162: Stop Missing Vaginal Discharge & PID Questions on Exams

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 162 covering vaginal discharge, cervical disease, sexual health, and pelvic infections for your exams. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review where we look at each and every week a section of medical content a little bit differently. In a way that’s going to help you pass your exam, retain the information, do the best you possibly can on your tests. Our goal here is to get you through PA school, retaining as much as you can, learning as much as possible, and doing the best on your exams. That’s what we do here.

Everything I do is focused towards that outcome. We don’t do things by just regurgitating data. I was talking a lot with the surgeon I worked with yesterday about how we don’t do well retaining lists, and most students have always been so smart and always worked so hard that they’ve been able to survive. Then they get to PA school and the volume is just ridiculous. And they can’t keep up because the tools they use, the tactics they use just aren’t enough. It’s not even that they’re not enough. It just doesn’t make any sense.

They’re just not doing it right. The analogy I use is like a guy digging a ditch with a shovel who is struggling every day, digging ditches with a shovel, and then someone walks in and says, “Hey, I just bought this shiny new backhoe. Why don’t you give this a shot?” And it’s not that he’s not working hard. It’s not that he’s not putting in the time and effort. It’s just using the wrong tools, not the wrong tools, insufficient tools for the job, right? The overload is too much. It’s okay if all you want to do is dig a 10 foot ditch on your property and you have a shovel, great, you’re not going to go buy a backhoe, but if you have to build an entire development or a city, you’re not doing that with a shovel.

And that’s what most students are trying to do with the content that they’re learning. So here we focus on how to do it in the best possible way. So you retain more, hold on to more, do better. With actually less work, that’s the fun part, that’s the cool part. At first, when you start to change what you’re doing, it’s a little clunky, takes a little effort, it’s a little tiring. Of course it is because you’re learning a new tool. In the end that should pay off.

It should pay off dramatically for you. Our motto here is think different, work different, score different. And so we do this with each and every episode where we cover the medical content, if you haven’t been here before. But we do it with a bit of a twist. And you’ll see that as we move along today. If you want to, if you enjoy the way that we do things here, the next best step is to participate in the 33 Days to Pass the PANCE program. That’s where we go really deep into this content.

The next April cohort is up and running now. We’re on, as I’m recording this, day seven of that cohort. So it’s just starting to get off the ground and starting to run. Students are just now starting to see some effects. Like I said, things take a little while to turn around. We don’t do it in a day. So it takes about a week or so before people start to say, wow, this is really having an impact.

And that’s just at the point where we’re at. So it’s a ton of fun to see. Anyway, you can find out more about that at physicianassistantexamreview.com/33. But for right now, let’s jump into today’s priming questions. Strawberry cervix on pelvic exam should make you think of what diagnosis? Strawberry cervix on pelvic exam should make you think of what diagnosis? At what age does routine cervical cancer screening begin?

At what age does routine cervical cancer screening begin? What’s the first line treatment for gonorrhea? What’s the first line treatment for gonorrhea? What syndrome occurs when PID spreads to the liver capsule? What syndrome occurs when PID spreads to the liver capsule? That sounds terrifying. A postmenopausal Bartholin mass should raise concern for what?

Postmenopausal Bartholin mass should make you think about what concerning situation. We’re going to start with vaginitis, which can be caused by multiple things. And the way that I did this, I just grouped it all together because I think it makes more sense. Rather than separating these out, like I said earlier, I don’t like to learn in lists. We learn by looking at how they’re going to come on questions, how things are going to show up, how things are going to be put together for you either on your exams or in the office. So vaginitis we cover as a whole not separating it out. This is an inflammation or infection of the vagina.

Commonly caused by bacterial vaginosis, or vulvovaginal candidiasis or trichomonas. The way that we diagnose this is by, the way this is going to come in your test question is going to be by the vaginal discharge. They’re going to give you what the vaginal discharge looks like, smells like, the pH, et cetera. Then they’re going to ask you either what’s the treatment or what’s the diagnosis. Risk factors here are antibiotic use, corticosteroids, diabetes, pregnancy, those are all for candidiasis or point towards candidiasis as your risk factors. Multiple sexual partners are risk factors for bacterial vaginosis, and new or multiple sex partners can also be trichomonas. Clinical presentations for bacterial vaginitis, a thin gray white discharge with a fishy odor worse after intercourse.

