148 PANCE Question Walkthrough GU

Hello and welcome to the Physician Assistant Exam Review Podcast. This is a special episode for two reasons. One, we just finished GU, and two, it’s being released on Christmas Eve. So I thought we’d change things up a little bit from our normal format and cover question walkthroughs. This is important because I want you to be very, very clear. This show is not about medical facts. It’s not about medical content.

It is the backdrop for how we normally run the show is through medical content, but that’s really not what this is about. It’s about how to think, how to study, and how to perform on high-stakes exams. Our motto is think different, work different, score different. So we use medical content as the backdrop for walking through thinking, working, addressing anxiety, all of those pieces. Because to me, there’s so much more to going through PA school and getting as much out of PA school as possible than just cramming in as much medical knowledge as you can gather. PA school is designed not just to teach you the content, but to teach you a school of thinking, a method of thinking, a way of thinking, a way to take initiative. That’s actually something we look for in our students.

Are they thinking? Are they taking initiative? I’m rarely looking for do they know the facts of my surgery. Occasionally because we need to talk about it. But that’s the backdrop for what we’re talking about. I know that my students in the OR can learn about the surgery. They wouldn’t be there if they weren’t able to learn.

What I want them to show me is can they think? Can they connect dots? Can they take some initiative? And that’s a lot of why I see students struggle with the PANCE. They’ve memorized thousands and thousands of facts, but it’s those linking and those connections and those steps in their thinking that are missing or jumbled or their anxiety gets the best of them and all the things they know they can’t really get out of their head. They start to spiral. That’s why I created 33 Days to Pass the PANCE.

It was a structure to teach all of the skills that go into PA school and high-stakes exams, into learning, into test-taking, into managing anxiety. While I’m on the topic, the next cohort begins February 1st. Registration will launch in the middle of January, so just pay attention for that. But I just wasn’t really meant to be talking about that. It’s just, it’s the nature because it’s what we do here. Think different, work different, score different. That’s what 33 Days is about.

That’s what the Physician Assistant Exam Review is about.

So let’s, with that being said, let’s jump in and walk through our questions so you can sort of see what we’re talking, what I’m talking about as it relates to those.

All right. So with that long buildup, let’s start with question number one. This is all going to be in the GU system, right? So if you’ve been listening to the show, it’s going to seem a little bit easier, but I like that because we’re not talking about the content. We’re talking about the structure of the questions. We’re talking about the flow of the question. We’re talking about how you think about the questions.

So sometimes I like to do questions off of what we just learned so that we’re not so focused on the content, so that the content’s easy for us. Hopefully. Well, in this case, we’ll see how we go. A 68-year-old man presents with progressive urinary hesitancy, weak stream, and nocturia over the past year. He denies dysuria, fever, or hematuria. Digital rectal exam reveals a smooth, symmetrical, enlarged prostate. PSA is mildly elevated.

Which of the following is the most likely diagnosis? Sorry, I just noticed something in the formatting of these questions that I thought I’d fixed. Acute prostatitis, benign prostatic hyperplasia, prostate cancer, chronic pelvic pain syndrome, or bladder cancer. A 68 year old man presents with progressive urinary hesitancy, weak stream, and nocturia over the past year. He denies dysuria, fever, or hematuria. Digital rectal exam reveals a smooth symmetrical enlarged prostate. PSA is mildly elevated.

Which of the following is most likely diagnosis? Acute prostatitis, benign prostatic hyperplasia, prostate cancer, chronic pelvic pain syndrome, or bladder cancer? In this case, our answer is B, benign prostatic hyperplasia. And this is classic BPH, right? There’s gradual obstructive urinary symptoms over time, over a year, plus a smooth and large prostate. This is benign enlargement until proven otherwise. There’s no infectious process.

