Hello and welcome to the Physician Assistant Exam Review Podcast. Today, in episode 126, we’re going to be covering cerebral concerns for the third time, part three, with comas, hydrocephalus, and syncope. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And I hope you are off to an amazing 2025. There’s so much to be excited about, so much going on in your world, I’m sure, in my world as well. It’s a really, really exciting new year.

I’ve got a ton of things on the table, but most importantly, the thing I want to share with you that is the top priority for today is that tonight I’m going to be hosting a Master Class on passing the PANCE. If you don’t have your spot reserved yet, get over to physicianassistantexamreview.com/masterclass. It is 100% free and I’m going to go through 45 minutes of what I can give you in 45 minutes to help you boost your scores as much as possible. I’m going to be hosting that tonight and then again on Thursday. So there’s going to be two days, Tuesday night and Thursday night, the 14th and 16th, 8 p.m. Go over to physicianassistantexamreview.com/masterclass to register for that and save your spot and get there tonight. The other thing is that today is the opening of registration for the 33 Days to Pass the PANCE February cohort.

The cohort will begin on the 1st, but there are things we have to do beforehand. I have to get some software set up. I have to get everybody in inside. I have to get some, you know, some logistics done beforehand. So registration opens today and it will end next week. There’s a finite period there. I have to get everybody in and get everybody started before the first.

The results for this program have been nothing short of phenomenal, helping students move their PANCE scores after getting scores lower than they had hoped for, helping students pass end of rotation exams when they were struggling to do that before, helping didactic students get further in their student journey than they thought they were capable of. So I’m really excited to be hosting the first cohort of 2025 and getting that out there. You can find out more information and register at physicianassistantexamreview.com/33. Just the number is 33. And that will take you to the page. If you have any questions at all, any concerns, let me know if you have concerns about timing of the program, when it fits into your schedule, whether you should do it now, whether you should wait. Just shoot me an email.

No problem. I’d be happy to answer any questions. And likely next week sometime I will be doing Q&A sessions to answer any of those questions that you have. Or maybe I’ll even bring some prior students onto those calls and host a Zoom call. That way you can ask questions directly of me and directly of previous students. So keep your ears peeled for that. If you’re not on the email list, you might miss that.

So definitely go over to physicianassistantexamreview.com and get onto the email list. You’ll get all that information.

All right. Without further ado, let’s jump into the third and final part of cerebrovascular issues for the neuro section of the blueprint. So for our priming questions, we’re going to begin with a few. And again, as always, these are designed to get you thinking, designed to get you involved in the process. My goal isn’t just to cover the material. Your faculty does an amazing job of that. You don’t need me just to cover the material.

What we’re doing here is spending a little extra time to get it to sink in, to get it to solidify in your brain. So that’s what these priming questions are for. I’ve come across numerous studies that talk about learning or answering questions and thinking about the material before you receive the material, before you sit through a lecture, before you sit through and listen to a podcast, is an effective way to almost build, let’s say, shelving out to store the information on. It sort of creates this, I’m missing the word here, creates this structure for you to add information to. So that’s why we do the priming questions.

Okay, so which physical exam finding suggests orthostatic hypotension? Which physical exam finding suggests orthostatic hypotension? What are the components of Cushing’s triad? What test is diagnostic for vasovagal syncope? What test is diagnostic for vasovagal syncope? What initial lab should be checked in all comatose patients to rule out a reversible cause? What initial lab should be checked in all comatose patients to rule out a reversible cause?

In this case, I just want one. What symptom distinguishes syncope from seizures in the patient history? What symptom distinguishes syncope from seizures in the patient history?

All right. So, now that we’ve got that all set up and ready to go, we’re going to start with syncope. Syncope is a transient loss of consciousness. So, person passes out, right? This is due to global cerebral hypoperfusion, so you’re not getting blood flow to the brain. This usually has a rapid onset, it lasts a short period of time, and the patient has a spontaneous recovery.