This has minimal inflammation, not really itchy. If it is itchy, you’re thinking more candidiasis or trichomonas. Candidiasis is a thick white cottage cheese discharge with intense itching and vulvar erythema. Because it has, if it has no odor, you’re going to move away from candidiasis, right? You’re going to move towards BV. Trichomonas is a green yellow frothy discharge with an odor. So you’re going to move toward trichomonas as well.

It has vulvovaginal irritation and a strawberry cervix on exam. The question stem is going to say something like a woman with vaginal discharge. And then you’re going to have to match that up, right? We sort of said that a minute ago.

All right, so you have the physical exam findings. Now we talk about the diagnostics, the lab studies and physical exam labs and studies. So again, here’s where we separate these diagnoses. So for bacterial vaginosis, it’s going to be a positive whiff test, so you get that fishy smell with the KOH prep. Clue cells on the wet mount, clue cells is a big one. pH greater than 4.5. For candidiasis, the KOH prep shows pseudohyphae and budding yeast.

That’s another big one, right? The pH is normal. If the pH is elevated, it’s probably not candidiasis. So if it has an odor and it’s elevated, probably not candidiasis. Trichomonas has, wet mount shows motile cells. Remember, you probably looked at something similar in your labs. pH here is greater than 4.5 also.

And your nucleic acid amplification test is going to be positive. So here, if you have a normal pH, it’s candidiasis. If it’s elevated, it’s BV or Trichomonas.

So let’s move into our treatments for bacterial vaginosis, metronidazole, 500 milligrams PO BID times seven days. You can do clindamycin cream times seven days, and you don’t need to treat partners because this is not an STI. You can also do metronidazole intravaginally times five days, which is preferred in pregnancy. For candidiasis, here’s fluconazole, 150 milligrams single dose, or a topical azole. In pregnancy, you’re going to do the topical azole instead. Don’t do fluconazole, it’s teratogenic. In my head, I just kind of remember that all the antifungals are nasty, right?

So it kind of makes sense. I’m not going to, at least in my head, it makes sense where I’m going to use those in pregnancy. For trichomonas, in females, it’s metronidazole 500 milligrams PO BID times seven days, treat every partner. In men, it’s metronidazole two grams PO as a single dose is the recommendation right now. I’m not sure exactly how they would ask that, but a lot of times they don’t ask specifics on medications they may, but it’s just sort of shifting standards. What I would do though is I would mark down and see that the first line treatment in BV is the same as in trichomonas. 500 milligrams PO BID times seven days.

So if I have that information, it’s less that I have to worry about. So now I know if the pH is elevated, I’m going to be giving metronidazole 500 milligrams PO BID times seven days. Right, that’s pretty straightforward. I can lock that in. So I’m always on, like I said, I’m always on the lookout for stuff like that. That’s a big one to me. I would be marking that down on my flash cards.

So the stem is going to be something like a pregnant woman, and it’s like, how do we treat this? And you don’t want to pick fluconazole. That’s really the key here. For exam keys. Fishy smell plus clue cells plus gray discharge is BV, cottage cheese plus pruritus plus normal pH is candidiasis. What about for trichomonas, what do you think? Do you remember?

Frothy, green-yellow, strawberry cervix and motile organisms. If the pH is less than 4.5, you’re thinking candidiasis, right? We just said that. And BV is not an STI, you don’t have to treat the partners.

Let’s move on to cervicitis. This is an inflammation of the cervix most commonly caused by chlamydia or Neisseria gonorrhoeae. This is frequently asymptomatic. That’s important, especially in your test questions. It can be found on routine screening. So you need to kind of pay attention for that. Risk factors are new or multiple sexual partners.

Age under 25. That’s your chlamydia picture. History of STIs and inconsistent condom use. Untreated cervicitis can move to ascending infection, which is PID. We’ll get to that in just a second. Pelvic inflammatory disease. Our clinical presentation here is a mucopurulent discharge from the cervical os, yellow or green, visible on a speculum exam.

One of the big keys for me here is a friable cervix. So if the cervix bleeds easily, you’re thinking of cervicitis. You basically just have inflamed tissue and infected tissue. When you touch it, it just sort of gets this bleeding on it. So you’re also going to have post-coital bleeding or intermenstrual spotting, which is not really going to be menstrual spotting, but it’s going to be bleeding from the cervix. Again, many patients are asymptomatic and you’re going to diagnose this with your nucleic acid amplification test. The question stem is going to be something like a young sexually active woman with a mucopurulent discharge on speculum exam, on routine screening with no symptoms.

