Barry Schoenborn

Article / Updated 06-20-2023

A lot of pathology and Physician Assistant Exam questions concern the small and large intestines. Here you see conditions such as irritable bowel syndrome (IBS), ischemic bowel, inflammatory bowel disease (IBD), celiac disease, and diverticulitis. Irritable bowel syndrome (IBS) Irritable bowel syndrome (IBS) is a diagnosis of exclusion after other conditions have been ruled out. It’s a clinical diagnosis — you can’t diagnose this condition with endoscopy and biopsy or barium swallow as you can with many other GI conditions, because the findings are often normal. Common symptoms include constipation, diarrhea, or a combination of both. A stereotypical candidate for IBS is someone under a great deal of stress who has problems with either diarrhea or constipation during the day. In a typical PANCE question, you get hints such as “it has been going on for a while,” “both endoscopy and colonoscopy are negative,” “and stool studies, including those for ova and parasites, are negative.” A very common syndrome associated with IBS is fibromyalgia syndrome. The treatment for IBS includes recognizing the triggers, including food, physical stressors, and psychological stressors. Many of the anticholinergic medications, such as dicyclomine (Bentyl), have been tried in treating IBS. Ischemic bowel Ischemic bowel, also known as ischemic colitis, commonly occurs in older individuals. Risk factors and medical conditions associated with ischemic bowel include atherosclerosis of the intestinal vessels, atrial fibrillation or the presence of a left ventricular mural thrombus, and a hypercoagulable state. Low blood pressure can precipitate mesenteric ischemia due to hypoperfusion of these vessels. Here are key points about ischemic bowel: The classic presentation is pain out of proportion to clinical findings. The person (usually with one of the preceding risk factors) can have diffuse midepigastric pain but also have a benign physical examination. The pain worsens after eating a meal. Blood flow to the mesenteric area increases after a meal to aid with digestion, and the timing of the abdominal discomfort in relation to eating can point to ischemic bowel. A person can have mesenteric angina or mesenteric ischemia, which is an acute problem. If a large amount of the bowel is affected, expect to see a lactic acidosis and an anion gap on the CHEM-7. If the affected person’s abdominal pain is just an episode of angina, you may not see a lactic acidosis. If findings suggest an acute mesenteric event, the best way to look at the intestine is an exploratory laparotomy. A CT scan of the abdomen and pelvis with oral contrast may suggest bowel wall thickening, but this is a nonspecific pattern that you also see with other types of colitis. That being said, the CT scan is the best test for looking at the integrity of the bowel wall. Inflammatory bowel disease (IBD) Inflammatory bowel disease (IBD) is a comprehensive term covering two different but overlapping conditions: Crohn’s disease and ulcerative colitis. Both of these conditions confer an increased risk of colon cancer. Crohn’s disease is an inflammatory condition that can involve any area of the GI tract from the mouth to the anus, although it’s usually predominant in the ileum and ileocecal region of the small intestine. When confined to this area, it’s called regional enteritis. Histologically, Crohn’s disease is characterized by noncaseating granulomas on tissue biopsy. The etiology behind the inflammation is unknown. Note that this condition affects all layers of the intestine. When it affects the small intestine, especially the ileum, Crohn’s can cause malabsorption of key nutrients, especially the fat-soluble vitamins A, D, E and K. Here are the key points about Crohn’s disease: It usually occurs in younger people, with an initial onset in the teenage years up to the mid-30s. It’s characterized by the presence of skip lesions as well as what looks like a cobblestoning mucosa on colonoscopy. Crohn’s can affect the anus. If on you’re asked about the presence of anal fissures on the PANCE, think Crohn’s disease. Treatment can involve steroids and salicylate derivatives such as mesalamine. Antibiotics such as metronidazole can be used. In advanced cases that have been refractory to treatment, you can use intravenous infliximab. Surgery is not curative in Crohn’s diseas. Ulcerative colitis (UC) overlaps with Crohn’s disease to some extent, but here are some key differences: Unlike Crohn’s, ulcerative colitis involves only the superficial mucosa, not all layers of the intestine. Ulcerative colitis doesn’t have these skip lesions; the area of inflammation is continuous. Ulcerative colitis is predominantly in the sigmoid-rectal region. In fact, a common presenting symptom of ulcerative colitis is hematochezia and a colonoscopy that demonstrates ulcerative proctitis. Crohn’s, on the other hand, is predominantly in the small intestine, is sometimes in the large intestine, and can affect the anus. Crohn’s disease has a higher rate of strictures than ulcerative colitis. Both are associated with the possible development of obstruction, abscess formation, perforation, and fistula formation. Ulcerative colitis increases the risk of developing sclerosing cholangitis. Remember Charcot’s triad of right upper-quadrant pain, fevers, and jaundice for the diagnosis of cholangitis. Ulcerative colitis treatment can consist of steroids, although it primarily consists of 5-ASA derivatives. They can be given either orally or rectally. Both ulcerative colitis and Crohn’s disease can be associated with extraintestinal manifestations, which makes sense because both conditions are inflammatory. They can be associated with eye disease and certain skin lesions, including pyoderma gangrenosum and erythema nodosum. IBD is also associated with inflammatory arthritis. IBD, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis are examples of the seronegative spondyloarthropathies. All are associated with HLA-B27 expression. The arthritis associated with IBD is thought to affect more of the peripheral joints, especially during an active flare of IBD. Which of the following conditions can be associated with caseating granulomas? (A) Crohn’s disease (B) Sarcoidosis (C) Ulcerative colitis (D) Tuberculosis (E) Silicosis The correct answer is Choice (D). Tuberculosis is associated with caseating granulomas.

