Hello and welcome to the Physician Assistant Exam Review Podcast. For over a decade now, my mission has been to empower anyone learning medicine to excel in their studies and enjoy their lives. That includes PA students, NP students, medical students, pharmacy students, and anyone else who’s struggling to learn medicine and hang on. Having helped over 10,000 students over the past 12 years, we’ve assisted individuals just like you in achieving the grades they truly deserve while breaking free from struggle and stress. Our goal is to guide you along the spectrum from those moments of struggling to hang on through passing, then comfortably mastering your studies all the way to becoming an anxiety-free test taker.

Now, that may be a stretch for some of you, but I promise you it’s possible because I’ve seen it happen hundreds, if not thousands of times. We accomplish that by focusing on four crucial areas. Number one is medical content, of course, ensuring you’ve got the building blocks you need to succeed. But number two, three and four are usually a little less looked after. Number two is advanced learning strategies, learning how to learn, becoming a student forever. Next is test-taking techniques, approach and strategy when moving into an exam. And lastly, peak performance, especially as it relates to learning and high-stakes exams.

So whether you’re nearing the finish line or just got accepted to school, we’re here to help you reach your potential and make your journey the best it can be. We’re going to do that today in episode 122. As we talk about the peripheral nerve disorders, we’re going to incorporate all those other things as we move through this. We’re going to begin again with some advanced learning strategies by beginning with our priming questions. If you don’t know, the priming questions are designed to get you actively engaged in this podcast, to get you actively engaged, not to be sitting back in your chair, not to be listening as you drive, not to be doing the laundry or out for a run and not really paying attention, but to get you sitting forward and paying attention so that your brain is ready to work. Even if you don’t know the answers to these, that’s fine. There’s no problem with that.

But it’s the idea, the thinking, the mental work that goes into the priming questions that gets you started and gets your brain motivated, even if you don’t realize it’s happening.

So let’s go ahead with them. What are common symptoms of carpal tunnel syndrome? What is a common initial symptom of Guillain-Barre syndrome? These are all symptom-based today, so pretty straightforward. What are the hallmark symptoms of complex regional pain syndrome, or RSD? What are the common sensory symptoms associated with peripheral neuropathy? You can sort of sense a theme, right?

As we move through today, you hear me often talk about differentiating diseases and how you’ll have to do that. I was actually working with a student this morning when I realized, again, how important this is when it comes down to test questions. When you get to a test question, there are going to be answer choices that are going to go together. So in this case, I’m presenting peripheral neuropathies, Guillain-Barre syndrome, and complex regional pain syndrome together. And one reason for that is because they’re going to show up on your test together. They’re going to show up as answer choices to the same questions together. In addition to that, what other two things pop right into mind that you’re going to have to know on test day, if we’re talking about Guillain-Barre, what other diseases would you have to know?

I’ll give you a hint. We just talked about them. Well, multiple sclerosis and myasthenia gravis. So as we move through these, just like in the priming questions, I want you thinking about how these diseases relate to each other. Don’t learn things in a vacuum. Don’t learn things one at a time. Don’t learn lists.

Build out your knowledge into a web that’s interconnected so that you can retain more and remember more, and it will increase your recall dramatically. So you’re learning these together, not separate. We’ll wrap it all up together at the end, but I want you to be thinking as we move through how that works. We’re going to start with complex regional pain syndrome, CRPS, which is also known as reflex sympathetic dystrophy, RSD. I actually didn’t even realize it was RSD. I used to work somewhere that we saw a lot of it, but I never really knew that was the name. We’d always just call it RSD, and everybody knew what we meant.

So there’s that. This is a chronic condition characterized by severe, persistent pain and sensory disturbances following an injury or surgery. That’s a key there. A chronic condition characterized by severe, persistent pain and sensory disturbances following an injury or surgery. This is often triggered by surgeries, fractures, or soft tissue injuries. It can sometimes develop without a clear injury, which does make the picture a little tough. But hopefully in your exams, it’ll usually have some type of injury.

