Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 118, covering brain trauma and an improved idea to help you with memorizing medications. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And I wanted to start out today by saying thank you to all of the community members here. I’m thrilled to have you be a part of this community. I’ve gotten to meet some amazing people, some wonderful practitioners, faculty members, and students alike.

It’s just been a blast for me over the last decade, putting the show together and running this community. One of the things that I just put together for the community is a brief book called 54 Study Tips, right? So over the past decade, I’ve been putting together tons and tons of information for you, but I put it together in a nice concise document here, 54 study tips. And you can find that at physicianassistantexamreview.com/54, just the numbers 54. And you can head over there and pick that up. It’s pretty concise. It doesn’t go into a huge amount of depth, but I think you’ll find some pretty interesting techniques in there.

Some of the things will be things that you’ve done for sure, but there’s a reminder in there is you’ve done them in the past. Maybe you know about them, but are you still doing them? And there’s going to be a bunch in there that are new for most of you that might just change your scores dramatically over your career. So you can go ahead and pick that up again, physicianassistantexamreview.com/54. And it’s just been a thrill for me to, like I said, to meet the people in this community, to spend time with them, the nurse practitioner students, the med students, the pharm students, the PA students. There’s just so many people. That it’s just been, like I said, it’s just been a thrill for me every day to come in here and do record this show.

And I just want to make sure that you’re aware of that. I just wanted to say thank you. For those of you new to the show, what we do here is we produce content in an effort to get you to get the most out of school, not just to get through school, not just to survive school, but for you to get the most out of school, for you to learn and become the best possible student, for you to get the best possible scores on your test by becoming the best test taker you can be. And ultimately pass the PANCE and land your dream job. Those are my goals. I do that here on the podcast through medical content, right? That’s mostly what we cover here.

The email list and some of the other products and services I have available go a little bit deeper down the path into being a better student, into being a better learner, into being a better test taker, things like the 33 Days to Pass the PANCE program. Those sorts of things are a little bit more geared to creating better students. But here on the podcast, we cover medical content primarily, with a little bit of a bent toward test taking and studying. But today we’re going to be covering brain trauma, and like I said, at the end we’ll cover a method for improving your retention of medication names. It’s, it’s something that I missed out on, but it can be extremely valuable.

Let’s go ahead and get started. Today we’re going to be moving into, we’re starting neurology, which is for the first time we’re moving out of musculoskeletal. Today will be our first day in neuro. Along with that means we’re going to be starting with some brain trauma. So we’re going to, today we’re going to keep it relatively brief as we enter into this new topic. We’re going to be covering concussions. To begin with, we’ll move on to post-concussion syndrome and traumatic brain injuries.

So we’re going to get started with our priming questions today. Number one, what score on the Glasgow Coma Scale represents severe impairment? What score represents severe impairment? Can you list three symptoms of concussion? Can you list three symptoms of concussion? Name two anti-nausea medications. Name two anti-nausea medications.

And then our last one for today, explain the Stroop Color Test. Explain the Stroop Color Test.

All right, we’re going to begin with concussions. Concussion is also known as a minor or mild traumatic brain injury. This results from head trauma causing blunt injury to the brain. Clinical presentation here, pretty straightforward. This is something you’re probably familiar with. You get headache or pressure inside the head, which may worsen over time. You can get a temporary loss of consciousness.

That’s a pretty significant sign. Confusion or feeling in a fog. You can get amnesia surrounding the traumatic event. Dizziness or recurring sensations of seeing stars. Tinnitus. Nausea and vomiting. Slurred speech.

Delayed response to questions. This list is a little long, by the way. Fatigue, difficulty with concentration and memory, irritability and crankiness, loss of balance and an unsteady gait, excessive crying, changes in eating or sleeping patterns, seizures, vision or eye issues like blurred or double vision, light sensitivity, and then a bump or a bruise on the head where you’ve been affected, right? So, concussion clinical presentation is is what you would imagine, right, if you saw someone with a concussion. It’s sort of straightforward. I say that sounds kind of silly, right? But I’m picturing like a boxer, right?

Who gets up and he’s stumbling around the ring and they show him with blurred vision in a movie. And he’s, and you know, there’s the famous scene in Rocky where he turns to his trainer and says, I see three of them. And Mickey says, well, hit the one in the middle. And that’s what you’re talking about with a, with a concussion, right? That blurred vision, that staggering gait, that dizziness. You often see it with a ringing in the ears portrayed in movies or in TV shows, right? And you can imagine the headache going along with it.