Cheat Sheet / Updated 04-27-2022

Grasping some technical math basics can simplify everyday situations faced by many professionals and even non-professionals, including having to solve word problems, calculate tips, make change, or match American and metric measurements.

Cheat Sheet / Updated 04-13-2022

When you're preparing to take the PANCE or PANRE, you may feel like you have to know an endless amount of information. How will you ever remember all the details of so many diseases and conditions? Here, you can review some useful mnemonics that will not only help your recall as you prepare for your physician assistant exam but also improve your clinical acumen.

Cheat Sheet / Updated 02-28-2022

Using real-life math can simplify everyday situations. Math comes in handy every time you take a trip, go shopping, or do projects around the house.

Cheat Sheet / Updated 01-20-2022

No matter what initials you have after your name (RN, CNA, PA, and so on), you can bet you’ll see math on a daily basis if you’re going into (or are already in) a career in the medical field. Grasping some medical math basics — such as how to break down medical dosage problems into steps and use conversion factors — can simplify everyday situations all health care professionals face. In addition to just knowing math, you’re going to need to know how to read and interpret doctors’ orders, and spot when there’s potential trouble.

Article / Updated 05-13-2016

A common scenario you deal with clinically and for the Physician Assistant Exam (PANCE) is inadvertently finding a lung lesion on a chest radiograph. You’re looking for something, and bam! There it is. What do you do about it? You assess the lesion on the radiograph: Check the other lung findings to make sure that you’re just dealing with a pulmonary nodule. Other lung findings should be normal. Examples of abnormal findings include the presence of atelectasis or a recurrent pneumonia that won’t go away despite repeated treatment with antibiotics. The presence of adenopathy, especially hilar adenopathy, should be inspected on the chest radiograph. Know the size of the lung lesion. The number 3 is the key. If the lung lesion is < 3 cm, you likely have a lung nodule. If it’s > 3 cm, you’re likely dealing with a lung mass. The larger the lung lesion, the more likely that you’re dealing with a malignancy. Look at the edges of the lesion. A lung malignancy has irregular or spiculated borders. Benign lesions tend to have smooth edges. See whether the lesion contains calcium. More often than not, calcification suggests a benign lesion. In fact, calcification has many benign causes, including old, healed infections or reaction to a foreign body. Granulomas are a perfect example of a nonmalignant calcified lung lesion. However, if the calcification is irregular or eccentric, there’s a higher chance that you’re dealing with a malignancy. If all else fails and you need a better assessment of the solitary nodule, obtain a CT scan. This step may or may not be necessary. After you’ve looked at the characteristics of the lesion, look at the characteristics of the person. Is he or she old or young? A smoker? An older person who smokes has a higher chance of malignancy. You can watch people who are at lower risk with serial imaging, but for those who are at higher risk, you may need to get a biopsy to find out what you’re dealing with. You’re evaluating a 55-year-old man who presents to the ER with hemoptysis. He hasn’t been feeling well for a while. He says he has intermittent episodes of dizziness and diarrhea that comes on for no reason. He feels flushed. This has been occurring for a few weeks. You obtain a chest radiograph, and it shows a tumor located on the right mainstem bronchus. What does this lung mass likely represent? (A) Small-cell lung cancer (B) Legionellosis (C) Tuberculosis (D) Carcinoid tumor (E) Pulmonary embolus The correct answer is Choice (D). Carcinoid tumor is a neuroendocrine tumor that, although not aggressive, is treated like a lung mass. Some patients can have the symptoms mentioned in the question, including dizziness, diarrhea, and flushing, because the tumor secretes serotonin. A CT scan is used for staging, because the most common place of spread is to the liver. The treatment is surgery.