Here’s the key, though. This is a condition with an exaggerated response of the nervous system. It’s an exaggerated response to an injury. So what you wind up with is a patient who’s reporting severe pain, way out of proportion to what’s going on. It’s a burning, throbbing, or searing pain. And it just doesn’t match up. Almost like, what’s the other example of this?

Can you think of it? Because I was just going to say it. But let me give you a chance to think of it. What’s the other example in medicine that we talk about pain out of proportion to exam is actually the words that they use. That’s ischemic bowel, right? Ischemic bowel is pain out of proportion to the exam. And that’s what RSD is.

It’s pain way beyond what you would ever think. So it’s super sensitivity to cold, to touch, even the lightest contact. So patients will actually say, I can’t even put a sheet at night over my foot or my hand because it hurts so bad, just that little bit of touch. And if you don’t know about this, you might think those patients are out of their minds because they’re so over-exaggerating what you think should be happening. But if you know about this syndrome, then you know it’s definitely a possibility, something to keep an eye out for. And for me, I saw this. I worked in a foot and ankle orthopedic office, and we saw a lot of RSD.

Not that it was all our patients, but it was some of them. I’m trying to think. There were some that were our patients, but because we worked in foot and ankle, we would get sent these patients who just had this unbelievable pain and their docs or their podiatrists or whoever couldn’t figure out what the problem was and they would come to us. So I just saw an exorbitant amount of RSD to the point where I thought it was really common. And then I realized that, no, we just got lots of it sent to us. But it’s just this crazy, crazy pain way out of proportion to what’s going on. So, somebody sprains an ankle, someone has a surgery for a bunion, and they just can’t even walk.

They can’t… they’re screaming in pain all the time. It’s just this constant thing. You can get muscle spasms. One of the ways you can identify it is skin color changes. I think that has to do with the vascular issues beneath the the surface there. You can get swelling.

And it can spread beyond the original injury site, but typically that’s the area it’s going to be in. The diagnosis is clinical based on those symptoms that we talked about and the complaints we talked about. There’s not really any lab tests that are going to help here. You may want to consider, like we’re talking about, other things that could be going on. Could it be neuropathy? Because that burning, stinging kind of pain may be similar. So you want to keep that in mind.

Treatment here includes physical therapy, occupational therapy, and NSAIDs, steroids, gabapentin, beta blockers, bisphosphonates. They may or may not work, right? But these are things that we throw at it. You could do nerve blocks. They may, this is not going to be in your exam and I don’t want to go too far down this road, but they sort of can reset those nerves and give them a chance to break out of that with the specific types of nerve blocks. But just something to think about.

All right, let’s move on to Guillain-Barre syndrome. Guillain-Barre syndrome is an autoimmune disease often occurring after an infection or surgical procedure. So when we’re studying things together, complex regional pain syndrome after an injury, Guillain-Barre syndrome after an injury or an infection. I feel like the questions usually have an infection of some kind. So I think that might be what I would more attach this to. This can be life-threatening because it can affect the respiratory muscles. And the key here is ascending paralysis.

Ascending paralysis. It typically begins in the hands and feet and progresses into the legs and then more centrally. You can get muscle pain. And this usually comes on over a few hours to a few days. Lab studies and physical exam findings here. It’s just going to be really that weak muscle. So that ascending weak muscle test.

You’re just going to test for strength as you would. The other thing you’re going to test here, and this should stand out to you, is the absence of deep tendon reflexes. That’s going to be not quite pathognomonic, but really should send off alarm bells for you for Guillain-Barre syndrome. Absence of deep tendon reflexes. They can also get changes in temperature and pain sensation. And you can do an EMG to show some slow nerve conduction and sort of prove it a little bit. Treatment is going to be supportive care, especially if there’s a respiratory issue.

These patients can get better with plasmapheresis to filter out the antibodies or IVIG. Remember, this is an autoimmune-initiated disease, so there’s some sort of infection or surgical procedure your immune system goes a little haywire and starts attacking the nerves. So plasmapheresis to remove the antibodies or IVIG may help. Most cases will improve within about four weeks, and most patients completely recover. Next we have peripheral neuropathy. This is a disorder resulting from damage to the peripheral nerves. Common causes would be things like diabetes.

