121 Movement Disorders – Best episode ever

Hello and welcome to episode 121 of the Physician Assistant Exam Review Podcast. I realized I screwed up last week and it should have been neuromuscular disorders and I called movement disorders. This week we’re actually going to be covering movement disorders and in a way that they will hopefully stick right in your brain. My name is Brian Wallace. I’m the founder and creator here at Physician Assistant Exam Review, and I’m so glad that you’re here with me today, because I’ve dedicated myself to moving students from struggle and stress to success and confidence. That’s really the direction I’ve been heading more and more lately. And as I’ve been talking more with students and more with PA programs, I’m finding that’s the direction that moves the needle the most, is moving students along that spectrum from struggle, from hanging on to passing, doing well, and then excelling.

And I do that by exploring medical content, of course, as well as discussing advanced learning techniques, optimized test-taking practices, and peak performance, especially as it relates to high-stakes exams so that you can get the grades you deserve and enjoy your life. That’s the point, right? And that’s really been my goal over the last decade, but it’s becoming more and more honed in as we go. And I’m really excited about this week’s episode because of some things I did in the background to enhance the learning from what I’m doing. And I’ll talk about that a little bit as we go. In fact, actually, let me just jump right into that now. I’ve been working on some things that will really move the needle for you and give you ways to incorporate some very well-studied, well-proven techniques into your work so that you can retain more and do better on your exams.

I’m going to post, as I always do, the notes from this particular section on the website. You can find that at physicianassistantexamreview.com/121, and you’ll see all of the notes. But in addition to that, with this episode, I’m going to give you four other methods, practices, let’s say, tailored to today’s discussion that will help to get the information to stick in your brain. That’s going to include multi-format questions and the sticky stories I’ve been sending out to the members of the email list that they’ve been absolutely loving. I think you’re going to get a kick at it, and I’ll walk you through essential tremors right there on the website. So, you can see that at physicianassistantexamreview.com/121. The other thing I want to talk about quickly before we get into the content from this episode is that next week is Thanksgiving.

So, first, I want to take a minute and say, you know, Happy Thanksgiving. I hope you’re taking some time off to spend with your family, to spend with some friends, that I know I have some students who are, you know, nose to the grindstone, working really hard toward their PANCE. But even for them, I suggested, hey, maybe you get up a little bit early on Thanksgiving morning, and you get your work done by 10, 11, or noon. And then you spend the rest of the day with your family and friends. Maybe don’t drink because then Friday becomes a mess and a little slow, but take some time. You need to take a break. You need to breathe a little in between.

I know a lot of students who have spent so many months, so many weeks, tense and cranking and working really hard that sometimes a little space is the best possible thing you could have and will help you retain more and think more clearly.

Now, in addition to it being Thanksgiving, I also want to let you know that I’m putting together a Black Friday package. I get questions from students all the time about if I provide discounts on my materials, and I usually don’t. I sort of do here and there, but most of the time I do not. Although right now, coming up with Black Friday, I’m going to be doing the biggest discount I do of the year by far. This package is going to include The Final Step, No More Test Anxiety, Test Taking 101, Rotations 101, and the course I put together, Maximize Your Time and Efficiency, as well as a couple other things. And you’re going to get all of that for 75% off. But here’s the deal.

That’s only on Black Friday. That’s only for the 24 hours of Black Friday that that 75% off applies.

Now, if you want to find out more about what’s in that package, how it works, and you want to get notified when that happens that you don’t miss out, go to physicianassistantexamreview.com/blackfriday, real easy physicianassistantexamreview.com/blackfriday to get more information and get notified when that becomes available. But again, at 75% off, it’s absolutely when you’re on, you’re going to want to check out.

Okay. Oh, and then one last thing before we jump into our priming questions, I do just want to thank the students and faculty at Pace University. I had an amazing couple of days up in New York at Pace University working with the students there. Absolutely tremendous group. Very engaging, very engaged. Great questions. It was a great time.

I think it really had a big impact and the discussions we had were fantastic and the faculty was spectacular. So I just wanted to reach out and say thank you. It’s been a, was a very busy October for me heading out to Duquesne to do a workshop for the students there. Heading and then I went almost, I had a little bit of downtime and went almost directly into running the Marine Corps Marathon with my sister on October 29th. That was the first marathon I’d ever run. It was a spectacular event. I wouldn’t recommend it to anyone else who hasn’t done it.