There’s nothing else going on here, right? They’re not talking about a fever. There’s no nodules. There’s nothing that indicates that it’s a cancer. So as you walk through these answer choices, one technique that we teach in 33 Days is to look at each and rule them out, right? So acute prostatitis, what would have to be present for acute prostatitis to be the correct answer? You’d need fever.

You’d probably have a tender prostate. You’d have dysuria. What about for prostate cancer? How would this question look if it was a prostate cancer question? Well, the prostate wouldn’t be smooth, right? It wouldn’t be soft. It’d be hard, irregular, or have nodules in it, that kind of thing.

What if the answer was going to be chronic pelvic syndrome? What would it look like? What would have to be in the stem? Well, in this case, there would be pelvic discomfort, right? And you wouldn’t necessarily, well, I guess you could have prostate enlargement, but you probably wouldn’t on your test question. What would it be for bladder cancer? What’s your number one sign for bladder cancer?

And if you don’t know it, this is something you need to learn as you do your test questions. Don’t just blast through them. What would be your number one sign for bladder cancer that’s not present here? Hematuria, right? And then maybe you’d like to see something like a smoking history.

All right, that one should have been pretty straightforward.

Let’s keep moving. A 17-year-old sexually active boy presents to the emergency department with severe left testicular pain that began suddenly two hours ago while playing video games. He reports nausea but denies fever, dysuria, or urethral discharge. Physical exam shows a swollen, tender left testicle that is high riding with a horizontal lie. The cremasteric reflex is absent on the left. Urinalysis is normal. Which of the following is the most appropriate next step in management?

A. Empiric treatment for epididymitis with ceftriaxone and doxycycline. Obtain a Doppler ultrasound before urology consultation. Attempt manual detorsion and discharge if pain resolves, immediate surgical exploration, administer NSAIDs and scrotal elevation. And the answer here, of course, is D, immediate surgical exploration, right? This is a sudden onset of testicular pain is torsion until proven otherwise, right? We’re terrified of this because it’s a life-changing and there is a time limit on it.

It’s also this sudden change. So if we’re looking at what I just talked about, if we look at our answer choices and we say, okay, what about epididymitis? Well, that’s going to be more gradual onset, right? That’s not going to be so sudden. Also, the cremasteric reflex probably would still be there. So what about a Doppler ultrasound? So yeah, a Doppler would be great, but we’re not going to delay for that.

So it’s our good answer. It’s not the best answer. And that’s what usually trips me up. Attempt manual detorsion and discharge if pain resolves. You’re really going to want surgical correction if at all possible. NSAIDs and scrotal elevation.

Now, So maybe, but we need to get this patient on the operating room table. Plain and simple. You need to understand the setting. You need to understand the severity of the issue.

All right, let’s do another one. A 42-year-old man presents to the emergency department with acute flank pain radiating to the groin. He is nauseated, but afebrile. Physical exam shows right costovertebral angle tenderness. CT scan without contrast reveals a 6mm stone in the distal ureter. Urinalysis shows hematuria, but no leukocytosis or nitrates. Serum creatinine is normal and pain improves with IV ketorolac.

Which of the following is the most appropriate next step in management. A is immediate ureteroscopic stone removal. B is start tamsulosin and arrange outpatient follow-up. C is benign empiric antibiotics. I’m sorry, not benign, begin empiric antibiotics. D is admit for IV fluids and pain control. E is schedule extracorporeal shockwave lithotripsy.

A 42-year-old man presents the emergency department with acute right flank pain radiating to the groin. He is nauseated, but afebrile. Physical exam shows right costovertebral angle tenderness, and a CT scan without contrast reveals a 6-millimeter stone in the distal ureter. Urinalysis shows hematuria, but no leukocytosis or nitrate. Serum creatinine is normal and pain improves with IV ketorolac, which of the following is the most appropriate next steps in management. Take the stone out, start tamsulosin, begin empiric antibiotics, admit for IV fluids and pain control, schedule shockwave lithotripsy. But what we have here, right?