I don’t know if you’ve ever experienced this. It’s a little bit frightening. So if you’ve ever been hit hard, you get stunned. But if you a little bit more, it becomes that concussion symptom. I had it happen to me once in the operating room. We have these monitors around the room that hang from the ceiling on our on boom arms. There’s usually three of them in a room for laparoscopy, so you can position them, and they’re great.

But I was actually doing a plastic surgery case you know in one of these rooms, and we were usually push the screens up out of the way so they’re not anywhere near where someone could walk into them because they’re just basically hanging television screens. And at the end of the case, I went to… I think I went to go get the bed or something, but I turned abruptly and smacked my forehead as, you know, very hard right into the side of one of these screens. And I immediately went down, got sort of lost, lost my ability to find my way around. I remember getting to the surgeon’s lounge and sitting on the couch. And one of the members of my team, one of the other PAs was like, man, I think you should probably go to occupational health. And I remember sitting on that couch thinking, I don’t think I could get to occupational health.

Now I’ve been to occupational health a ton. I’ve been in this hospital for 15 years. Not that I go there that often, but you go there for your TB test. You go there for a lot of different things. So maybe a couple of times a year, it’s not hard to find. And I just remember sitting there thinking there’s no way I could get there by myself, which was a scary feeling, right? For someone who normally feels pretty comfortable in their own skin.

I’d have that confusion, that feeling of fog. And I came home, I had to have my wife come pick me up, I couldn’t drive home. And I remember just sitting on my front porch and thinking that I was very comfortable just sitting on my front porch, that I really didn’t even want to do anything else. So that’s kind of the symptoms that you’re looking for. Lab studies and physical exam findings. The big key here is what you’re worried about is you’re looking for an intracranial hemorrhage, right? You’re looking for a severe bleed.

That’s what you want to make sure is not going on. So you’re going to do a neuro exam. You’re going to check the pupils. Obviously unequal pupils can be concerning. You’re going to check their hearing, strength, sensation, balance, coordination, and reflexes, right? The Glasgow Coma Scale, there are three parts to that. The eye opening, the verbal response, and the motor response.

You want to get the higher scores better. So usually it’s a one to four for eye opening, one to five for verbal response, one to six for motor response. And you rate them based, you rate the patients based on how much they’re, how well they respond to these different requests, right? So I have when you call their name, do they spontaneously open their eyes and look at you? Do they not open their eyes at all, right? One to four. Verbal response, you need them just to answer you back.

Can they do that spontaneously? Do they need prompting? Motor responses, how do they move? Same thing. And it’s just on a scale of one to four, one to five, and one to six with a 13 to 15 being pretty normal and severe impairment being eight or below. Again, if you’re worried about an intracranial hemorrhage, if you’re worried about something more severe than a concussion, you’re going to get a CAT scan or an MRI to test for that. There’s not really a lot of treatment for concussions.

The biggest issue is prevention, right? You want to avoid these. This is why when I, when usually, and before that incident, and now quite often, even more frequently, when I entered the operating room, if we’re not using those screens, I always push the monitors up because I’ve seen a lot of people actually do what I did. I know at least four other people who have had that issue over the years. And so you want to be paying attention, right? You want to prevent these injuries if at all possible. So things like helmets when you ride bikes or skateboards or anything like this, where you may fall and hit your head, obviously football, those sorts of things is what we’re trying to do.

You also want to prevent recurrent injuries, right? Within the same time frame, you want to let that brain heal before a second traumatic event occurs, right? That’s what, that’s where they take, they have the, sport protocols where they pull you out for a period of time after an injury like that. You can take ibuprofen and acetaminophen to help with headaches and pain management. Really it’s sleep and rest. And one important factor is just that continuous monitoring, monitoring of the patient for the first 24 to 72 hours. There’s a couple of reasons for that.

One is with that loss of gait and stability and balance that they may be at risk to fall again. And then there’s also the concern again about that maybe more severe brain injury. You want to be keeping an eye out for symptoms that are getting worse and you may be considering an intracranial hemorrhage.

Next, we have post-concussion syndrome. This is a set of symptoms that can persist for an extended period of time after a concussion. So, it doesn’t go away right away. I know I was like 2 or 3 days before I was comfortable, but it can last much longer than that into months. Clinical presentation here. Headaches are most common. Dizziness, vertigo, nausea, still with that doubled or blurred vision.

