What do a zebras have to do with the PANCE or PANRE?
There is
an old saying in medicine when you hear hoof beats think horses and not zebras.
No we don’t think patients are horses it is just a saying to remind us to
evaluate a patient’s signs and symptoms with the mindset that common things
present commonly and uncommon things present uncommonly. An example is a
patient that presents with a cough, low grade fever and mild shortness of
breath. The “horse” is likely a common cold, bronchitis or maybe early
pneumonia. The “zebra” would be an uncommon disease like sarcoidosis. The rule
can go even farther and there is even the ever elusive unicorn. The “unicorn”
is a disease seen once in a lifetime and occurs in only a few hundred patients.
So what does this all mean, when evaluating patient’s think of common disease
processes first and move on to zebras when the disease does not improve or
specific clues appear.
The PANCE
and PANRE is a test of zebras because it does not use actual clinical
prevalence of a disease into account but ability to write a question. Common
diseases would be bronchitis and hypertension, but since the PANCE and PANRE is
not a clinical exam but a test of recall the use of zebras is quite common due
to the ease in which questions can be written by the test writers. This means
that diseases like sarcoidosis and scleroderma which have easily definable
criteria are often questions to identify the disease but CHF is not a common
question. When relating to CHF it is usually about a medication or the type but
rarely diagnosis. Sarcoidosis on the other hand is easy to write about because
of the specific clues to the disease identity.
An example
of sarcoidosis-
A
34-year-old female presents with a 1 month cough, shortness of breath, elevated
ESR and elevated ACE levels are noted on lab work. Her x-ray demonstrates
bilateral hilar adenopathy, what is your initial diagnosis?
Scleroderma
COPD
Sarcoidosis
Systolic heart failure
Interstitial pulmonary fibrosis
COPD
Sarcoidosis
Systolic heart failure
Interstitial pulmonary fibrosis
A CHF
question
A
55-year-old diabetic male presents with an acute exacerbation of shortness of
breath at rest, exam reveals bilateral crackles, a PMI displaced downward and
to the left and 2+ pedal edema. In addition to his lisinopril, furosemide and
oxygen what medication should be added to his regimen?
Metoprolol
Nitroglycerin
Diltiazem
Amiodarone
Bumetatide
Nitroglycerin
Diltiazem
Amiodarone
Bumetatide
Answer is
Nitroglycerin
Beta
blockers are contraindicated in acute CHF (they make it worse, negative
inotrope), in this case Nitro should be added. Diltiazem would worsen the
condition (negative inotrope), Amiodarone is an antiarrhythmic and Bumetatide
is another diuretic.
How does
this relate to my PANCE or PANRE experience?
Students:
remember that what you did on rotations or do in clinical practice differs
greatly from the NCCPA exam.
Practicing
PAs: remember that your personal clinical experience may be the worst thing to
take into your test. You know exactly
what is good for the patient in front of you.
This may differ from current standard of care or guideline even though
it is best for the patient. Experienced
Pas have seen many patients and have seen the one in one thousand case where
the standard does not apply. The PANRE
question features a patient who is not real, who is not in front of you. The answers will be based on standards. Do not apply your personal patient experience
to these questions as it will likely lead you astray.
The
Blueprint is over 550 topics with only about half the topics being tested in
your session. One hint I often give is to review the orthopedics section with
heavy emphasis on the rheumatology questions as they will make a bulk of the
questions you will see in that blueprint area. Remember to think of the zebras
when taking the exam. Also remember test writers don’t add useless information
or write tricks into a question. Pick the best answer based on the information
given, don’t what if or add information not there. Remember the question always
has to correct answers you need to pick the best one just remember it is not a
clinical prevalence based exam but a recall exam so keep the zebra in mind.
http:www.helpzebra.com
Good luck