It would probably be number one. I saw a ton of that in my foot and ankle practice. Tons of diabetic neuropathy. Alcohol abuse would be another. Vitamin B12 deficiency would be another. Certain medications, autoimmune diseases, all sorts of things can cause this. Anything that’s going to attack those nerves.

But those top three, those three would be the three that I would hang on to. Diabetes, alcohol, vitamin B12. And this is that stocking glove distribution, which I didn’t understand what that meant when I was in PA school. It was another word I just memorized, right? Like currant jelly stool. I just memorized. I didn’t know what it meant.

It didn’t mean anything, so I couldn’t really hang on to it. Stocking glove distribution just means the pain, the sensory, what patients get starts distally. So they get this numbness, tingling, and pain that starts kind of in the toes and moves up to feet and then encompasses the ankles and kind of moves up to legs as if you were putting on a stocking or a sock. So it would be in that distribution. It would be the entire foot, right? It would be all the way up to the ankle. Same thing in the hands.

It would start out maybe in the fingers and move up into the hands as if you were putting on a glove. That’s the distribution that this comes on in. So that’s all that it means. It’s not really that complicated. I don’t know. It just didn’t make sense to me at the time, but it’s really pretty straightforward. So again, clinical presentation.

Patients are going to come in complaining of numbness, tingling, burning pain in those distal extremities. They can get some weakness and loss of reflexes. The other thing you’re going to get is sensory loss. So this is the big one. They get sensory loss if those nerves are damaged. Why does that matter? It matters for a whole host of reasons.

Number one is if you lose sensation, let’s say in your feet, you then also lose balance and you’re a fall risk, right? If you can’t feel the ground, you have a problem with walking. You’ll notice these patients look down as they walk. The other thing is, and as you know, with diabetes, patients are susceptible to wounds, right, to pressure sores. The reason is, if you’re standing on your feet, you and I, if you stand in one spot long enough, and I do it all day long in the OR, if you stand in one spot long enough, you get a sensation that you need to shift, that you need to move, and you start to kind of wiggle back and forth. Well, the reason you’re doing that is because the oxygen and it has been cut off to the tissue you’re standing on. The blood supply is sort of cut off.

Now, it can last for a while, right? It doesn’t need constant blood flow, but it does need blood flow regularly. So, you feel that sensation to move. You may feel it sitting in your chair right now, that you need to just kind of wiggle a little bit. Some of that is the pressure onto that skin that’s stopping the blood flow to it. Well, when you feel that sensation, you move to a different, to have a different pressure point, at which point the blood will flow into the old pressurized area, and replenish the oxygen and remove the waste material and all that good stuff. But if you’re not getting those sensations, that’s when you get the breakdown or if you can’t move, right?

So if we’re talking about patients who are like quadriplegics, they may have the sensation, but they can’t move to solve that problem. So, or for other reasons, I think that didn’t really fit together well, but you get what I mean. If for some reason a person can’t move, the sensation wouldn’t matter. But in this case, we’re talking about the sensation. So without the sensation, you have repetitive injury. You can also get repetitive injury from lots of things like just stubbing your toe, right? If you don’t realize that you did it, it’s a problem.

These patients are susceptible to burns in particular. It’s a good one. Because again, you don’t get that feedback. You don’t get that sensation. So if something is burning you and you don’t feel it, well, then you don’t pull away from that source of heat, right? So then you run into a problem there. And the other thing as far as clinical presentation, in a B12 deficiency, you can get cognitive changes in memory loss and mood disturbances.

So if you have a question that’s talking about peripheral neuropathy with cognitive changes, that’s when you’re going to be looking at B12, a B12 deficiency. Lab studies and physical exam findings. Well, what are we going to be looking for here? A nerve conduction study. So we can show reduced nerve conduction in affected nerves. You’re going to get some blood work because we’re going to be looking for, are they an uncontrolled diabetic? What are the B12 levels?

And then you’re going to do a physical exam. Like I said, you’re going to do sensory deficit tests. You’re going to do motor weakness. You’re going to do reflexes. You’re going to look at skin integrity in order to determine what’s going on. The mainstay of treatment here is to deal with the underlying cause. So for diabetic neuropathy, you’re going to work on glycemic control.