What’s the story? What’s going on? We have a patient with a stone in his ureter, a six millimeter stone. So what’s the best process for moving that forward? We would really just want that stone to pass spontaneously at six millimeters. That would be the hope, right? That’s the hope.

So if we look at our answer choices, how are we going to get that done? We’re not really going to do an immediate ureteroscopic stone removal. Right? That’s really not necessary. We’re not in renal failure. We’ve got no pain. They’re in pain, but they’re not excruciating pain.

There’s no reason to go ahead and do that right now. The start tamsulosin as an alpha-1 blocker, That’ll help relax smooth muscles in the distal ureter. And this increases the likelihood of a spontaneous stone passage. So this is a really good option. C, begin empiric antibiotics. There’s really no signs of infection here. There’s no discussion of a fever.

There’s no discussion of any kind of other issue. D, admit for IV fluids and pain control.

Now, this isn’t crazy by any stretch, right? IV fluids is a great idea. We want that stone to move. So we’re going to hydrate, hydrate, hydrate. Pain control is a great idea. This patient’s going to have a lot of pain, right? So we’re going to want to deal with that.

But they really don’t need to be admitted under this situation. So that’s going to be removed for that reason. Extracorporeal shockwave lithotripsy. This is considered if conservative management fails or for a larger stone. So again, we’re hoping that this stone passes. So A and E here get removed because of the size of the stone and that we just kind of hope that it passes on its own. What I want you to see is how I walk through that question, the steps I take and what I’m thinking as it’s developing in front of me.

Let’s move on to the next one. A 29-year-old woman presents with two days of dysuria, urinary frequency, and suprapubic discomfort. She denies flank pain, fever, chills, nausea, or vaginal discharge. Physical examination shows mild suprapubic tenderness without costovertebral angle tenderness. Urinalysis reveals positive leukocyte esterases, positive nitrates, and more than 50 white blood cells per high power field. Which of the following is the most appropriate diagnosis? Acute pyelonephritis, acute uncomplicated cystitis, interstitial cystitis, urethritis, and vaginitis.

One more time just to refresh you, a 29-year-old woman presents with two days of dysuria, urinary frequency, suprapubic discomfort, flank pain, fever, chills, nausea. I’m sorry, she denies flank pain, fever, chills, nausea, or vaginal discharge. Physical exam shows mild suprapubic tenderness without costovertebral angle tenderness. Urinalysis reveals positive leukocyte esterase, positive nitrates, and more than 50 white blood cells per high-power field, which are the following is the most appropriate diagnosis. So, if we look at some of these, she’s denying flank pain, fever, chills, nausea, or vaginal discharge, So, although it’s not there, so we’re thinking this is probably not a pyelonephritis. If she doesn’t have flank pain, she doesn’t have fever or chills, Pretty straightforward there. You’d expect all of those things, and maybe nausea and some costovertebral angle tenderness, all of those things.

So, acute pyelonephritis is ruled out almost immediately. If we’re looking at acute uncomplicated cystitis, what are we talking about? Well, this is a presentation that is in the bladder, and has positive urinalysis, without really any systemic symptoms, right? So, that actually cues in pretty well for acute uncomplicated cystitis. This is not my favorite topic. So what I would do is I would keep going to see if I could rule in or out the other diagnoses as we go. So what about interstitial cystitis?

Well, this would be more like a chronic pelvic pain with a negative urinalysis. This doesn’t really fit for urethritis. It kind of does, but not really, especially with all the issues in the urine. So this would be associated with sexually transmitted infections and urethral discharge, which we really don’t see here. There’s no history here that would describe her being sexually active. And it says explicitly, you know, it says no vaginal discharge. It doesn’t say no urethral discharge, but those would be similar, not exactly the same, but they’d be along the same path.