Now, the most important thing here, and I kind of thought about this for a minute while I was setting up this section, is why are we covering it under cerebrovascular? Well, one of the reasons is it’s a key differential, right? When you’re looking at people with strokes, TIAs, and seizures, you also need to just be thinking about syncope. So that’s why I think they put it here and it makes sense. There’s no problem putting here. We’ll probably cover it in cardiovascular as well or some other areas, but I think this is a fine place to put it because we’re always comparing things, right? And so this case, we’re comparing strokes, TIAs, and seizures with syncope.

So keep that in mind as we move through this section.

All right, so what causes syncope? So you can get some vasovagal issues, you can get some orthostatic hypotension, or other cardiac-related syncope. Clinical presentation, dizziness, lightheadedness, nausea, pallor, diaphoresis. Certain things that might bring it on more could be prolonged standing. Or exertion.

Now, here’s the key you can get for differentiating, right? Is you’re not going to have focal neurological deficits like you would in a stroke or a TIA. So you’re not going to see any of those neurological findings that you might see in a stroke or a TIA. So that’s going to be what we’re looking for. The difference is there. I just realized as I’m going through the notes that I said, you know, preceding symptoms, and I gave you dizziness, lightheadedness, nausea, pallor, diaphoresis. These are all things that might come before syncope, right?

But the syncope kind of is the clinical presentation. Just sort of stumbled through that in my notes. I hope that was clear. Lab studies and physical exam findings. Well, our initial focus here, and this is really important, is to rule out any life-threatening issues. So if you have a patient who passes out in front of you, you’re not thinking vasovagal at first, right? You’re thinking arrhythmias, MIs, things that would decrease blood flow to the brain and cause a bigger problem.

So I need to rule out life-threatening causes first. That’s the first step. A few years ago, I was at one of my son’s baseball games, and one of the players on my team, we had just won districts actually, which is kind of a big deal. We were celebrating taking pictures out by the scoreboard. And one of the grandmothers of our players, someone who I’ve known for a very long time because I’ve coached her son for years and years, or her grandson for years and years, and she was very involved. She actually went down during one of the pictures that we were taking, and there was a lot of commotion and everyone was freaking out. And the end result was it was I and a firefighter, the fireman was actually far superior to me as far as crowd control and dealing with the situation.

He was fantastic. But everyone starts freaking out, right? Because they’re worried that she’s having a heart attack, she’s having some structural issues or some problem. And the answer turned out to be, we got everyone cleared out. We give everybody jobs so that they could have something to do so that they weren’t bumping into each other nervous. Obviously they wanted to be helpful, right? But everyone sort of freaks out initially.

So we kind of set it up and we were taking care of her and she was talking to us at the time. So I knew that things were not going to be, you know, not perfect, but that we were heading in a good direction. Well, it turned out she had tripped and she was saying that she couldn’t breathe, couldn’t breathe. And that was why everyone was kind of freaking out. Well, what had happened is she had tripped over someone’s foot next to her in the picture. And when she fell, she had cracked a rib. So she was having pain with inspiration.

Now, this isn’t exactly a syncope story, but it’s just a look at the whole picture kind of story, right? She wasn’t having an MI. She didn’t have syncope, although at first it seemed like she did. But after getting the story and taking some time to assess the situation, it became obvious that it wasn’t a syncopal episode, that, you know, that there was an other underlying cause. So all I’m trying to say is look at the whole picture, especially when you’re treating your patients. Don’t jump to conclusions out of fear, but definitely have that differential in your head and be looking for those life-threatening issues because that’s what we’ve got to take over the fastest.

All right, let’s keep going here. Vital signs. Obviously, you’re going to want to do an orthostatic blood pressure for heart rate changes, a drop in systolic BP greater than 20 millimeters of mercury or diastolic 10 millimeters of mercury suggestive of orthostatic hypotension. Cardiovascular exams. You’re going to be looking for arrhythmias, irregular for arrhythmias. You’re going to be looking for murmurs. You’re going to be looking for signs of heart failure.

So what are some signs of heart failure? If I pause here and just say, okay, what are some signs of heart failure? Do they come to mind? How about JVD and edema?

Next, we’re going to be looking and assessing for neurological symptoms.