I’m not going to be one of those zealots. I did it. I’m happy I completed it, but that will likely be the last one I ever do. I did that on Sunday, the 29th, and then drove the four and a half, almost five hours up to Pace University to present on the 30th and 31st. And it turned out to work out just fine. I was worried heading in, but I could walk okay on Monday and Tuesday and it really went great. So it was just a bit of a whirlwind, but everyone was amazing and it was a fantastic time.

And like I said, I’m optimistic that not only did we have a good time, but that we moved the needle for the students there and made some impact. And I wanted to thank everybody involved in that. That was really a group effort and it took a long time to get that together. So thank you for that.

All right, let’s go ahead and jump into our priming questions for this section and let’s get started. How is the tremor of Parkinson’s different from an essential tremor? How is the tremor of Parkinson’s different from an essential tremor? Right, when we study, we talk about comparing things and learning them, how they’re going to come up in your questions. So this is a very basic one that’s going to come up. What is the typical age of onset of Parkinson’s? Actually, we’re just going to continue that theme.

Can you picture in your mind how old the person is who comes in that you’re not diagnosed with Parkinson’s disease? Where do they fall on the spectrum of age? The next two questions are going to follow the same suit. What is the typical age of onset of Huntington’s disease? What is the typical age of onset of Huntington’s disease? What is the age of onset for Tourette’s syndrome? What is the age of onset for Tourette’s syndrome?

All right, so as you can imagine, our movement disorders are going to be Parkinson’s, essential tremor, Huntington’s disease, and Tourette’s syndrome. We’re going to begin with essential tremor. This is often referred to as a familial tremor. You may hear that term certainly very commonly used because it’s an autosomal dominant inheritance pattern as it’s believed to be. And this is the most common movement disorder. How patients present uncontrollable rhythmic movements, typically involving the hands, head, or tongue. So they’re rhythmic movements, right?

And action tremor, that’s important here. It’s during voluntary motion. So what that means is when someone’s trying to reach for a glass, when someone’s trying to pour a glass. I’m thinking of different examples and I keep coming back to the same one. So it’s when someone’s trying to do something. It’s an intention tremor, an action tremor. And again, that’s important because Parkinson’s, we’re going to talk about in just a second, but hopefully, maybe you already know, Parkinson’s is a resting tremor.

So it’s when the patient is not moving. And that’s one way you’re going to differentiate those two and see the difference in the clinic and on test questions. This may also affect the voice, and less commonly, the lower limbs can be involved, but usually you think about it in the hands and maybe in the head or the tongue. This tremor intensifies with fatigue, stress, caffeine, and a couple of other triggers. We’re not going to go down the whole list. Lab studies and physical exam findings. Well, as you can imagine, this is primarily based on symptoms, right, and signs.

These are no specific laboratory tests here, but you could do an EMG or some other things to rule out some other causes, but usually this is going to just be a clinical diagnosis. Treatment. Mild cases may not require any treatment depending on how the person is doing. Lifestyle modification. So you’re going to want to avoid triggers. So anything that increases, that patients notice increases their tremor. So again, things like fatigue, stress, and caffeine.

First line medical treatment, as it gets worse, could be something like a beta blocker like propranolol. Antiepileptics might be used. Something like gabapentin might be tried. Benzodiazepines might be tried. But it depends a lot on how the patient’s symptoms are and how they’re progressing. One thing you’re going to want to talk to your patients about, in this case, if you diagnose someone with an essential tremor, is that they’re going to notice an improvement with alcohol. It tends to make the tremor less, right, and help to make it a little bit better.

Obviously, there’s problems with self-medicating with alcohol to remove the essential tremor. So you’re going to want to have that discussion with your patients for sure.

Next, we have Huntington’s disease. Huntington’s disease is also an autosomal dominant neurodegenerative disorder with cognitive decline, psychiatric issues, and movement disorder. So that’s how you’re going to look at this. Cognitive decline, psychiatric issues, and movement disorders. It’s a whole picture. There’s also a clear inheritance pattern where offspring have a 50% chance of inheriting the gene, which is found on chromosome 4. Symptoms don’t typically begin until age 30 to 50 for Huntington’s disease.

This disease is progressive and incurable, and there’s about a 20 year life expectancy from the onset of symptoms. So this is a rough one. These patients will experience mental status changes including irritability, moodiness, depression, anxiety, and eventually dementia. Again, it’s characterized by those psychiatric findings but then also by the movement disorder and the cognitive decline. So the movement disorder is known as chorea, which was always hard for me to understand. I just didn’t get it in PA school. It didn’t make any, still, I don’t, just because the term is weird, it doesn’t have anything to do with the problem.