Same thing with vaginitis. There’s no discharge, odor, or pruritus. So it doesn’t lead me in that direction. So even though for me personally, I wasn’t, I’m not super confident in this area. So B looks a little scary to me, uncomplicated cystitis. Sounds like it’s possible, but I’m not sure. When I go back through and I look at the other answer choices, I start to see that I really don’t have another option here.

It’s obviously not acute pyelonephritis. It’s obviously not urethritis. It’s obviously not vaginitis. Could it be interstitial cystitis? Maybe, but with that positive UA, not the case anymore.

All right, a 26-year-old man presents to the emergency department two days of gradually worsening right scrotal pain and swelling. So again, right away now, from what we’ve just talked about, we’re ruling things out in our heads, right? He’s got gradual worsening and right scrotal pain. We’re thinking possible torsion, but not really, because of the timeline. And at 26, just a little bit out of the age range, I think. He reports dysuria and urethral discharge. Again, urethral discharge.

Now I’m not thinking at all torsion. I’m heading a different direction. On further questioning, he states that he is sexually active with more than one partner and does not consistently use condoms. Temperature is 98.4. Heart rate’s 82 beats per minute. Blood pressure’s 124 over 76. And respiratory rate’s 14 breaths per minute.

So I read that and I say, okay, that all looks pretty normal. Physical exam shows an enlarged, tender right hemiscrotum with erythema. Interesting. Elevation of the scrotum partially relieves his pain. The cremasteric reflex is intact bilaterally. Doesn’t really help me too much because I already wasn’t thinking torsion. Urinalysis shows leukocytes.

Which of the following is the most appropriate treatment? Immediate surgical exploration. Well, remember, what was that for? That’s going to be for a torsion. And we’ve already said this really rules out torsion as we go through it. Ceftriaxone and doxycycline. Oral ciprofloxacin.

NSAIDs and scrotal support only. High-dose trimethoprim-sulfamethoxazole. What’s that, Bactrim, I believe? I’m correcting. So, let me run through it real fast again. I’ll speed it up a little. A 26 year old man presents to the emergency department with two days of gradually worsening the right scrotal pain.

He reports dysuria and urethral discharge. On further exam… I lost my place in the question. He states that he is sexually active with more than one partner. Doesn’t use condoms. Vital signs are normal. Physical exam shows an enlarged, tender right hemiscrotum with erythema.

Elevation of the scrotum partially relieves his pain. Urinalysis shows leukocytes. And which of the following is the most appropriate treatment. So what are we thinking here? Well, right off the bat, we’re thinking with him being sexually active, that he’s got some kind of sexually transmitted disease, right? So this presentation is really consistent with epididymitis, right? Not urethritis.

Why not urethritis? Why epididymitis? Well, because of that tender right hemiscrotum and that enlarged scrotum. So what are we going to do for epididymitis? Well, in this case, what we would do is ceftriaxone and doxycycline because we’re thinking about gonorrhea and chlamydia. What about oral cipro? Why wouldn’t we use that?

Well, it’s used for enteric organisms in older men or those with urinary instrumentation issues. So it doesn’t really cover the bugs we’re looking for here. What about NSAIDs and scrotal support? Well, we have an active infection, right? So NSAIDs and scrotal support, not really our first line. And what about our high-dose Bactrim? Not the first line for sexually transmitted epididymitis.

Pretty straightforward there. Alright let’s do another one. A 74 year old man is brought to the emergency department by his daughter because he has been increasingly confused over the past two days. She reports that for several months, he has been taking a very long time to urinate, going back and forth to the bathroom at night, and often saying that he feels the urge to urinate even after he finishes. She also notes that his lower abdomen has looked more distended. His medical history includes hypertension, osteoarthritis. Medications include lisinopril and daily ibuprofen.