Now, we’re not going to get them, right, in just a single episode. So we’re going to, but we’re going to be looking them because we’re going to be ruling out a stroke or a TIA. We’re going to be giving looking for reasons, in this case, to not do a CAT scan or an MRI. Right? On that person’s grandmother, I wasn’t concerned about doing a CAT scan or an MRI because it didn’t look like a stroke. She didn’t have any neurological deficits. Normal findings in most syncope cases, unless there’s an alternate diagnosis.

So, you’re also going to be looking for signs of dehydration. This can cause syncope, right? So, dry mucous membranes, delayed cap refill, decreased skin turgor, that kind of thing. And then, of course, head trauma would be another.

All right. As far as studies go, so you could do an ECG to evaluate for those arrhythmias. You could do a tilt table test, a diagnosis for a vasovagal vasovagal syncope, orthostatic vitals like we talked about, a Holter monitor or echo to look more into cardiac issues. And then lastly, like I said, is imaging. But we’re really not going to do a CT or an MRI here unless there are those focal neurological deficits.

Now, treatment for syncope. If it’s vasovagal, you’re going to talk to the patient about avoiding the triggers, the longstanding. You’re going to increase salt and fluid intake and consider beta blockers for refractory cases. Orthostatic hypotension, you’re going to think about hydration or slow positional changes, compression stockings, those sort of things. If it’s a cardiac issue, obviously we’re just going to address that cardiac issue.

All right, let’s talk hydrocephalus. Hydrocephalus is an excess cerebral spinal fluid accumulation in the brain’s ventricles leading to increase intracranial pressure. So we get an increase in cerebral spinal fluid leading to an increase in intracranial pressure.

Now, this too, I was a little bit unsure of how to put into this section, right? So I could, because usually for me, there are two places to think about it. One is in peds when you have a newborn or an infant and two is in adults. So it’s sort of split. But I understand it also makes sense to cover it here. So we’re going to cover it here. So I’m going to tackle both because it’s not a whole lot of information.

So I think you can handle it. Clinical presentation. In infants, you can get an enlarged head circumference or seen at a well-child visit. You can also get difficulty feeding, persistent irritability, or developmental delays. You can also get sun-setting eyes, which is just a downward gaze.

Now, in adults, you can get a gradual onset of difficulty walking, described as imbalances or shuffling gait, complaints of worsening memory or confusion.

Now, this is key. It’s often mistaken for dementia. I actually worked with a neurosurgeon from time to time. I work in a surgical practice where I work in multi-specialties, so we help anybody who needs who needs help, orthopedics, plastics, ENT, GYN, everything. And one of the neurosurgeons I used to work with did a lot of work with hydrocephalus patients. And he would talk about how he would have these patients who were very demented or couldn’t walk or were struggling. And we’ll get to the treatments later, but he would put in a VP shunt and drain the fluid, that’s excess cerebral spinal fluid, and the patients would recover dramatically.

And everyone was kind of stunned because they’d… they’d miss this diagnosis. So something to consider when you have a patient who is expressing these symptoms. You can get new or worsening urinary incontinence. And then in a more acute setting, you get sudden severe headaches and nausea and vomiting, altered mental status, including confusion and lethargy. And that’s how he would describe these patients would be very lethargic, not real responsive. And once he decreased that pressure, just the dramatic difference that they would have.

Lab studies and physical exam findings. In infants, we’re talking about an enlarged head circumference, bulging fontanelles, split cranial sutures, and sun-setting eyes, right? So just think about what that would look like to someone whose cranial sutures aren’t closed yet, right? So that’s how that would be. Adults, signs of increased intracranial pressure, so papilledema, cranial nerve palsies, a Cushing’s triad. So that’s hypertension, bradycardia, irregular respirations. Cushing’s triad, hypertension, bradycardia, irregular respirations.

You can get gait instability. Cognitive impairment or mental status exam is what you’re going to want to do to check on them. Imaging. So you can do a CT or MRI to look for enlarged ventricles with or without signs of obstruction. And you can do an ultrasound in infants. I didn’t think about this, but it came up in my research. You can do an ultrasound in infants with open fontanelles.