What do we do next? How do we treat this? So for diagnostics, it’s going to be that nucleic acid amplification test. We’re looking for chlamydia and gonorrhea here. This is the most sensitive available test. You can do a cervical swab or urine specimen. You may do a wet mount because you’re ruling out trichomonas.

If you’re suspecting gonorrhea, you may do culture and sensitivities, so you can figure out what to treat it with.

All right, as far as treatments go, this is typically empirical, at least initially, you’re going to be treating for both. The ceftriaxone 500 milligrams IM single dose is for gonorrhea. The doxy 100 milligrams PO BID times seven days is for the chlamydia. So you would go ahead and empirically treat with both of those. Now what if the patient’s pregnant? You’re going to give azithromycin. One gram PO single dose because doxycycline is contraindicated.

For gonorrhea, you’re going to give ceftriaxone, 500 milligrams IM as a single dose. Same as non-pregnant, doesn’t change anything. In this case, you’re also going to want to treat the partners because this is an STI. If you don’t treat the partners, you’re going to see this person back. So mucopurulent discharge plus friable cervix is cervicitis until proven otherwise. If it’s asymptomatic, positive NAAT, we’re still going to treat that because the asymptomatic part doesn’t matter. Empirically, we’re going to give ceftriaxone and doxycycline.

In pregnancy, instead of the doxycycline, we’re going to give azithromycin. And if this is left untreated, it can progress to pelvic inflammatory disease, which we’re about to get to in just one second.

Okay, let’s talk about pelvic inflammatory disease. PID. This is an ascending infection of the upper reproductive tract, so the uterus, fallopian tubes, ovaries, and the surrounding structures. This is usually polymicrobial. Chlamydia and gonorrhea are the most common. But you can get anaerobes or normal vaginal flora, which can also get involved. So essentially, if the patient has had cervicitis that’s untreated, that’s a risk factor, sexual partners, prior episodes of PID, and an intrauterine device will elevate the risk for about three weeks post placement of PID.

So when the patient comes in, what do they look like? What are they complaining about? This is kind of nasty. This is not a pleasant situation. Right? They have an ascending infection. The hallmark here is cervical motion tenderness.

So if you touch the cervix or move the cervix at all, the patient is in extreme pain. This is often, I remember it even in when I was in school, referred to as the chandelier sign. And that was because it hurts so much that if you have the patient up in stirrups and you touch the cervix, that patient will be jumping to try to grab onto the chandelier to get away from you. It’s that much pain. You get uterine tenderness and adnexal tenderness on bimanual exam. You can get lower abdominal pain, fever, purulent cervical discharge. And this can be pretty nasty.

I see this, I don’t treat this, but I do see the ramifications of this. I work in surgery and we do a ton of GYN, lot of laparoscopic, lot of robotic work. And I’m not going to say often, but I do see the scar tissue, the adhesions that come following pelvic inflammatory disease, just it creates a significant inflammation within the abdomen that makes everything just stuck together and a total mess for us to work with. It can be really, really nasty. Fitz-Hugh-Curtis syndrome. This is a bad, bad situation. This is perihepatitis from ascending PID.

So this is the patient presents as a right upper quadrant pain with pleuritic tenderness and pain. The patient looks like they have a liver or gallbladder problem, but the pelvic exam tells the entire story here. You want a high index of suspicion in the right population because this right upper quadrant pain is coming from their PID. This is where the liver capsule has now been infected from their pelvic inflammatory disease. So in general, you’re going to get a young woman with lower abdominal pain, fever, and cervical motion tenderness. And then you’re going to have to figure out how to treat it or what you think it is or something along those lines. As far as PID goes, there’s no test per se to find it, right?

So it’s a clinical exam. You need cervical motion tenderness, you want to find uterine tenderness, adnexal tenderness, sexually active history, that kind of thing is going to point you in this direction. You’re going to be looking for chlamydia and gonorrhea on that nucleic acid amplification test, but you’re not going to wait for it to treat this person, right? We didn’t wait for it in cervicitis, we’re certainly not going to wait for it in PID. You can do a pelvic ultrasound to look at the tubes and ovaries and see if anything’s going on if they’re thickened or fluid filled. If there’s any adnexal masses or abscesses, you may want to do that depending on the patient. They could have elevated white blood cell, ESR, C-reactive protein.