For B12 deficiency, you’re going to give them B12 and manage anything like anemia that goes along with it. You can give things like tricyclic antidepressants or gabapentin. Gabapentin or pregabalin may help with nerve pain. And then you’re going to do things like rehab, like physical therapy to maintain muscle strength and flexibility and motor awareness, occupational therapy to work around their sensory deficits and to work with their balance and that sort of thing.

Now, again, understand their complications along with peripheral neuropathies, burns and wounds, infections, falls, all that stuff. Really important to note in these patients. Maybe not on your exam, but definitely in the clinic, things you want to educate your patients on.

All right. Well, that was quicker than I had expected, but that brought us through the three things we wanted to cover for peripheral neuropathies. Not for peripheral neuropathy, for peripheral nerve diseases.

So let’s talk for just a second about how these are going to show up and how you have to differentiate them. So I said at the top that you have to know the difference between myasthenia gravis, multiple sclerosis, peripheral neuropathies, Guillain-Barre, and complex regional pain syndrome. You have to be able to tell them apart. Because on test questions, those are going to be the four or five answer choices you’re going to have to separate. But it’s not that complicated if you know the one or two things that make each of them different. So when I’m studying, that’s what I’m looking for. I’m looking for what are the couple of things that separate these apart from each other so that when I see that, it pushes me in a really good direction.

It may not be 100% correct, but if I’m right 95% of the time, I’m willing to accept that. And so let’s just talk about these five things as compared to each other. We just got done with peripheral neuropathy. So what’s the mainstay for peripheral neuropathy? What would you see in a test question? What would you see in a description of this? Well, for one, they’re going to be slowly progressive, right?

They’re not going to come on quick. They’re not going to come on after an injury. These are going to be patients with diabetes or alcoholics or some kind of problem where they might have a B12 deficiency. They’re in that stocking glove distribution. So you can see how that picture will be painted in a test question. What about Guillain-Barre? Think that through.

We just finished it. So, tell me, what would Guillain-Barre syndrome look like in a test question? How would it be described? Well, this wouldn’t be slowly progressive. This would be more rapidly progressing over hours to days to maybe a week or so. Ascending muscle weakness and paralysis, starting in the legs and moving up. What was the other thing that I said to be aware of when it comes to Guillain-Barre that will help separate it?

Absence of deep tendon reflexes. That was one that should jump off the page. If you see that, it doesn’t mean it’s Guillain-Barre, but it should certainly move it up on your list. Higher on your differential. And it’s going to be what? What’s going to be happening before a patient gets Guillain-Barre syndrome most of the time. They’re going to have had some sort of injury, surgery, or an infection, a viral infection.

And they’ll probably mention that in your test question. Not always, but probably. What about complex regional pain syndrome? Well, this is, I was about to say always. That’s a hard thing to say. This is usually going to be following an injury or surgery or something like that. Can you have a patient come in who has no history of injury and they have RSD?

Of course it’s possible, but I can’t imagine a test question asking you to identify RSD without a injury, without some sort of event. But what is even if that were the case, what terms would push you towards RSD? Well, if the patient’s exam was and pain were far out of proportion to what you would expect. You know, if they have an ankle sprain and they can’t walk and they’re writhing in pain just laying on the bed they’re talking about how they can’t sleep at night because it hurts so much and that just the sheets touching it are is excruciating. That’s an RSD patient. The temperature is different from one side to the other. The color is different from one side to the other.

The swelling is different from one side to the other.

So let’s talk about MS and myasthenia gravis. Same questions. What makes MS stand out in a test question? What’s the descripting terms that make MS stand out? Relapsing and remitting course, right? That’s the part that really jumps off for multiple sclerosis. I had this weakness that comes and goes.

Can’t really tell why. There’s all kinds of other characteristics. Of course there are. But to me, if I’m trying to separate out different things that affect my, give me muscle weakness, that’s what I’m going to hold onto for multiple sclerosis. I’m going to hold onto that relapsing and remitting course. Sure, there are MRI findings I’m going to want to see. Lots of other things, but that’s what I’m going to use.