Additional studies, you could do a lumbar puncture. This isn’t going to be done in acute increased intracranial pressure, but it can be diagnosed, diagnostic, and relieve some symptoms a little bit. Treatments, acute management is going to be emergency external ventricular drain to reduce intracranial pressure, mannitol or hypertonic saline for temporary ICP reduction. We talked about those previously, right, when we were talking about strokes, that mannitol or hypertonic saline to decrease intracranial pressure. So that just continues here. If you understood it there, it should make sense as we move on. So in chronic management though, so not under an acute situation, we’re going to do a VP shunt.

So a ventricular peritoneal shunt. This is standard treatment for long-term CSF diversion. So this is a tubing that you put into the ventricle within the brain, and you run it down into the peritoneal space and you drain out the fluid. And there’s a little valve inside of that drain that can be adjusted as to how much gets drained. And it’s a little magnetic valve. It’s kind of cool so that you can adjust it in the office. And actually my nephew who has cerebral palsy also has one of these.

They put that in him when just after he was born and they’ve had to replace it a handful of times, but that’s what he has to manage the cerebral spinal fluid inside of his ventricles.

Now, one thing to note is you can get what’s called normal pressure hydrocephalus. So this is where the ventricles are. There’s extra fluid in them, so they’ve expanded and they’re enlarging, but the pressure is normal, so it’s easier to miss. And largely that’s what we’re talking about, that prolonged longer symptoms is that normal pressure hydrocephalus. Again, here it’s going to be a VP shunt is going to be a way to handle that. So, always, always, always suspect in older adults who are demonstrating the symptoms of urinary incontinence, dementia, shuffling gait. What else did we talk about?

We talked about irregular respirations, bradycardia, hypertension, worsening memory, confusion, dementia. Think about normal pressure hydrocephalus and definitely take that into consideration. Something else to think about is, and this has happened, is if you have a patient who has a VP shunt, and they suddenly develop these symptoms, well, that shunt needs to be evaluated, right? And maybe that valve needs to be adjusted or something else needs to happen, that they’re having some kind of problem with that shunt. So keep that in the back of your mind. Probably not going to come up on your exam, but something to keep in your head.

Let’s talk about comas, and then we’re going to wrap up this section. Comas is a little bit longer than I was expecting it to be because it pulls from a lot of different areas. So a coma is a state of unresponsiveness where the patient cannot be awakened, lacks awareness, and does not respond to external stimuli. Results from widespread cortical dysfunction, brainstem damage, or both. Common causes include metabolic derangements, structural brain damage, or diffuse neuronal dysfunction. Clinical presentation, a patient is unresponsive and fails to react purposefully to verbal commands, physical stimulation, or environmental cues. So they’re just not responding in a normal fashion.

History, if you’ve got a witness, this could be a sudden collapse, gradual decline, or there could be other symptoms that went along with it like a fever, seizures, or recent trauma, right? So those are all pieces of the puzzle you’re going to want to put together. If you come across a patient in a coma, if you’re going to reverse these things, it’s nice to have this information in order to know where to go.

All right, just like we talked about with the syncopal episode, your first thought on a patient who seems to be in a coma is going to be focused on stabilizing airway, breathing, and circulation, right? We want to make sure that they survive. So we want to make sure that, and just probably should in a syncopal episode as well. So there’s that. Physical exam. So we’re going to do neurological exam on these people, right? So we’re going to start with Glasgow’s coma scale.

This is a tool for basically putting a level on the state of consciousness that a patient is experiencing. So there are three pieces to the Glasgow Coma Scale. It’s eye-opening, verbal response, and motor response. And you score their response. I’m going to go through how in a second if you haven’t heard this before. I’m going to go through how you score it in just a second. But you get a point for each one of those.

So eye-opening, verbal response, and motor response. So the scale goes from three to an upwards and upward end of 15.

Okay. 13 to 15 is mild brain injury or fully conscious. 9 to 12 is moderate brain injury. And less than 8 is severe brain injury often indicates the need for intubation and close monitoring.