And it just means jerky, random, uncontrolled movements. I don’t know why that was so hard for me to grasp that those two things just equal each other. And if I bought into that, I would have done much better in this section and in a couple others. But chorea just means jerky, random, uncontrolled movements. So these patients will have chorea, and that’s the most characteristic feature of this disorder, of this disease. They can get fidgetiness, restlessness, rigidity, abnormal posturing, balance and gait disturbances that may bring them into your office. They can wind up with difficulty swallowing and even difficulty speaking.

So again, you’re thinking about how this is going to present in your office or how this is going to present on a test question. This is going to be a 30 to 50-year-old who comes in because they’re having issues mentally. Either things are becoming more difficult or cloudy, they’re becoming more irritable, and they’re having these odd movements that they can’t control. That’s the picture you want to be painting. So here, diagnosis is going to be confirmed through genetic testing. There’s an expanded CAG repeat on the HTT gene. And again, in an autosomal dominant it’s autosomal dominant, so offspring will have a 50% chance of inheriting the disease.

So, that’s going to be something you’re going to have to speak with patients about. Obviously, if they have children, it’s going to be a concern. For Huntington’s disease, MRI is going to be more sensitive than CAT scan to show the cerebral atrophy of the caudate nucleus. As far as treatment goes, like we said, there’s no cure. So you’re going to work on symptom management and supportive care. Psychiatric symptoms. So for those, you’re going to look at antidepressants and antipsychotics.

For the movement issues, neuroleptics might work. Like olanzapine, risperidone, haloperidol. Dopamine depleting agents may be helpful for the movement disorders as well. Tetrabenazine. And then finally supportive care. Counseling, speech therapy, occupational therapy, physical therapy to help with mobility and balance in those things. But a lot of it is going to be counseling.

Again, especially if the patient has children. Or is thinking about having children. Parkinson’s disease is next. This is a degenerative disorder of the central nervous system caused by the death of the dopamine-producing cells in the substantia nigra, leading to an imbalance between dopamine and acetylcholine. So that’s really what you want to hold on to there, right? There’s an imbalance between dopamine and acetylcholine. Similar to Huntington’s disease, it’s characterized by motor symptoms known as Parkinsonism.

Parkinsonism looks different than the chorea of Huntington’s, but that’s where you’re going to be separating these two when on test questions and in the office. That’s where you’re going to be looking for how are these different. Well, the description of those motor symptoms is what’s going to be different. The other thing is Parkinson’s is going to be found in people usually older than 60 years old. Meaning that’s one way that you can differentiate this from Huntington’s disease. Huntington’s disease is usually 30 to 50. Parkinson’s is people 60 and over.

Now, again, that’s just more to remember. And I talk about not necessarily retaining lists of data and information, but you can picture in your head the Huntington’s patient being on the younger side, 30, 35, just having had children. In that age range somewhere, and the Parkinson’s patient moving into more that grandparent phase of life. Again, that’s a broad stroke. I’m not saying that that’s how it all works, and obviously you can get Parkinson’s disease earlier than that, but I’m optimistic that the test writers aren’t going to do that to you. So it’s just, again, for me, it’s a way that I picture, I paint that picture in my mind of each disease and how they’re separate and how they’re different so that when I get to the exam, as I read through the stem, they just start to present themselves as one way or another. And I know that I’m going to be looking for, you know, as I go into a question like this, is it going to be essential tremor?

Is it going to be Parkinson’s? Is it going to be Huntington’s? Those are the things that I’m going to have to separate on that exam, right? So I’m looking for how to do that. Our clinical presentation with Parkinson’s, again, that motor function issues. So it’s that resting tremor often referred to as a pill rolling tremor tremor because the way that the fingers and thumb move together as if someone has a pill in their hand and they’re turning it over and over and over. Sometimes that description may confuse you more than it’s helpful.

But if you picture someone just holding a pill between their pointer finger and their thumb and just rolling it between their fingers, that’s what that tremor looks like. And it’s a resting tremor, again, as compared to our essential tremor earlier, which was an intention tremor. So, that person would struggle, let’s say, having a bowl of cereal, they’re trying to bring the spoon to their mouth, is when the tremor would kick in and they’d have they’d shake the food off of the spoon. They couldn’t eat cereal or soup. That would be difficult for someone with a significant essential tremor. For Parkinson’s, though, we’re talking about a resting tremor. So, as they’re sitting still, that tremor kicks in.

