126b: Syncope, Hydrocephalus, Coma PANCE Questions

Good morning and welcome to the Physician Assistant Exam Review Podcast companion episode. My name is Brian Wallace, the host and creator here. And what we’ve been doing on these companion episodes is pulling apart the information from the previous podcast so that it sticks better. The goal is to make this information part of you, part of what you think about, just like your route to school is part of you, just like making how you make dinner and how you leave the house and how you make your coffee all become part of you. They’re not things you have to think about anymore. They’re just what you do. That’s my goal in medicine for you.

And we do that with active engagement and repetition. So one of the things we’re going to do in these companion episodes is we’re going to break down the information from the previous episode into really, really tight, tiny bits. And the idea isn’t that that’s everything you need to know. The idea is, my strong belief is that if you can explain a disease with a crayon to a five-year-old, then you’re in good shape. That’s really what these episodes are about. It’s about distilling it down to the least you could get across to someone and have them understand it, or the least you need to remember in order to get a question right.

Now, that’s, again, not everything you know for sure. There’s way more. But if we can start at this tiny, tiny place and we can work to create this tiny detail, that shows understanding, and it also is a lot less to hold on to. And then you can rebuild from there. We’re also going to take some time to build up from there into some test questions and walk through those, and you’ll see how that works. So, I’m glad you’re here. Thank you so much for coming.

These are going to be a lot of fun. I think you’re going to get a lot out of them. If you get a lot out of them, please share them with your classmates. Please share them with a friend. It may be the difference in someone who’s really struggling and having a tough time getting by, and somebody who’s doing just fine. So I’d love it if you could share the show and the resources with them. That would be great.

All right, let’s jump right in. Last episode, we talked about syncope, hydrocephalus, and comas. So like I said, we’re going to start by just distilling down this information as tight as we can get it. So for syncope, one of the important things is that it is of short duration and there’s no neurological deficits. That’s how you differentiate it from all of the other things that look like syncope. Your causes are things like vasovagal, orthostatic hypertension, hypotension, sorry, and other cardiac issues. So your workup’s going to be an ECG.

Maybe you’re going to look at orthostatic blood pressure. You might do a tilt table test for a vasovagal response. And your treatment is just going to be treating that underlying issue. So giving fluids, avoiding triggers, et cetera. Hydrocephalus, key differentiation point here is that it’s increased intracranial pressure, right? That’s what we have going on. So you get things like headache, gait instability, and urinary incontinence.

In infants, you get an enlarged head, sun-setting eyes, and bulging fontanelles. For a diagnosis, we’re going to do a CT or MRI and look for those enlarged ventricles. Treatment, you’re going to do a VP shunt to get that fluid out of there. Coma. The main thing that I feel like we need to hold on to here is the Glasgow Coma Scale, and if we’re going to distill that even further down, less than eight on that scale, intubate. Right? That’s the, the little rhyme that goes, but it actually works really well for this.

The clues in the pupils, so if you have fixed dilated, you have a brainstem herniation. If you have pinpoint, you’re looking at opioids or a pontine lesion. I actually had that question. I got it right in my BLS class last week. They asked about pinpoint pupils, and I was very confident in my opioid answer, even though this is not something I deal with on a regular basis. So that was fun. Treatments here are going to stabilize ABCs for a coma, right?

You’re going to treat the underlying cause, glucose for hypoglycemia, naloxone for overdose, mannitol for ICP, et cetera, and so on. So that’s just, again, pulling that down. And what I want you to be able to create that list, right? I want you to pull that down as tight as you can. Don’t just follow what I do, but do what makes sense for you.

All right, so let’s now talk about some very tight, very short questions we can build from that. These are the kinds of things that I think about when I think about making flashcards. So something like, what key symptom differentiates syncope from a seizure? And we didn’t cover this directly here, but we covered it in the last episode. What key symptom differentiates syncope from a seizure? Actually, let’s just run through all of these like I do with the priming questions. What triad is seen in normal pressure hydrocephalus?

What triad is seen in normal pressure hydrocephalus? This one’s a little too easy now. At what Glasgow Coma Scale score is intubation typically required? At what Glasgow Coma Scale is intubation typically required? What is the first-line treatment for increased intracranial pressure in hydrocephalus? What pupil finding suggests opioid toxicity? What test is used to diagnose vasovagal syncope?

And that repetition and locking it in is how we make sure we’re building out those strong neural networks. So, let’s back up to the top. What key symptom differentiates syncope from a seizure? I would say absence of postictal confusion, of that postictal phase. What triad is seen in normal pressure hydrocephalus? Gait disturbance, urinary incontinence, and cognitive decline. At what Glasgow coma scale is intubation typically required?

Hopefully you nailed this because we just talked about it. It’s less than eight. Less than or equal to eight. What first line treatment for increased intracranial pressure? Again, pretty straightforward. Ventricular peritoneal shunt, VP shunt. What pupil findings suggest opioid toxicity?