All that’s not going to be definitive, but it will push you in the right direction. Again, we’re not going to wait for cultures here. We’re going to go ahead and start treating this the minute we suspect it. If it’s mild to moderate, we can treat them as an outpatient. Again, ceftriaxone 500 milligrams IM single dose, doxycycline 100 milligrams PO BID times 14 days, and metronidazole 500 milligrams PO BID times 14 days. This is nasty, we want to get out in front of this. We may have to put this patient in the hospital if they have something like a tubo-ovarian cyst, if they’re pregnant, if they can’t tolerate oral meds, or if they are failing outpatient therapy, then we have to bring them in.

And we’re bringing them in for IV antibiotics, right? So here we’re going to do ceftriaxone plus doxycycline, or clindamycin plus gent. Again, here we have to treat the partners because we are concerned about reinfection, of course.

Exam keys. Cervical motion tenderness is PID until proven otherwise. Right upper quadrant pain in a young woman with pelvic findings, Fitz-Hugh-Curtis syndrome. This is all a clinical diagnosis. We’re going to treat them before the cultures come back. If they have a tubo-ovarian cyst, I’m sorry, a tubo-ovarian abscess, we need to admit them. If it’s left untreated, like I said, you can run into some serious issues with adhesions and messes within the ovaries and the tubes, leading to ectopic pregnancies, infertility, chronic pelvic pain, all of these things.

Like I said, it looks like they just had a massive grenade go off in their abdomens and now everything is stuck together. So you can imagine it gets much more difficult for everything to work the way that it should. Dysplasia is next. It’s abnormal squamous cell changes of the cervical epithelium, graded as cervical intraepithelial neoplasia, one, two, or three. So CIN, one, two, or three. I always struggled with this abbreviation because it didn’t mean anything to me. So if you can hold onto in your head cervical intraepithelial neoplasia, levels one, two, and three, it might be better than CIN, one, two, and three.

I don’t know, maybe it’s just me. This is generally thought to be caused by HPV, human papilloma virus, most commonly type 16 and 18. What are risk factors here? Well, again, this isn’t super complicated. Just like the rest of our sexually transmitted diseases, it’s going to be multiple sexual partners, early sexual activity. The difference here is going to be smoking or immunosuppression. There’s also the vaccination available so someone who’s unvaccinated is obviously at a higher risk than someone who’s been vaccinated for this.

Clinical presentation, this is really going to be asymptomatic. We’re going to find this on a screening. We’re not going to find it. The patient is not going to come in complaining about it. So what does diagnostics look like? Well, we’re going to do screenings once patients turn 21. 21 to 29, we do a pap smear every three years.

We usually don’t do an HPV cotest. We’ll get to this in just a second, what all this means. 30 to 65, we do a Pap smear and an HPV cotest every five years, which is the preferred route, or the Pap alone every three years. Over 65 would discontinue if we have all negative screens up to that point. A Pap smear is cervical cytology. So we’re just scraping some cells out of the cervix and taking a look at them under a microscope. That’s what a Pap smear is.

We’re finding if those cells have changes. If there are changes in some of those cells, if they don’t look like they’re supposed to, it’s really that simple. One of the things, I was on the coaching call last night with the 33 Days students. And one of the things I was talking about is how complicated we make things. I know I do. I made this so hard in my head, so difficult to understand. And the reality is, if you wanted to see if there are changes in the cells, you get a cotton swab, You rub it on the area that you want to get the cells from, and then you look at those cells on a microscope.

That’s what the Pap smear is. It’s cervical cytology. We’re looking for any abnormal cells, and we’re doing this as a screening test to see if there’s anything going on. So results can be normal, or you can get atypical squamous cells of undetermined significance. You can get low-grade squamous intraepithelial lesions, or high-grade squamous intraepithelial lesions. Again, those are long names, so it seems hard, But really you have normal. There are some changes, but we don’t really know.

There are some low grade changes, and there are some high grade changes. It gets a whole lot easier when you look at it like that. The HPV cotest is looking for the HPV DNA. It’s sent along with the Pap smear. You don’t have to do it. It’s not a separate swab. It comes off the same exact swab, so it’s easy to do.