He’s afebrile with blood pressure of 158 over 92 and a heart rate of 88 beats per minute. Physical exam reveals a distended, mildly tender suprapubic region. Digital rectal exam shows a markedly enlarged smooth prostate. A bedside bladder scan demonstrates 900 milliliters of retained urine. Laboratory studies show BUN of 58, creatinine of 3.1, which is increased from its baseline of 1 three months earlier. Urinalysis shows no protein and no casts. Which of the following best categorizes the cause of this patient’s acute kidney injury?

A. Prerenal azotemia. B. Acute tubular necrosis. C. Postrenal obstruction. D.

Acute interstitial nephritis, E. Glomerulonephritis. But we have an older man here who’s having difficulty urinating. He also has a distended abdomen. He’s afebrile. Has frequency in nocturia. Bedside bladder scan shows 900 milliliters of retained urine.

And he has acute kidney injury. What’s going on? Well, this is classic for a post-renal kidney injury, right? This is a post-renal issue. And you can see that because he has that super enlarged prostate on digital rectal exam and he’s retaining 900 milliliters retained of urine. So we have our cause here. We’re backing everything up from that prostate.

We can’t drain. So that’s our major, major issue. If it was a pre-renal azotemia, it would be associated with a volume depletion or hypotension, not retention. When we talk about not having any casts, then we’re kind of going to rule out acute tubular necrosis and not with the distention we’re talking about. And as soon as you talk about the prostate, it should become pretty obvious. For acute interstitial nephritis, it’s usually produced with pyuria, eosinophils, rash, or fever. Glomerulonephritis would be a cause of hematuria, proteinuria, and often red blood cell casts.

So, just completely different pictures. So, if you understand those, this shouldn’t be a huge, huge jump, and especially if they’re going to give you things like the BPH and the residual volume. The hard part comes when these are mixed in to every other topic, and you’re a little confused, and you’re not sure what’s coming next, and you’re not sure where you stand, and you’re not sure if this is GU, or if this is renal, or where we are. So, take a breath when you go through a question like this. Pick out, why are they telling me that there was a rectal exam? Why are they telling me about the residual volume? Why are they telling me about the vital signs?

Why are they telling me about the difficulty you’re in? What’s the purpose behind all those clues? Are they pointing me towards something? Are they pointing me away from something? Why are they saying that there’s no cast? Well, if they say there’s no cast, then you look in the answer choices and there are things that generally have cast, then it becomes pretty easy to put those, you know, not immediately eliminate them from the possibility, but maybe they have a very low chance of being right. So, then you double check all that stuff, but none of this should take all that long.

I’m not saying you should spend hours and hours on these questions. I’m saying as you go through them, this should be a checklist of things that you do, a setup for how you think about questions, how you move through a question, what you consider as you’re looking at it, and just having some kind of a plan of attack as you go through your test questions. I think it’s enough to listen to today. I have a couple more written here, but I think we’re going to leave it alone at that because it’s hard to hold on to all this information in your mind as you go through it without visibly looking at them. I’ll post them on the website so you can see those and the rest of the ones that I completed. So you’ll have access to those if you go over to the website and check them out there. Those will be there, free, easy, 10 questions from GU you can take a peek at.

If they’re not up yet, just give it a minute. They will be up shortly. If this episode helped, I want you to really, really understand that it’s not about memorizing the facts. It’s about memorizing the facts and knowing how to apply them, knowing how to use them. Knowing what things you need to know and how you’re going to work against each other because it’s all about taking your exams. It’s all about passing your end-of-rotation exams. It’s all about passing your PANCE.

So here at Physician Assistant Exam Review, I want you to think a little differently about how you work and then work a little differently than everyone else so that you can score differently than everyone else and what you’ve been doing. If you’ve been working hard but not seeing your scores reflecting. That’s the gap we’re looking to close. And this and so many other skills are what we teach inside of 33 Days to Pass the PANCE. You can get more information about that at physicianassistantexamreview.com/33. And until next time, keep working, keep practicing. And remember, this is about skills and skills can be trained.

All right, that’s it for today. Merry Christmas. And I look forward to talking to you guys again next week.