be prevention, right? Barrier protection for sexual intercourse. And then we can use antivirals, oral or topical, depending on the location and what we’re dealing with. So again, acyclovir, valacyclovir, famciclovir.

The last one we’re going to cover for today is influenza, which is probably a good time to be talking about influenza as it’s making its way through the population currently. We have the RSV, COVID, and influenza making their way through the population. I’m not sure which one of those my family had for about two weeks, not too long ago, but we are finally through the other side of it, and it was certainly one of those three. So you all are probably fairly familiar with influenza. If you are in school at the moment and you’re experiencing this winter, it should be pretty obvious how this works. You should know somebody who’s had this if you haven’t. So use that as your way to hang on to this, right?

So influenza virus is an RNA virus in the Orthomyxoviridae family. There are three subtypes. I’m not sure how relevant that’s going to be for your PANCE, but it’s interesting to note. Influenza A has aquatic birds are the natural host. It is the most virulent type. It causes Spanish flu, the Asian flu, and bird flu. Influenza B, where it has humans as the most natural host, and this influenza B mutates slower than influenza A.

And there is an influenza C, which infects dogs and pigs. Generally, this is an airborne transmission, although I was reading that you can get it from surfaces. There’s some debate as to how long it is infectious on surfaces. Initially, there were some studies done that showed, I think it was two to four days, and then more recently, there were some studies done showing that maybe that was down to four to 12 hours, depending on the surface, because the initial studies might have… My understanding was they were done where they were looking for evidence of the virus, not whether or not it was still infectious at that point. So if a virus landed on a, I don’t know what, like a desk, for example, and then you swabbed the desk and looked for DNA evidence of that virus four days later, you may still find evidence of the virus, but it may not be a virus that can cause an infection at that point, right? So that’s a little bit of a difference there.

So there is some thought that you can pick this up from surface contact, but really the more important issue is airborne transmission. Children younger than five and adults greater than 65 are at significant risk for severe complications. The other thing that will lead to severe complications is anyone who has trouble clearing secretions, right? Because influenza causes a lot of mucus buildup. So you have someone who has trouble clearing secretions, they can get into trouble quick and increase their risk for pneumonia and things of that nature. Clinical presentation, fever, aching muscles and joints, sore throat, chills, sweats, headache, photophobia, congestion, fatigue, and weakness. Those are some major ones for the flu in particular, that just feeling like you got hit by a truck, that severe fatigue, the muscle pain, those kind of things are more descriptive of the flu as opposed to a cold and how you might parse it out in a clinical setting.

And a lot of times this is diagnosed clinically, right? So that clinical assessment is necessary. You can do a rapid influenza diagnostic test. You do a throat swab or nasal secretions for PCR, and you can do a viral culture if you want to actually find out what type of flu we’re talking about. But the problem with the viral culture is it takes about a week to get back, so it may not be that useful as far as treating people. People can become severely ill with this, as again, as I’m sure you’re aware of. So a pulse ox and a chest x-ray might not be a bad idea.

Treatment, we’re going to start with prevention, so yearly vaccination for everyone older than six months old. You’re going to start with supportive care and then move into a couple of medications. The neuraminidase inhibitors, which I can’t pronounce, stop the release of the virus from the cells, so it slows down its ability to replicate, Relenza and Tamiflu are the two that I hear about the most. Relenza is zanamivir and Tamiflu is oseltamivir. The important designations here is that Relenza, you have to be older than seven years old to use. And then Tamiflu, you need to be older than 12, although I believe there are lower doses available for younger kids.

All right, that’ll take us as far as I want to go today. I know sometimes these can be complicated and easy to mix up, so I don’t want to take too many in one spurt, but you will be getting the rest of them very, very soon, much sooner than the last show came out. I promise you that. So for today, let’s move on to our study tip for today. Our study tip today goes hand in hand with the reason why I put this show together, and that’s the idea of planning out 2023 and planning out your next year and looking forward to what’s coming and what’s going to be happening. Some of you are going to be moving into PA school. I know there are a lot of pre-PAs who listen to this show.