Hearing loss and tinnitus. You can get a reduced sense of smell or taste. Light and noise sensitivity is a big one. I know for me, it was… I couldn’t look at the screen, so even when I went back to work, I had to not do laparoscopic surgery for a couple of days because the screens would bother me looking at the the video screens. These patients may also have emotional changes. So, they may be easily irritable.

Increased anxiety and depression. Sleep disturbances. Changes in behavior and interests. So, personality changes. Lack of energy and interest in usual activities. Sudden emotional outbursts. They may have difficulty remembering things, problems with concentration and attention.

That seems to be one that stands out, right? Slowed reaction times. Challenges processing information and problem solving. Difficulty learning new things. Those are all possibilities in that post-concussive state. And again, that can last for months. Lab studies and physical exam findings here.

Well, again, we’re going to assess muscle strength and coordination and sensation. But then most importantly, we’re going to be assessing the mental processes, right? So there’s a bunch of different tests out there where you can do that. I’m just going to name a couple here, but certainly you guys, I’m sure, can name even more than this. The Stroop Color Test is a good one. That’s where you assess the ability. So what this one is, is it’s when they put up on a screen something like the word red, but it’s printed in green.

Right? Or the word blue, but it’s printed in red. And they ask the person taking the test to name the color of the word. What color is the font? So it’s a processing issue of can you look at the word red that’s printed in green and give the answer green, right? Is that possible for you? Another one is the two and seven processing speed test.

So they give a patient a list of random numbers and say mark all the twos and ignore all the sevens. And they may time this depending on the way the test is administered. So, if it’s on paper, you know, the easiest way to explain it is to be on paper and pencil. It’s just a rows of digits and they have to circle all the twos, right? And how many mistakes you make, either missing twos or checking off sevens or other numbers, that sort of thing are all red flags. And then how quickly you can do it is also part of that test. The Rivermead Post-Concussion Symptom Questionnaire is just a questionnaire about those symptoms we talked about earlier.

How bad are your headaches? Are you having vision problems? All of those things, again, just revisited and sort of put into a system, into a questionnaire so it can be evaluated over time. There’s the Hopkins verbal learning test, which I thought this was kind of funny as I’m reading through it because it’s one where they ask a patient to basically give them a list of words, do some distractions, ask them that words again, do some distractions, ask some net words again. And all I could think about was this is just like PA school, right? This is what PA school is. And if you’re struggling with it, so it’s another way to evaluate that cognitive process.

And then again, CAT scans and MRIs, if you have further concerns. Treatment here. So again, don’t have fantastic treatment for this, but here’s what we’re going to do. So first of all, medications, NSAIDs or Tylenol for headaches and pain. Patients may require anti-nausea medication like metoclopramide or ondansetron. So that’s Reglan and Zofran are just common anti-nausea meds. Antidepressants may be helpful.

So sertraline, which is Zoloft, which is an SSRI, tricyclic antidepressants like amitriptyline. This also is used in these patients because it helps with headaches and chronic pain. So it may be used a little bit more frequently in post-concussive patients. Cognitive behavioral therapy may be helpful for emotional and cognitive symptoms. And then just education for the patient and the families for how to cope with these situations. Something kind of interesting to me is the neurotherapy, which is conditioning technique, which involves providing a conditional audiovisual rewards based on specific brainwave activity, so retraining the brain. And then our last one for today is going to be traumatic brain injuries.

So this is a physical injury to the head, which disrupts normal brain function. So we’re going from concussion to traumatic brain injury. So basically the next step. Clinical presentation here is going to be similar, but worse, right? We have a headache, we have loss of consciousness, memory problems, confusion, dizziness, nausea, and vomiting. Again, we’re going to get, in this situation, it’s going to be something more severe. So we’re going to probably start out with a CAT scan or an MRI.

Yeah, we’re going to do that Glasgow Coma Scale, less than eight is very significant in a neurological exam. Once again, treatment here is going to be prevention. How do we prevent people from getting these severe brain injuries? Helmets are a good one. Seatbelts are mandatory. One of the biggest problems with car accidents is that the person becomes a projectile if they don’t have a seatbelt on. From there, it really depends on the severity of the injury.