It usually begins in one limb or on one side, but certainly can spread. The other major one that sticks out in my head for Parkinson’s is bradykinesia, so slow movements. This would be from difficulty getting up out of a chair would be the thing that comes to mind here. It’s just that slow muscular movement, so it’s hard to do these things that take dynamic strength. That would also go to the muscles of the face. So they get decreased facial expression. So they look very flat.

They also have a characteristic reduced arm swing when they walk. So these patients, when they walk, you’ll notice that their arms don’t move. They can also get rigidity. So again, just taking that a step further, they can get rigid, which may look like lead pipe or cogwheel rigidity, meaning as they move, they’re very stiff and it’s not jerky like chorea, but it’s jerky in the sense that if you lift your arm up, it’ll move to one spot, then the next spot, then the next spot. That’s what they mean by the cogwheel motion. They get a shuffling gait, which is another term you’re definitely going to see in here. And they have an increased risk for falls.

Parkinson’s patients also can have psychiatric issues with loss of executive function, difficulty planning, and inhibition of inappropriate actions. They can have speech disorders, mood alterations like depression and anxiety, and even get so far as hallucinations and delusions and dementia in later stages. So as I go through those, if I’m studying this, I don’t spend a lot of time on the psychiatric issues for Huntington’s and Parkinson’s. They’re important if you’re treating a patient. To me, they’re less important if you are studying for an exam. Why? Well, because if I’m studying for an exam, I’m going to have to differentiate essential tremor, Parkinson’s, and Huntington’s disease in a test question.

Well, the psychiatric issues, although manifesting differently out in the world, on a test question, they’re going to look very similar between Huntington’s and Parkinson’s, right? They’re not going to be that different. I have anxiety, I have depression, and I have dementia. When I look at Huntington’s, I’ve got irritability, moodiness, dementia, depression, anxiety, and apathy. So it’s a little bit different, absolutely. And then more of the irritability part comes in, I think, with Huntington’s. But they’re close enough that it’s going to be hard for me to differentiate them on an exam using the psychiatric features.

When there are other obvious features you could use, like the movement disorder, the difference between chorea and bradykinesia, the difference between the tremor in Parkinson’s and no tremor in Huntington’s, you’re going to use different parts. So although the psychiatric issues are extremely important to the patient and to you as a practitioner, to you as a student, that’s not where I would spend my time. Parkinson’s patients also have difficulty with sleeping. They can have autonomic nervous system issues like urinary incontinence, orthostatic hypertension, sweating, constipation. Eye and vision abnormalities and sexual dysfunction. So to me, if I’m looking at a test question, all of those things I just went through, the autonomic issues may come up in the vignette. You certainly could have a patient who presents with a resting tremor, a shuffling gait, and urinary incontinence.

But for me, when I’m studying again, the autonomic nervous system stuff, it’s good if I know it because that will help to clear up the picture. If I’m thinking, okay, this is probably Parkinson’s, and then I see urinary incontinence and I have to stop and think and say, geez, does that go along with Parkinson’s? Does it not go along with Parkinson’s? So it’s helpful to know it because if I know it does go with it, then it confirms my suspicions and moves me forward. But if I see that on a test and I’m not sure, but I really think it’s Parkinson’s and I come across something like urinary incontinence and sexual dysfunction, I’m not going to abandon my initial thoughts because I come across those two things. So they’re not going to be the things I most focus on when it comes to Parkinson’s, but they’re definitely going to be helpful and they will show up in your vignettes for sure. But like I said, you’re not going to key in on urinary incontinence and sexual dysfunction and think Parkinson’s.

That’s not how that’s going to work. They’re going to be the supporting thoughts, the supporting clues, the supporting pieces as you go through your exam. Lab studies and physical exam findings, primarily a clinical diagnosis based on history and physical exam. You can get a CAT scan or an MRI, but really you’re just ruling out other causes. And as you go through Parkinson’s, you will hear about Lewy bodies for sure. The problem is we can’t examine the brain on that level unless we’re doing an autopsy. So they’re not helpful for diagnostics.

Treatment. Parkinson’s cannot be cured. So similar to Huntington’s and essential tremors. We’re not curing this. So we’re focusing on management of symptoms and providing quality of life. In this case, there are multiple medications that can be helpful. You’re going to start with anticholinergics for mild motor symptoms like amantadine, benztropine, and then levodopa combined with carbidopa.