Pinpoint pupils. And that one we didn’t talk about today, but should be on your list of things you know. What test is used to diagnose vasovagal syncope? And the answer here is a tilt table test. Those questions are designed to be rapid fire so you can get through lots of information really fast, but ask questions and use recall to pull that information back up. That’s largely what I did in order to create the book, The Final Step. I used to, when I was getting ready for my PANRE, and I put it together so that I could spend time quickly going through notes, quickly going through material.

If you’re interested in taking a look at that, it’s at physicianassistantexamreview.com/TFS for The Final Step. You can check it out there. I want to now take those questions and build them into PANCE type questions and show you how knowing those basic building blocks then translates into PANCE questions. Now it doesn’t cover, again, doesn’t cover everything and that’s not our goal. Our goal is to pick up some points. So we’re going to look at the questions we just used, and we’re going to turn them into PANCE questions, and then you’re going to see how that connection gets made, but how you can get through a ton of information with those rapid fire questions that build out.

So let’s start here. Question one. An 82-year-old man is brought to the clinic by his daughter due to progressive difficulty walking, forgetfulness, and recent episodes of urinary incontinence. So you should have alarm bells going off. His gait is described as slow and shuffling. A non-contrast CT scan shows enlarged ventricles with no evidence of obstruction. Which of the following is the next best step in confirming the diagnosis?

A, MRI of the brain. B, lumbar puncture with CSF removal. C, electroencephalogram, EEG. D, serum vitamin B12 levels. In this case, the answer is going to be B, lumbar puncture with CSF removal, because we have got normal pressure hydrocephalus. We’re going to diagnose it with a reduction in symptoms after we remove some of that CSF. The VP shunt is the definitive treatment, but that’s not in our list.

The MRI, we’ve already got the CT, so we’re happy there and so on and so forth. But you can see how we moved up that ladder, right? Question number two, a 35-year-old woman is found unresponsive with shallow breathing. On exam, she’s difficult to arouse and has bilateral pinpoint pupils. Her respiratory rate is six breaths per minute. Which of the following is the most appropriate initial management? Flumazenil, naloxone, lumbar puncture, CT of the head.

Right, well, you know, we talk about how, you know, people come to me all the time and say there aren’t key terms on the PANCE and I would argue with them and, you know, because there absolutely have to be and pinpoint, bilateral pinpoint pupils would be one of those things I would definitely hold on to. This is obviously going to be an opioid issue with our decreased breaths in a 35-year-old with no obvious trauma going on. So our answer is going to be in naloxone, right? It’s going to suggest opioid toxicity. So we’re going to use naloxone to reverse that. But you can see how that comes directly from those short, tight questions and from that short information. Question three, a 26-year-old woman presents with recurrent episodes of dizziness and lightheadedness.

She reports that the episodes typically occur after prolonged standing or emotional stress and are preceded by nausea and diaphoresis. Again, alarm bells should be going off here. She has no loss of bladder control, tongue biting, or confusion after these events. A tilt table test is performed and reproduces her symptoms with a drop in blood pressure. Which of the following is the most likely diagnosis? Orthostatic hypotension, vasovagal syncope, cardiac arrhythmia, and seizures.

Now, if you’re anything like me, you’d pick a orthostatic hypotension, but you’d be wrong because it’s vasovagal syncope. Not that orthostatic hypotension isn’t a good answer, but it’s not the best answer for what happened to this patient. We’re talking about the syncope, not the reason for it. So it’s triggered by the emotional stress, pain, and prolonged standing. It’s preceded by autonomic symptoms like nausea and diaphoresis. That tilt table test confirms it. You know, it all is very, very clear.

But to me, the tough part in this question is not picking orthostatic hypotension. I would pick that probably nine out of 10 times and be angry later on about it. Because one of the things that I was actually just reading about is the idea that we get taught in schools about right and wrong answers, right? If you do math, there’s one right answer. If you do certain problems, you get down to one right answer. In the world, there’s a difference out there between being wrong, being really wrong, being right and being really right, right? That’s a scale.

There’s a spectrum. And it’s something I struggle with because I think my first answer is always the right answer. I find the same exact thing as I play chess and I’m learning to play chess. Whatever solution to a position I come to, I assume is the correct one. Because I’ve trained myself to think there’s only one right answer when there are scales of right answers. So that’s something to consider, something I want to dive into more in the future.

All right. So those were some great questions. What I want to do next is just walk through some PANCE questions at different levels and show you how that works a little bit. So I’ve got three questions for you here, and then we’re going to be done for today. Question one, a 76-year-old man presents with worsening gait instability, urinary incontinence, and memory impairment over the past few months. A CT scan shows enlarged ventricles with obstruction. What is the definitive treatment for this condition?