So let’s run through the different pieces here. So for eye opening, you can have no response, which gets you one point. If they open their eyes in response to pain, that gets you two points. If you’ve opened your eyes in response to a verbal command, it’s three points. And if you have spontaneous eye-opening, it’s four points. Verbal response is on a similar idea, right? So no response is one point.

If they respond to incomprehensible sounds, that’s two points. If they respond with inappropriate words, that’s three points. If they respond with confused conversation, that’s four points. And if they’re oriented, that’s five points. So no response is one, just sounds is two, words, but they don’t really make sense is three, they’re participating in the conversation, but it doesn’t really make sense is four, and then oriented is five. This is going to be hard to remember from this, you’re going to have to go back to the website. If you go to physicianassistantexamreview.com /, what is this, 126, you’ll be able to find the notes for this and see these, it’ll be a lot easier for you to remember them.

Motor response. Number one, you get one point for, you guessed it, no response at all. You get two points for decerebrate posturing, so extension to pain. Extension to pain is two points. Decorticate posturing is flexion to pain. You get three points. If a person withdraws from pain, that’s four points.

If they can localize the pain, that’s five points. So if that’s just withdrawing from that particular pain set rather than a whole body reaction, and six is they can obey commands. So you can see you thought that less than eight seemed a little bit of a tough score. But the reality is, you should be scoring higher than eight on this test here, right? So go back, look these over. This is definitely something that I think you should memorize, because it’s just a straight memorization question, right? It’s it’s kind of tough, and it stinks.

But that’s really what it is. This to me is memorizing a list. Unfortunately, not my favorite activity, not the best way I think to learn. But in this case, that’s what it is. So it’s that Glasgow coma scale. You get a point for eye opening, a point for verbal responses, and a point for motor responses on that 3 to 15 scale. 13 to 15 is normal or very minor injury.

9 to 12 is moderate brain injury.

Okay, in addition to that, a couple things you should know about comas. So you want to look at their pupils as well, right? So a fixed and dilated pupil means you’ve got a brainstem herniation. Things are bad. Pinpoint pupils are pontine damage or opioids. So opioids is a big one, right? So it’s definitely something you should know.

I would 100% know that, mark that down, highlight it, make a flashcard about it, something. Pinpoint, pupils, opioids. Corneal reflexes, if they’re absent, it indicates a brainstem dysfunction. Motor response to pain, like we said, if it’s the decorticate posturing, it’s cortical damage. If it’s the decerebrate posturing, brainstem damage, that’s where you get really low on that scale, right? And if they don’t have a gag reflex, you’re looking at brainstem involvement. You’re going to be looking as well as we’re talking about physical exam findings for any signs of trauma like fractures, bleeding, bruising, etc.

You’re going to be looking for needle marks, perhaps, signs of meningitis or sepsis, those sorts of things. As far as imaging goes, we could do a CT or an MRI to rule out a stroke or a mass lesion or a herniation. We could do labs, right? So what’s the first lab we’re going to get on someone who appears to be in a state where they’re unconscious and unresponsive? Well, to me, it’s going to be that blood glucose, right? Because you can get there with hypoglycemia and it’s extremely easy to reverse.

Next, this might be a toxicology screen. You want to do an ABG for hypoxia, hypercapnia, and metabolic acidosis. You’re going to get some electrolytes and check your renal functions. And then you can also do an infectious workup, right? Because we’re going to want to know if it’s meningitis, encephalitis, those sort of things that can cause this problem. So you might want to do a lumbar puncture and some blood cultures if you have a fever that went along with this or some other symptoms or signs. You could also do an EEG to rule out status epilepticus.

And you might want to monitor the intracranial pressure depending on where you’re going, what you’re thinking, right? Because we’ve talked a lot about that. Treatment, what are we going to do about this, right? So, first, like we said, we want to make sure we’re watching our ABCs: airway, breathing, circulation.

Now, intubation may be necessary. So, we need to be paying attention to this, right? Said below an eight, we need to be concerned that their airway might need to be protected. Next on our list, we need to be thinking about reversible causes. So, this strikes me as being very much like ACLS. We want to be looking for these immediate issues. So, what are our reversible causes?