So, again, with a concussion, it’s kind of a mild traumatic brain injury. We rest and manage the symptoms. A moderate to severe traumatic brain injury, they’re probably going to be hospitalized may require surgical intervention. They’re probably going to require some physical therapy to function again, speech therapy to be able to talk again, and cognitive therapy to work through some of these issues. But these are severe brain injuries from traumatic experiences. Things like falling off skateboards, bike accidents, can all lead to these issues. I remember clearly, as a student working in the trauma bay at the hospital I was in, and someone who’s probably my age now, out for their morning bike ride, and was struck by a car.

And although he had a helmet, still wound up with a traumatic brain injury. And his recovery is going to be a long, long road based on the exam we did for him. Medications for these patients, pain management and anti-seizure meds may be necessary. And then similar to concussion and post-concussion is going to be the antidepressants, anti-nausea meds, all of these things to help with symptoms.

All right, well, that’s going to bring us to the end of our opening discussion of neurology.

So let’s move into our study tip for today before we get to answering our priming questions. So I came across something that I’ve used a long time ago, but I had completely forgotten about. Actually, I just put this together into the 54 study tips. This is one of them, but I thought I’d share it with you guys here. One of the keys to memorizing things is being able to pronounce them. This is something I’m terrible at. Obviously, you listen to the show, so you know that.

Pronunciation is difficult for me, as it is for a lot of people, especially when you talk about things like medications. Right? We tend to have a hard time pronouncing medication names. That’s why we lean toward the brand names because they’re a little easier to pronounce. But you’re going to need to be able to do it. And it’s really hard to remember something that you can’t pronounce. I talk about free data points in the air and how hard it is to retain them.

Well, it’s even harder if you don’t have a name to go with the thing you’re trying to remember. Right? So a major key to memorization is to be able to pronounce and say the words. One, it’s just that being able to pronounce it will help you retain it, but being able to say it gives you again another way of, what’s the word I’m looking for? Another, I’m struggling with words, but it gives you another sensation, being able to speak the words aloud, being able to hear your own voice saying that. It makes a tremendous difference. Another sense.

That’s what I’m looking for. I’m struggling to come up with. Another sense that you can bring into your study. I talk about that too. So one of the tips in the 54 study tips is making sure you can pronounce the term. And I have two different ways you can do that. There are websites, real simple to look up.

One is howjsay.com, which is H-O-W-J-S-A-Y.com. And the other is howtopronounce.com. Both give you some really nice, usually four or five different people saying the words, so you can get a good feel for how they should sound. And then you practice a little afterwards, and you pretty much have it nailed. This will go a long way towards retaining your medications. Everything, really, because if you can’t pronounce the names of your diseases either, it’s going to be a problem. But more for me, I’m thinking about pharmacology.

That’s where I really struggled with this, because I couldn’t pronounce the names, right? So then I couldn’t, I had trouble to hold on to them, because I didn’t know them. I had nothing to hang on to. So again, howjsay.com, H-O-W-J-S-A-Y, and howtopronounce.com, H-O-W-T-O-P-R-O-N-O-U-N-C-E.com. Head over to those. Especially, like I said, just type in the medication name, and you’ll be amazed at what you’re able to find there. If you haven’t discovered that yet, it’s pretty cool.

All right, let’s hop in and discuss our priming questions. What score on the Glasgow gutlock? Glaucoma. I guess that’s a natural thing to do with the way this is set up. The Glasgow coma scale represents severe impairment. Eight and below, right? What was normal?

What was normal? Think about it for a second. 13 to 15. List three symptoms of a concussion. This should be easy. There’s lots of them. And again, just picture that boxer stumbling around the ring.

Headache, blurred vision, confusion. The list goes on and on and on. Name two anti-nausea medications. Name two nausea medications. Ondansetron, which is Zofran, and metoclopramide, which is Reglan. Explain the Stroop color test. I don’t know that you need to know all of these tests, and I’m sure they’re going to give you more, like I said, but you should be able to handle a few of them.

This is the one where the color words are shown in varying color fonts, meaning something like purple is printed in red, and they ask you what color is this? And you have to say purple. But that just requires discernment, right, in thinking.

All right, that wraps up our study questions for today, our priming questions. Awesome work, really good job today. Again, so happy to have you on board here. If you’re looking for more, check out the study tips, physicianassistantexamreview.com/the numbers 54 to pick up those study tips and really help improve your grades, improve your scores, improve your retention, all those things will be within that document. So go ahead and check that out.

All right, until next time, take care. Good luck on your exams. Thank you.