This just gives you a risk stratification. If you find HPV DNA, you get a little more concerned. You can do a colposcopy, which is the next step after abnormal pap smear, which is just looking inside the vagina at the cervix, putting eyes on it. You use acetic acid and that will highlight abnormal areas. If it turns white in those areas, that will highlight some, if there are some of those epithelial changes. And if you’re concerned, you’re going to do a biopsy because you want a better look. So rather than just taking a couple of cells, we’re going to take a tissue sample and actually look at this thing to see what’s going on.

So this is now where we’re going to grade it. So that’s where the two different things come in where I used to get super confused and I would just go around in circles and I just would ignore this whole section because I didn’t want to learn it. It’s really not that hard. The Pap smear comes back as normal, atypical, low grade changes, high grade changes. When we have those findings, we’re going to do something about them. We’re going to get a biopsy and then we’re going to find if we have mild, moderate, or severe, carcinoma in situ. That’s it.

The biopsy is going to tell us that. If so, let’s back up. If I get CIN1, mild changes, I’m going to observe it and I’m going to repeat the Pap in a year. A lot of times this will just regress spontaneously. Your body does amazing things at healing itself. I mean, it’s hard to wrap your head around all this. And you’re probably not getting much of it in PA school, but your abnormal cells are being taken out by your immune system all the time.

Abnormal cancerous cells are being taken out by the immune system all the time. They’re present in your body, just like bacteria is present all over your body, all inside of your body. Your immune system is battling this constantly for you. So a lot of times your immune system will solve this problem on its own with a CIN1. Sometimes it can’t. Sometimes it gets out of control, and the infection or the cancer cells start to win. And CIN2 we’re going to observe in women under 25 because it will probably regress, but in women older than 25 we’re going to go ahead and take care of this problem.

If we have severe, carcinoma in situ, so CIN3 you’re going to treat this no matter what the age of the patient is. First line is a loop electrosurgical excision, or a LEEP, oh, excuse me, a loop electrosurgical excision procedure, or a LEEP. This is where you go in with a, it’s like, I’ll try to figure out how to describe this. Pretend you had a pen casing, so none of the insides in it, but inside of that pen was a stiff wire on a loop and then you charge that wire with electricity. So what you do is you put the patient into a lithotomy position, you put them in stirrups, you have the speculum so you can see, then you take this pen like device, extend that wire a little bit out that loop of wire out, touch it to the cervix and then you activate the electrocautery through it and now you burn off the tissue that you’re going after. You could also do a cone biopsy, so this is a cold knife conization. And those are just ways that you want to basically chop that tissue off and cauterize the area.

There is an HPV vaccine, so that’s not really treatment, but prevention. This is recommended through age 26. And then if you have a really big problem, you can wind up with a hysterectomy. Obviously, this isn’t the first choice, but if things get really out of hand here. So we talked about HPV 16 and 18 being your high risk for cervical dysplasia. If you have an abnormal pap smear, you’re going to do a colposcopy and then a biopsy. CIN1, you’re going to watch it.

CIN2 or 3, you’re going to treat, or observe if under 25. You’re going to do a LEEP or cone biopsy to check it out. And obviously you’re going to want them to stop smoking, but you may see that in your question stem.

All right. Bartholin gland cysts and abscesses are next and we’ll do human sexuality, and then we’re going to be done for today. Bartholin gland cysts and abscesses. So these are the glands that sit at 4 and 8 o’clock at the vaginal introitus and provide lubrication during arousal. When the duct gets obstructed, the fluid backs up and you get a cyst there. And then it gets infected and it becomes an abscess and it gets to be painful. These are not STIs.

But gonorrhea or chlamydia can be the source. But they’re often polymicrobial because it’s just trapped fluid in there. This is usually reproductive-aged women, super rare after menopause. And if it is seen after menopause, we’re talking about a carcinoma. You want to check this out. You want to be very concerned about this. Your other risk factors are STI exposures and prior duct obstruction.

So whenever you’ve had this before, it reminds me of a tubal pregnancy, previous history of one, put you at risk for another one, right? Clinical presentation, you get a cyst: unilateral, non-tender labial swelling at the vaginal opening, often found incidentally, no fever or fluctuance. Because again, this is just a little cyst, so it’s a little ball of fluid under the skin. So the patient may notice it and maybe a little irritated until of course it becomes an abscess. This is the same location but very tender and very painful. Also erythematous. You can get a fever along with this, right, because you’re fighting off this infection, but I wouldn’t say it’s normal.