Well, like we said, correct hypoglycemia with dextrose, that’s easy, that’s fast. Administer naloxone if opioid overdose is suspected. Narcan, right? If we have find an electrolyte imbalance, so we can treat that. So if you’ve got hyponatremia, hypercalcemia, whatever it is, and if it is a seizure, if you discover that, then we can use antiepileptics. There we go. That’s the word I’m looking for.

Lastly, we can, or not lastly, but we can move on to reducing intracranial pressure.

All right. By now, hopefully, you know our standard treatments for that, hypertonic saline and mannitol. You may need a surgical intervention for mass lesions or hemorrhages. And then if we do discover meningitis or encephalitis, we’re going to be giving antibiotics, right? And if this winds up being a hemorrhagic stroke, we might want to reverse anticoagulant. So it’s all these different pieces of what’s causing this, right? The coma isn’t the disease, just like syncope.

These aren’t the diseases. They are the symptoms or the manifestation of these disease states. So it’s important to understand what’s going on underneath the surface, what the diagnosis is so we can treat it. Another story pops into my head where I had a patient when I was back in foot and ankle and the doc I was working with, he would crack me up. I thought he was hysterical, but we had a patient come in and he’s like, okay, we need to get, you know, I’m not sure exactly what’s wrong. So we’re going to get an MRI so then we can make some better decisions. And she’s like, okay, so what should I do now?

And he’s like, well, we’re going to get an MRI. And she’s like, well, what should I do now? And he’s like, well, we’re going to get an MRI so I can find a diagnosis because I can’t treat what I don’t understand. I can’t treat something I don’t know. So when we talk about treating a coma, we’re talking about treating the underlying disease, what caused the patient to be in this state of unresponsiveness. So as we’re thinking about this, understand the symptoms, understand the progression, understand the pupillary responses, understand Glasgow’s coma scale, and understand reversible causes. To me, that’s where your questions are going to come from, or at least where they can largely come from.

All right, before we answer our priming questions, let’s talk a little bit about our study tip for this week. As you know, I love to conclude these. I’ve gotten great responses from people. Some people think that the content is the key to these episodes, but to me, it’s honestly the content is almost there to get you to the study tip. The study tip here for today is going to be about music you listen to while you study. I have a lot of students ask me questions about this, especially during the 33 Days program. What type of music should I use?

Some people tell me not to use music. Some people tell me to use music. And there’s a lot of different back and forth on this. I think this is a personal decision, something you need to test out. For me, I need to have sound, I need to have music, I am far too distractible to not have sound, especially if there’s anyone else in the house. I was actually just traveling over New Year’s, and we were with my sister-in-law and her family, and I would get up early to do some work. I love getting up at like 5, 6, or 7, while everyone else is sleeping until 8, 9, or 10, and the house is still dark, and it’s quiet, and I can really focus in and get my work done.

And then I have the rest of the day. So if I can get two, three, four hours in before anyone else is up, then I’m killing it. But what I found is without the, you know, there was a lot, how do I explain this? There was a lot of wind where we were. We were right on Lake Ontario. Like we rented a house right on the lake. We were up visiting my nephew in college over the break because he plays basketball and there’s no one else at the school.

So he needed some company. So we went up over New Year’s and visited him. And the house is right on the lake. And so it was incredibly windy. And I was loving it because I liked that sound effect. The problem is as soon as I heard someone moving at all upstairs, I lost my concentration. I couldn’t even think a little bit.

It just goes right through me. So the point in all this is I love having sound and music to keep me from being distracted by the world around me. I use noise-canceling headphones. I love the AirPods with noise-canceling. They finally fit in my ears. The old ones never did. You can use whatever ones you like, but the noise cancelling for me is key.

It’s a really big factor. And then what I use is something sounding really full, something that fills all of the sound. So, if I’m listening to music, it doesn’t work great because one, the music can be distracting, but two, there’s quiet points in the music, and then I hear the other things in the house. So, if I hear, for example, while I’m working in my office at home, if I hear my wife talking to my kids or something I just start to think about what they’re doing and what they’re talking about and how this works, or if I’m at a coffee shop, same thing. If I can overhear the conversation next to me, well, now I’m eavesdropping on that conversation and I’m not getting anywhere. So I find that noise-canceling headphones are key and then full sound. So something really, really full.