And levodopa is a precursor to dopamine, and then carbidopa helps the levodopa to not be metabolized in the bloodstream but actually get into the brain. And then there are a few other medications that increase the effects of levodopa or stimulate dopamine receptors like dopamine agonists. Pergolide is one, bromocriptine is another. So there’s a couple of medications that can be used to help fight the symptoms of Parkinson’s. On the list for surgical interventions is deep brain stimulation and ablative surgeries like pallidotomy. I don’t really know a whole lot to speak on that. And then lastly, it’s just going to be that supportive care, that focusing on improving quality of life, physical therapy, exercise, and supportive services.

And again, this is a disease that is not curable, right? So this is going to take a lot of counseling for family members for the patient as they move forward. Our last one for today is Tourette syndrome. Not sure if there’s a difference, quite honestly. This is a neurodevelopmental disorder characterized by motor and vocal tics. Typically begins between ages 2 and 15 with symptoms of improving in late adolescence. Why do I put that down?

Why do I care? Again, I’m trying to differentiate these disorders, one from the other. Tourette disorder comes up between ages 2 and 15. Much different than essential tremor and Parkinson’s and Huntington’s, right? It’s different. This is in kids. Parkinson’s is in that grandparent age.

Huntington’s is more in that little kid, you know, just married, having children age. So consider that as you’re painting these pictures. It’s likely inherited with potential brain abnormalities contributing to the condition. Coprolalia, which is involuntary swearing, which is what most people think of when they think of Tourette, is actually not that frequent. I can’t help but think, I don’t know if you guys have seen the amazing, probably the best comedy of all time, What About Bob, starring Bill Murray. And he is a psychiatric patient who follows, who humorously follows his psychiatrist onto vacation because he can’t miss his appointments. So he follows him to vacation and ingratiates himself with the psychiatrist’s family, much to the chagrin of the psychiatrist, but the family love him and it is just hysterical.

And one of the things is he convinces the youngest son that he has Tourette’s. So in one hysterical scene, they are jumping up on their beds, cursing and swearing as the psychiatrist walks in angrily and they basically blame Tourette’s for the problem and say that they can’t help it. But like I said, that’s just how I hold on to this one. And it stands out to me. If you haven’t seen it, though, it’s hysterical. Anyway, very rare, the minority of cases, but that is what it’s sort of known for. But it’s more those motor and vocal tics in general.

So clinical presentation, you can get… So when we talk about these tics, there are simple and complex tics. Simple for motor would be things like eye blinking, head jerking, shoulder shrugging, finger flexing, uncontrolled motor tics. Just think about blinking. Someone you see, and I’ve seen this in a couple people, just where they have this repetitive blinking that they just can’t control. Complex things would be sticking the tongue out, touching the nose, smelling objects, obscene gestures or flapping of the arms. Those would be more complex.

Vocal tics, again, simple and complex. They can be either. Throat clearing or barking could be simple. Complex would be things like yelling using different tones of voice. Repeating your own words or repeating others’ words, echolalia or again using vulgar words so that involuntary swearing. Lab studies and physical exam findings. Diagnosis here again is going to be clinical based on the presence of motor and vocal tics for at least a year.

You can do other testing to look for other issues. You know, the studies, the things I came across talked about maybe doing a urine drug screen and EEGs or MRIs or TSH levels. But that’s really to rule out other issues. It’s not really to diagnose Tourette syndrome. Treatments, most cases managed with behavioral therapy and medications are reserved for your very severe cases where it’s really causing a problem in the patient’s life. Behavioral therapy would be things like habit reversal training, comprehensive behavioral intervention for tics, exposure and response prevention. And then again, you can do medications, but that’s going to be more for very severe cases.

So things like a dopamine agonist might help. They used to use haloperidol, but now more like fluphenazine or pimozide. And atypical antipsychotic might help like risperidone. And again, they talk about here deep brain stimulation for severe cases and treatment-resistant cases.

Okay, and that will take us through our movement disorders. But I want you to see, and I’ve been trying to just push this more and more, the idea of when you study to be not studying in a vacuum, not studying one thing at a time, but setting these together and up against each other, you start to see what information you need, what information is maybe less important. People talk to me all the time about not having enough time to cover everything. And much to their surprise, I say, well, don’t cover everything. Don’t spend time on everything. Pick out the things you need to know and learn those and then add in the details as you go. So I want you to be looking for that as you move through, as you do your own studies.

Watch how I’m doing it here and demonstrating it for you, but look at when you’re doing your own work your own material, what that looks like.