The patient is in so much pain that they’re having trouble sitting and walking. Your stem here is going to be a woman with unilateral labial swelling and tenderness, usually at the four or eight o’clock posterior introitus. That’s really that location is going to be the giveaway. This is a clinical diagnosis. Yes, you can do cultures from the drained material. But again, if this is in a postmenopausal woman, you’re going to biopsy this. If it’s asymptomatic and you have this cyst there, you’re not going to go after it surgically.

You’re going to do a sitz bath, which is just a warm water soak and observation. You’re hoping the duct clears, and you’re keeping an eye on it. If it’s symptomatic, you can incise and drain it, but obviously this is a surgical procedure. This is going to be painful. Then you can take a small balloon catheter and place it in the incision to hold it open, so it drains over the next four to six weeks. If it still recurs, you’re going to marsupialize it, which is just taking out like an oval shaped window from the cyst wall so that it makes sure it stays open to drain. Cysts always do better if you can take out the cyst wall.

If you leave it, if you just open it and drain it and don’t do anything to the cyst wall, they tend to come back. Here are your exam keys again with that 4 and 8 o’clock position. Unilaterally, right? Because only one side is probably going to get an issue at a time. If it’s tender or fluctuant, you have an abscess on your hands. If it’s non-tender, it’s a cyst. So you’re going to drain it and stick a catheter in in order to help it close up.

Human sexuality and gender identity, and this is going to be mostly about, for your exam, I think, how you’re going to apply this clinically. So how you’re going to adjust your history taking and screening to the patient’s anatomy and actual exposure risk, not assumptions. So this is, I think that this is, I haven’t, honestly, I haven’t had a lot to deal with this as far as my personal exams go, but I think that’s what you’re looking at. So you’re looking at things like inclusive history taking, ask preferred name and pronouns at intake. Ask, do you have sex with men, women, both, or neither, instead of saying, are you sexually active? Those kind of things, that’s the language that they’re looking for. Ask about anatomy directly rather than assuming.

And of course, all of your screening follows anatomy, right? If someone has a cervix, you’re going to want to do a pap smear, following the guidelines, regardless of how they identify, regardless of their sexual orientation, we’re following the anatomy and treating the anatomy. You’re going to do your cervical cancer screenings. If they don’t have a cervix, you don’t have to do a pap smear. This applies to women in general, so if we do a total hysterectomy, we take the cervix out, you no longer have to do a pap smear, right? Just makes sense. I’d probably know what gender dysphoria is.

It’s clinically significant distress from incongruence between gender identity and biological sex. It’s the diagnosable condition, not the identity itself. It’s also important to point out that mental health, you’re going to be screening for depression, anxiety, and suicidality. Patients in the LGBTQ+ community often have a higher rate of this, so you’re going to want to bring it up for discussion. The question stem is going to describe a transgender patient who’s at risk, with screening and what screening applies or something about the history. The physical exam and your approach to it. That’s what I see coming.

I can’t tell you for sure because like I said, I haven’t had exposure to this as far as the PANCE goes or the PANRE for that matter, but that’s what I would be thinking about. Again, for exam keys, we’re going to look at anatomy, not gender identity.

All right, moving on. Our study tip for today, before we hit the answers to our priming questions, let’s cover our study tip for today. Our study tip for today actually comes from one of my students in the 33 Days program. And she posted something in our group, after one of the lessons in particular, that said, “I realized today that studying doesn’t have to be uniform. I had this picture in my head of what studying looked like. It was me sitting in a chair reading a book, making notes, and that is what I had identified as my image of studying. And that just doesn’t have to be the case.” And she went on talking about all the different ways she realized throughout the day that she would be studying.

All the different instances. And this is huge. If you think that all studying is, is sitting at your desk all day, you are not using the best tools possible. This is why I don’t love it when students come to me and they say, “You know what? I’m studying eight hours a day and I’m still not doing well.” Well, I don’t know what you’re doing for eight hours a day. Quite honestly, I have no idea what you could possibly do for eight hours a day and think you’re still functioning and still studying. My brain doesn’t work like that.