So I actually use coffee shop sound. I use a company called Focus at Will and they put together a fantastic couple of tracks that are just coffee shop noise. They’re really clean, really good, really easy to get into. And I just let them run. Another one I’ve been using more recently and spending a ton of time with is just on YouTube, looking for Tibetan bowls, so singing bowls, but with rain sound behind them. And that rain sound fills out the whole background, right? So that so nothing gets into my ears, that’s not being distracted by that rain sound.

And then the bowls seem to help for whatever, whatever reason. And I’ve been loving that. The key is, though, if you’re going to use YouTube, be very, very careful that you don’t wind up watching cat videos when you’re supposed to be studying. So I have a link in my favorites. When I open Safari, the very first tab, the little button that shows up on my home screen is a link directly to that. I was going to say playlist directly to that video, I guess you’d call it directly to that video, because I don’t want to see anything that’s suggested for me, anything that’s interesting for me to get lost down a rabbit hole for. I have that really dialed in.

All right. All right.

All right. So, now, I so for me, it works best to use some type of music to help me study. I know some people will say they don’t want it because on the PANCE, you won’t be able to have music. So, how does that work? I agree. But the deadening effect in that room, they have the sound deadening systems in place so that you don’t hear people moving around. You don’t hear people chewing on their pencils.

You don’t hear people tapping their fingers. And that, to me, is super distracting. So, that’s what I’m trying to avoid with this with the sound, with the music. And that just doesn’t happen on the PANCE. So as much as I would wish I could study in exactly the same environment and use the same tools, this works really well.

All right, let’s talk about our priming questions. Which physical exam finding suggests orthostatic hypotension as the cause of syncope? Hopefully this is pretty low-hanging fruit for those of you who have covered this before. A drop in systolic blood pressure of 20 millimeters of mercury for systolic and 10 millimeters of mercury for diastolic. What are the components of Cushing’s triad? Hypertension, bradycardia, and irregular respirations. These indicate increased intracranial pressure and possibly brain herniation.

What test is diagnostic for vasovagal syncope? This is just a really straightforward question, right? One-to-one. A tilt table test is the answer. What initial lab should be checked in all comatose patients to rule out a reversible cause? So what’s the initial one? What’s the easiest one to find, the easiest one to resolve?

In this case, it’d be blood glucose is what I was looking for. Certainly there’s a laundry list of answers here, but that’s the one I was looking for. What symptom distinguishes syncope from seizures in a patient history? What symptom distinguishes syncope from seizures in a patient history? The absence of a post-ictal state. So, that would indicate syncope.

All right. Fantastic. That brings to the end of cerebrovascular. Finally, we’ll be moving on next week. We’ll still be in neuro, but at least we’ll be moving forward. Not that we’re not moving forward. We certainly are.

But we’ll be moving in a direction. So, oh, before we go, again, just a reminder, tonight, physicianassistantexamreview.com/masterclass, share it with your friends. Please come, it’s going to be super helpful for you. We’re going to spend 45 minutes. I’m going to give you everything I can as far as passing the PANCE goes. Sign up there, register there. You can come either tonight or Thursday night.

I’d love to have you. I’d love to have your classmates, anybody who’s struggling, please pass it along to them. I’m going to cover a lot of material. It’s going to be super helpful. And if you’re looking for more, if you’re looking for, if your PANCE is coming up, if you’re struggling on your end-of-curriculum exams, if you’re struggling to stay in PA school and get through didactic year, definitely go over and check out physicianassistantexamreview.com/33 for the 33 Days to Pass the PANCE program. That’s where we’re going to get into real detail, real depth and really change the way that you do things and increase your scores.

All right. So fantastic. Until next week, I look forward to hearing from you guys, hearing about your scores, hearing about how you’re improving. And I look forward to that companion episode again next week covering the questions on this topic.

All right, take care.