All right, let’s talk about our study tip for today. I wish I could remember where I got this from because it’s so powerful and I just didn’t write down the name. I don’t know if I got it from someone on Instagram or I found it online. It was very recently, but somehow I’ve lost track of it because it didn’t seem like a big deal at the time, but it’s actually something that stuck with me quite solidly as I’m trying to get my work done. So this is specifically as you’re studying, but also would be incorporated, I guess, when you’re taking tests too, but you have less control then. This is the idea. If you’re struggling with staying focused, you’re struggling with staying on task, you’re struggling with getting back to work, this is such a simple idea and so profound.

Please don’t dismiss it out of hand. Please give it a second thought. The idea is if you’re struggling to stay focused and on task and get your things done, don’t introduce new tasks. Don’t bring in other ideas. What do I mean by that? What I mean is if let’s say I finish this podcast, I finish recording it. Well, then I have to upload it from where it’s recorded onto the computer.

Then I have to edit it a little bit. Then I have to upload it to the server that hosts it. Then I have to move the notes onto the website. I have all these things to do, right? Each one of them takes a little bit of time, but there’s also some delay in what I’m doing. So as the file is moving from the recorder onto the computer, there’s probably what, 45 seconds that it takes to move it. So what do you do with those 45 seconds?

Same thing. Once I edit it and then I export it, there’s probably 30 seconds of it when it’s exporting. Then when I upload it to the server, there’s probably 90 seconds to two minutes of but uploading to the server. What do you do during those times? Do you give yourself reasons to become distracted? So do I grab my phone and start playing Clash Royale or Clash of Clans? Do I check my email and see if anything’s come in that needs to be answered?

Do I check the discussion group for the 33 Days to Pass the PANCE program and see if anyone’s commented there and if there’s anything I need to respond to? Normally, that’s how I work. Normally, that’s what I would do. The problem is, then you struggle to get back to your task. You get struggle to get your work done. You struggle to stay with what you’re doing, because you’re introducing new tasks. So, if you’re trouble getting things done, stop introducing new tasks.

So, my focus has been in that 30 seconds to 90 seconds, while that file is uploading, and please understand that’s just an analogy, it could be anything, it could be anything while that file’s uploading, I just sit here. Or maybe I think about the next thing I have to do. But I’m trying very hard to keep from bringing in a new task because what happens when you check your email? What happens when you check your Instagram real quick? Sometimes nothing, but sometimes there’s something in there that you really should respond to. And then do you respond to it and spend time with it pulling you out of your work? Or just as bad, do you ignore it but know that you need to get back to it.

So now part of your brain’s working on that. So that can solve a ton of issues with time, with focus. Don’t introduce new tasks. Don’t bring new ideas into the situation. Focus on what you’re doing, get it done, then decide to move on to the other things. Then check your email, then check your Instagram. Set time aside to do those things, but don’t do them briefly or quickly in between your tasks.

It’ll make a tremendous difference. At least it has already for me.

All right, let’s answer our priming questions. Hopefully you can answer these now because we talked about them in great detail as we went through this. How is the tremor of Parkinson’s different from an essential tremor? Can you picture it in your head? Well, that essential tremor is an action tremor, an intention tremor. It gets worse with movement. The tremor with Parkinson’s is a resting tremor.

Also called a pill rolling tremor because of the way it looks. We talked about this a few times. What is the typical age of onset of Parkinson’s? Usually after 60 years old. What about Huntington’s? Do you remember? It’s usually 30 to 50.

And what about the age range for Tourette’s? Well, that’s five to 10 years. Normally can certainly be outside of any of those age ranges. But I’m hoping for your test. It won’t be because that’s going to encompass what 95, 99% of people.

All right, as we wrap up for today, I just want to remind you, I’m really, really excited about what I’ve put together for this particular episode, physicianassistantexamreview.com/121. We’ll get you to the notes and then the study aids that I’ve put together for this particular section. Also, if you’re interested in that 75% off deal, the most significant discount I do all year. That begins on Black Friday. It begins on Black Friday. You can get more information at physicianassistantexamreview.com/blackfriday. And you get all the information there as to exactly what that is.

And if you would like it, get notified when that does actually happen because it’s going to be only 24 hours.

Fantastic. Really glad you came. Really glad to have you here today. If you found the show helpful in any way, please share it with your classmates, share it with your faculty, share it with your cohort. It would really mean a lot to me and may just mean a lot to them.

All right, take care.