I’d be shocked if yours did. So what are you doing? You may be sitting your butt in the chair for eight hours a day. You may be at the library for eight hours a day, but I highly doubt you’re doing effective studying eight hours a day. So you have to think about what you’re actually doing for you, not what your friends are doing, not what your classmates are doing, not what your teachers tell you to do. Now they can all have input, but it’s a lot like my son who has a batting coach, right? He sees a guy who works with him on hitting and pitching.

He then has his regular team who the coach there wants to work on him with hitting. Then he has his national team where the coach there wants to work on him with hitting. So he’s got three or four different people giving him information on hitting. All of them are correct, none of them are wrong. There’s a hundred different approaches to hitting. There’s a million things you can work on and do. There are different systems, different philosophies, different approaches.

The same thing works in studying. There’s a million different techniques. There are a lot of different philosophies. What other people are doing and what other people are telling you to do or to try are good suggestions. But you have to understand how your brain works, how you function and apply the things that work best, test them and see. But I guarantee you, if I’m sitting with two people in the library, and if I could watch their brains over the course of two hours, they’re not doing the same things. They may look from the outside like they’re doing the same things, but they’re not doing the same things.

They’re addressing the material differently, creating images in their minds differently. They’re more or less distracted than each other. The other important key here is that studying isn’t always sitting at a desk. I was talking about this last night, I find that I’ll be working all day on something, but then on my run or my walk or in the shower or somewhere else. I’ll start realizing that my brain is subconsciously connecting all the things I was thinking about and it’s creating these paths and these patterns. And suddenly I’ll get a light bulb with how something connects to something else or how it’s going to show up or what it actually looks like. That all counts as studying.

Another thing I’ll do is I’ll put Post-it notes all around my house, especially the things I’m really struggling to retain. People ask, “Oh, how do you include spaced repetition? How am I supposed to go back to everything?” I don’t go back to everything, but I take one or two things I really need to know. And those go up on my kitchen cabinets. So every time I walk into the kitchen, I do a quick look at them. That’s called studying. That’s called reviewing.

If I’m in the car driving, I’ll turn the radio off. And I’ll try to either give a small lecture or go through a subject just in my head. This is all called studying. It doesn’t look the same for everyone. It’s not just sitting in a chair. I thought that was such a powerful idea I wanted to bring it to you guys.

All right, let’s move on to our priming answers. So for our first one, a strawberry cervix on pelvic exam should make you think of what diagnosis do you remember what this one is? Strawberry cervix on pelvic exam. This is trichomonas. At what age does routine cervical cancer screening begin? At what age does routine cervical cancer screening begin? 21, regardless of sexual activity.

What’s the first line treatment for gonorrhea? The first line treatment for gonorrhea is ceftriaxone 500 milligrams IM single dose. What syndrome occurs when PID spreads to the liver capsule. What’s it called? I know that you remember it because we just talked about it, but do you know what it’s called? Fitz-Hugh-Curtis syndrome. Postmenopausal Bartholin mass should raise concern for what?

Cancer. You’re going to biopsy this immediately. Beautiful.

All right. That takes us out today. We have a couple more in reproduction left. We’re really excited about how this is going. Really making our way through the content. If you are curious for more than this content, though, the last three episodes I went into some interviews with students who we worked with, who we taught skills to, who we had improve in the work that they were doing, really, really incredible stories in there. So if you want to go back and hit on those, I think it would do you a whole lot of good.

Like I said, that’ll lead us into the June cohort of 33 Days to Pass the PANCE. That program is good for any time during didactic or clinical year if you find yourself struggling. What we do is just present you with tools to help you to do better, to retain more, to get more out of your schooling and to pass your boards on the first try. That’s what we do in there. So that information is valuable no matter where you are. And the program is designed to fit into and around your schedule. It’s a little hard to explain, but the way that we do it, it’s done in packets throughout the day.

So you have no problem fitting this in if you commit yourself to it.

All right, this is also why here on the show, we don’t just teach medical content because it’s not the only important factor. We teach you how to look at the medical content, we teach you about test taking and about how the questions are structured and all of those different pieces. If you’d like to find out more about 33 Days to Pass the PANCE, head over to physicianassistantexamreview.com/33 to get more information there. And then I will see you guys next week, and we’ll be moving on with reproduction. Take care.