And although you don’t know what’s coming, it still makes sense to look at your calendar, look at your timelines, try to figure out what’s going to be important dates for you in the coming future. And start to begin, start to begin, begin to plan out the things that you’re going to need. And again, I know that that’s early and you may not be aware. But having a plan is going to help. If you’re moving into clinicals, again, you’re gathering resources. You’re eyeballing those times when you’re going to be leaving the classroom. You should be setting up ideas for ways to keep in touch with classmates because it quickly moves to a very lonely setting when you’re only seeing classmates, or at least you’re seeing them much less than you’re used to.

So begin to plan for that and how you’re going to handle that and how you’re going to study because your groups will be different. And some of you may be seeing graduation coming up and the PANCE and perhaps moving out of your apartments and graduation and looking for jobs. There’s a lot coming. Putting a little bit of thought into at the front end here can make a tremendous difference with all the changes coming in your life in 2023. I’m not saying you have to map out month by month or consider every detail because that’s not going to be possible. But creating some timelines. Looking at when is my graduation date?

When is my apartment lease up? Do I plan on staying? Do I plan on leaving? Marking down when you plan to start looking for jobs. Marking down when you plan to start studying for your PANCE. Marking down when you plan on taking your PANCE. Yes, getting that date down is going to be helpful.

Things start picking up speed very quickly. So, it’s advantageous to you to take a look into the- pull out a calendar and take a look into the future and see what’s coming. It gets overwhelming very fast. I know first year of PA school can be overwhelming, but that last year with all the changes overwhelms people very quickly. One, because PA school is tough, of course, but two, because of all, like I said, all the changes, the living change, the job change, the taking the PANCE, moving, all of that just, it takes a lot out of you. So I encourage you to get out in front and be prepared. And like I said at the beginning of the show, part of that is looking at how you’re going to be preparing for your PANCE.

And like I said, if you are interested in taking part in the 33 Days to Pass Your PANCE program, looking at when you’re planning on taking your examination, how long after graduation, and then looking at the cohorts I’m going to be offering and seeing what makes the most sense for you.

All right. Let’s answer our priming questions. What is mononucleosis? What is mononucleosis? So again, hopefully you don’t answer that by saying it’s Epstein-Barr virus, which it is not, although the two are often conflated. It is an increase in enlarged T cells. Owl bodies on histology should make you think of what two diagnoses?

Hodgkin’s lymphoma from the Reed-Sternberg cells and CMV cytomegalovirus. A sore throat with an enlarged spleen on physical examination should make you think of what diagnosis? Epstein-Barr.

Now, let me just stop here for a second, because I didn’t go over it. Epstein-Barr tends mononucleosis, Epstein-Barr tends to be something that when I picture it, I talk a lot about this obviously, when I picture Epstein-Barr, I’m thinking of a teenager, right? It’s called the kissing disease, because a lot of teenagers get it and pass it between each other through direct contact. That’s just a story that goes with it. I don’t know how true that is, but that’s a story that goes with Epstein-Barr. It’s known as the kissing disease, right? So you get people, teenagers, out of school for a couple weeks, and you also have to watch them as they return to athletic sports because of the enlarged spleen.

They can get a splenic rupture, so you have to be careful. Contact sports are out with an Epstein-Barr diagnosis. So that picture on your exam is probably going to be a, like I said, a teenager who is wiped out, extremely exhausted, and has this horrible sore throat. You know, actually a friend of mine’s kid just came down… I think he is 10, 11, something in that range. And he just had soreness and muscle pain. And eventually he realized that his throat had this awful exudate and they did the test and it turned out he did have Epstein-Barr.

So he was actually making fun of him if he had a girlfriend or not. I don’t know the results of that discussion, but that was a discussion. But anyway, just so you have that picture in your head, the difference there of what Epstein-Barr is. Now let’s finish up. What age groups are at the most risk for severe complications of the flu? What age groups are at the most risk for severe complications of the flu? And that’s younger than five and older than 65.

Perfect. All right. Well, that’ll take us out for today. So glad to have you with us. I really appreciate the community members who have been such a big part of this show, such a big part of this program for over 10 years now. Again, if you want to get involved with the 33 Days program, if your PANCE is coming up in 2023, definitely get over on the email list where you’ll get all of the details about that. And of course, if you got anything out of today’s show, if you got anything out of these shows and what I do here, please share the show with someone in your class.

And I think it really helped them and help you.

All right. Take care.