What’s the definitive treatment? Acetylcholinesterase inhibitors, ventricular peritoneal shunt, corticosteroids, or levodopa. So this is pretty straightforward. You have a normal pressure hydrocephalus with that classic triad of gait disturbance, urinary incontinence, and cognitive decline. So we’re going to do a VP shunt. This should be the kind of thing that you just cruise through. Now we’re going to take it up a level with this next question.

And again, you may not know that. I don’t mean to belittle you if you don’t know that. There’s lots of things not to know, but this has all of the key terms packed into this question. It’s pretty straightforward. This is the kind of thing that you should come to quickly or you just don’t know it. That’s the way this question is set up. Now this next one is going to be slightly more complicated, slightly more thought pieces you have to put together.

A 27-year-old woman presents with episodic lightheadedness and syncope. She reports that these episodes often occur after prolonged standing or when she’s emotionally distressed. She describes a prodrome of nausea, warmth, and diaphoresis before losing consciousness. The patient denies palpitations or chest pain. After a tilt table test, her symptoms are reproduced with a drop in blood pressure and bradycardia. Which of the following is the most appropriate initial recommendation?

Okay, so this is similar to the question that we talked about earlier, but it’s not the same. This is asking you to move another step, right, up the ladder. So our choices are A, beta blocker therapy, B, increased salt and fluid intake, C, pacemaker placement, or D, anticonvulsant therapy. Again, this takes a little bit more work because you have to come to your diagnosis and then come up with what our next move is going to be. So the patient has vasovagal sympathy, syncope, and that’s our diagnosis. That’s confirmed through the tilt table test. So what’s the first line treatment there?

Well, it’s going to be trigger avoidance, hydration, and increased salt to prevent episodes. So our answer here is going to be B, increased salt and fluid intake. Make sense? Beautiful.

All right, our last one is just a little bit more mentally challenging, right? It’s a little step up the scale of difficult questions. A 55-year-old man collapses while exercising. Bystanders report that he had no preceding symptoms and lost consciousness suddenly. He regains consciousness within a minute but feels slightly disoriented. His ECG shows a prolonged QT interval. Which of the following best differentiates this condition from vasovagal syncope?

Presence of a prodrome before loss of consciousness, loss of postural tone before collapse, positive tilt table test, symptom resolution with fluids, and rest. So this is a little tougher, right? Because I don’t mean to say harder, like the content’s not harder, but the way it’s structured and the way you have to think about it’s a little bit different. And this is where I think sometimes people get tripped up and they answer questions they know the content for and they get them wrong. This is why when people come to me and they’re like, I know the content, I can answer questions when people ask me, I answer my preceptors, but I’m not getting the test scores I want. I think part of it is running into questions like this, right? So which of the following best differentiates this condition from vasovagal syncope?

Well, in this case, the answer is the presence of a prodrome before loss of consciousness. Now this patient doesn’t have that, but that’s the thing that separates it, right? Because they were exercising and they have the prolonged QT interval, it’s likely a cardiac cause, right? As opposed to a vasovagal issue. But in this case, the thing that differentiates it is that presence of a prodrome before loss of consciousness or the absence in this case. So it’s just in the wording and in the structure of it. So spending a little time.

So sometimes people think that they have knowledge gaps when they don’t have knowledge gaps. They have a missing link in the question. And I do this all the time. I miss things because I’m reading, in my case, I’m reading a little bit too fast. So I go over things a little bit too quickly and I miss some term that’s going to push me in the right direction. So there’s a lot more. The point is there’s understanding the content, there’s getting that knowledge solid and locked in.

And some of these seem pretty easy because we just went over the notes. So I think in a lot of PANCE questions. If you just reviewed that section of notes and then go over those PANCE questions, they tend to feel a little bit easier in general. But a lot of it is also just the skill and structure of going through the questions, how you do it, how you think about it. And definitely spend some time thinking about that. Since I’m talking about that anyway, the February cohort of the 33 Days to Pass the PANCE program has kicked off the students and they are doing great so far. We’re pretty early on only in day four.

Hopefully by the end of this week, they’re rocking and rolling. But I do want to just let you know that the April cohort is going to be right around the corner. I am going to be limiting access to the April cohort. I’m going to have fewer seats in that for a couple of reasons. I’m retooling some things and I want just a little bit different structure. So that group will be limited. If you’re interested in finding out early about when registration opens for that, because you definitely want to get in and save your spot, just go over to physicianassistantexamreview.com/33 and you can sign up for to get notified before the general community so you can make sure that you jump in and get your spot.

All right, cool. So, that’ll wrap us up for today. That’ll take us out on our companion episode here. In the next week, we’ll be covering cranial nerve palsies. Really excited to keep moving through neuro and get these notes to you and get them out there. So again, if you’re having if you’re getting something out of the show, definitely take some time and go over it and over it and over it and go over some of the notes and write your own questions and think about how you’re doing things and then share it all with a friend. Share your questions with a friend.

Share what you’re doing. Share what you’re thinking and share the show with a friend.

All right. Take care. Best of luck.