What about myasthenia gravis? We talked about this before. What separates out myasthenia gravis in a test question? How would you write it if you were going to write this question? You’d have muscle weakness, right? But all of these have muscle weakness. So what makes muscle weakness and myasthenia gravis different?

It worsens with activity and improves with rest. Certainly, we could talk about that it has to do with facial muscles. We could talk about all kinds of different things. But the key is, worsens with activity, improves with rest. That’s how you’re going to separate out this differential. I hope that makes sense, and I hope that you can see it, because those are how you’re going to be asked questions on your exam. Oh, I forgot to mention at the beginning of the show, but I put together, just like I did for episode 121, I put together a an active study guide to send you more down the road of how to separate these, how to think about them, how to hold on to them, so that you can get these questions right on your exams, so that you can study in a more active way.

The guides include questions, stories, all kinds of things to really help you drive this stuff home and really make a big difference. So if you go to physicianassistantexamreview.com/122, that’ll bring you to the page where I have all the notes for this section, but it’ll also give you how to get access to that study guide. So you can get all the notes so you can go through this really easily. But in addition to that, you can get that active study guide that’ll walk you through each of these and really help to sink them home. So I really strongly recommend I have a lot of fun putting those together. It takes a bit of time, but it’s definitely, definitely worth it. So if you just go to physicianassistantexamreview.com/122, you’ll get that.

All right. Our study tip for today is really straightforward. It’s I just want you to think about how you do your work. This is not a specific tip. This is a very general philosophical tip. Think about how you do your work. When you do your work, what type of work are you doing?

How are you going about it? What resources are you using? Are you hopping from one to another? Have you picked just one? Consider how you’re studying and consider if there are two or three things you could adjust in your routine and test to see how they’re working for you. I was talking with a faculty member the other day who was saying they didn’t figure out how to study themselves in PA school until about a year in. And I think that’s probably pretty accurate.

Most of us flounder for that first few months as we get just slammed with stuff. And then we start to test things and try things. And then one of two things happens. We either do okay enough or we’re just surviving or we keep testing because we’re not doing well. But generally people kind of stop testing once they do okay. I want you to keep testing, keep looking, keep thinking about how you approach your studies and if there aren’t things you could improve or bring to your studies that would help.

All right, let’s answer our priming questions. I brought up carpal tunnel syndrome because it is in the blueprint at this point, but I talk about it in episode 110, the upper extremity under musculoskeletal. So I don’t really, I’m not going into detail in here. You can certainly go back, listen to that episode or hop over to episode 110, the show notes there to get a hold of that. Oh, I don’t know if you guys know this, but on the website, you can go to the blueprint to the site map and it has everything listed there really in order, really easy to find. But in the top right, there’s also a search feature for the website. So you can go up there and just type in carpal tunnel syndrome and it’ll bring you right to the entry on carpal tunnel or whatever else you’re looking for.

All right. So what are the symptoms of carpal tunnel syndrome? Numbness and tingling in the thumb, index and middle fingers. Definitely know that. What nerve is it? Do you remember? What nerve is it?

The median nerve. What’s the most common initial symptom of Guillain-Barre syndrome? Muscle weakness, often starting in the legs and spreading proximally. What are the hallmark symptoms of complex regional pain syndrome, or RSD? Severe pain, changes in skin color and temperature, and swelling in the affected area. What are the common sensory symptoms associated with peripheral neuropathy? Numbness, tingling, and burning in the extremities.

All right. Amazing work today. Great job. Way to stick with it. Way to keep thinking throughout this episode. Again, that’s such a huge, huge key. Definitely go over to the website, physicianassistantexamreview.com/122 to get that study guide and get all the notes.

If you haven’t looked yet, another thing, on a few weeks ago, a few months ago, I started really putting a lot more effort into the Instagram account I have. So if you go search Physician Assistant Exam Review, you will find the Instagram account where I’ve been posting a ton of questions and other things on there. It’s been a lot of fun. So definitely go check that out as well.

All right. Hope you had a great Thanksgiving. Take care. Best of luck. And I look forward to talking to you guys again soon. Thank you.