Article / Updated 04-25-2016

Many household projects require that you be able to calculate area or volume. Whether you're painting your kid's room, mulching your flowerbed for the winter, planting grass seed in the spring, or tackling any other project for which you need to find out how much of something you need to cover, knowing how to figure area and volume is a time- and money-saver. Calculating area To calculate area, you simply use this formula: area = length × width a = lw From there, you can get the other information you need: Figuring how much seed you need: Use the area formula to calculate the area you want to cover and then calculate the number of pounds of seed you need. Seed companies indicate how much coverage a pound of seed gives you. Simply divide the area you need to cover by the amount of area that 1 pound of seed covers. For example, if you want to cover an area of 1,625 square feet, and 1 pound of seed covers 600 square feet, you need about 3 pounds of seed (1,625 divided by 600 is 2.7) Calculating area to be painted: You can calculate the area of each wall and then add the values together, or you can determine the perimeter of the room (add the length of each wall) and multiply that value by the room's height. A room that has a 42-foot perimeter and 8-foot ceilings has an area of 336 feet. Calculating how many square yards of carpeting you need: First calculate the area of the room and then convert that number from square feet to square yards by dividing the area by 9 (a square yard is 3 feet wide and 3 feet long). Calculating volume When the area you want to cover has depth as well as height and width, you need to determine volume rather than area. Mulching a flowerbed is one such project: To protect your flowers, you need to spread a few inches of mulch over the whole bed. To calculate volume, you use this formula: volume = length × width × height v = lwh With that info, you can then do additional calculations to figure out how many bags of mulch to buy. Say, for example, that you want to cover 6.68 cubic feet with mulch (that's the volume you need for a small bed, mulching to a depth of 3 inches). Simply divide the volume you need by the number of cubic feet in a bag of mulch. If each bag holds 3 cubic feet, you need 2.23 bags. So buy 3 to be safe.

Article / Updated 03-26-2016

If you’ve ever had to match American and metric measurement units, you know direct comparisons of these unit systems can be tricky. If you need to know the metric equivalent of an inch, for example, or the American equivalent of a kilometer, use the following table to help you make a proper comparison between the two systems of measurement. American Length Metric Length * millimeter inch centimeter (0.4 inches) foot (12 inches) * yard (3 feet) meter (39.37 inches) rod (16.5 feet) * furlong (1/8 mile) * mile (5,280 feet) kilometer (0.6214 miles) American Area Metric Area square inch square centimeter (0.1550 square inches) square foot (144 square inches) square decimeter (0.1076 square feet) square yard (9 square feet) * acre (43,560 square feet) hectare (10,000 square meters, 0.01 square kilometers, 0.4047 acres) square mile (640 acres) square kilometer (0.3861 square miles) American Volume Metric Volume * cubic millimeter cubic inch cubic centimeter (0.0610 cubic inches) cubic foot (1,728 cubic inches) cubic meter (0.0283 cubic feet) cubic yard (27 cubic feet) cubic meter (0.7645 cubic yards) American Weight Metric Weight * gram grain * dram (27.3438 grains) * ounce (437.5 grains) * pound (16 ounces, 7,000 grains) * * kilogram (1,000 grams) hundredweight (100 pounds) * ton (20 hundred weight, 2,000 pounds) tonne (1,000 kilograms, 1.1023 tons) long hundredweight (112 pounds) * long ton (20 long hundredweight, 2,240 pounds) * American liquid volume Metric liquid volume * milliliter fluid ounce (29.5735 milliliters) * cup (8 fluid ounces) * pint (16 fluid ounces) * * liter (1,000 milliliters, 1.0567 quarts) quart (32 fluid ounces, 2 pints) * gallon (4 quarts) * American Temperature Metric temperature degrees Fahrenheit degrees Kelvin

Article / Updated 03-26-2016

Word problems aren’t just on school tests. You solve word problems every day in your work or even while you’re just out and about. Don’t worry — these steps make solving word problems easier than you think. Just follow these easy steps to take away the mystery: Read the problem. Begin by reading the problem carefully. Don’t jump to any conclusions about the answer until you understand the problem. Identify and list the facts. Look at all the information given in the story problem and make a list of what you know. Figure out exactly what the problem is asking for. Know what you’re trying to find. The problem often states the required answer, but sometimes you have to ferret it out from the information given. If an important fact isn’t there, you can often convert some piece of the given information. Eliminate excess information. The problem may include facts that don’t help you find the solution, so clear them out of the way. Pay attention to units of measurement. For example, if dimensions are given in inches, but the answer must be in square feet, you need to convert units. You can use a table of conversions, an online calculator, or your own memory to get the conversion factors. Draw a diagram. Sometimes a diagram helps you visualize the problem (but not always). Find or develop a formula. When you see the math that needs to be done, you probably know a common math formula to use for the computation. You will find that you use some special formulas again and again. Consult a reference. If you’re stuck, look for a reference of some kind, such as a conversion chart or even a blog where someone has encountered the same problem you’re having (although as always, consider Internet sources carefully). Do the math and check your answer. After you have an answer, be sure to test it. If the result is outrageously high or low, verify whether you made a mistake.

Article / Updated 03-26-2016

Although many cashiers simply dump all your change in your hand at once, counting change the old-fashioned way ensures that customers get the proper amount. Here’s an easy way to make a customer’s change, using counting and simple addition: Leave the payment in plain sight on top of the cash drawer. Say your customer gives you a $10.00 bill for a $9.56 purchase. Put it on the cash drawer while you gather the change. Count the change out and give it back to the customer, starting with the smallest coins and describing what you’re giving. For the example of $9.56, say “Your purchase was $9.56, out of $10.00. That’s $9.56, plus 4 cents (4 pennies) makes $9.60, plus 5 cents (a nickel) makes $9.65, plus 10 cents (a dime) makes $9.75, plus 25 cents (a quarter) makes $10.00.”