Download Physician Assistant Program

Physician Assistant Program
Summative Exam - KEY
2010
Name: ______________________
This open source exam serves to help document the achievement of program
outcomes. As such, each of the program’s 8 terminal outcomes is listed below.
After each outcome, one or more italicized questions related to the outcome
is/are asked and it is to these questions that students are asked to respond.
1
Demonstrate core knowledge about established and evolving biomedical and
clinical sciences and the application of this knowledge to patient care in their area of
practice.
2
Assess, evaluate and improve their patient care practices
3
Interpret and respond to the larger system of health care to provide patient care that
is of optimal value
4
Use investigatory and analytic thinking approach to clinical situations
5
Display interpersonal and communication skills that result in effective information
exchange with patients, their patients’ families, physicians, professional associates,
and the health care system
6
Show care that is effective, patient-centered, timely, efficient and equitable for the
treatment of health problems and the promotion of wellness
7
8
Display a high level of responsibility and sensitivity to a diverse patient population
Conform to high standards of ethical practice and to legal/regulatory requirements
When asked to do so, please include the URL of the source you used to
identify/develop/verify the correct answer. The URL must be from a reputable
information source (i.e. no quotes from Wikipedia please). Answers without
accompanying URLs (when URLS are requested) will be considered
incorrect. Some questions may not require the documentation of sources and/or
may allow you to use non-electronic sources (class notes, hard copy textbooks,
etc).
If you didn’t do so initially, please open this exam in a NEW window from
BlackBoard and save it on your computer now, periodically over the course
of time you are taking the exam and once you have completed it. Send the
completed exam to me ([email protected]) as a Word document, e-mail
attachment when you are finished. The attachment should be titled by
adding your username to the existing file name (eg jlucich Summative
Exam 2010.docx).
Program Outcome #1: Demonstrate core knowledge about established and
evolving biomedical and clinical sciences and the application of this
knowledge to patient care in their area of practice.
1) Find and paste the risk factors for the development of coronary artery
disease. Please provide URL of site you used to answer this question.
Increasing age
Male sex (gender)
Heredity (including Race)
Tobacco
High blood cholesterol
High blood pressure
Physical inactivity
Obesity and overweight
Diabetes mellitus
http://www.americanheart.org/presenter.jhtml?identifier=4726
2) Find and paste a discussion of the pathophysiology for endemic goiter.
Please provide URL of site you used to answer this question.
The thyroid gland is controlled by thyrotropin (TSH), secreted from the pituitary
gland, which, in turn, is influenced by the thyrotropin-releasing hormone (TRH)
from the hypothalamus. TSH permits growth, cellular differentiation, and thyroid
hormone production and secretion by the thyroid gland. Thyrotropin acts on TSH
receptors located on the thyroid gland. Serum thyroid hormones levothyroxine
and triiodothyronine feed back to the pituitary, regulating TSH production.
Interference with this TRH-TSH thyroid hormone axis causes changes in the
function and structure of the thyroid gland. Stimulation of the TSH receptors of
the thyroid by TSH, TSH-receptor antibodies, or TSH receptor agonists, such as
chorionic gonadotropin, may result in a diffuse goiter. When a small group of
thyroid cells, inflammatory cells, or malignant cells metastatic to the thyroid is
involved, a thyroid nodule may develop.
A deficiency in thyroid hormone synthesis or intake leads to increased TSH
production. Increased TSH causes increased cellularity and hyperplasia of the
thyroid gland in an attempt to normalize thyroid hormone levels. If this process is
sustained, a goiter is established. Causes of thyroid hormone deficiency include
inborn errors of thyroid hormone synthesis, iodine deficiency, and goitrogens.
Goiter may result from a number of TSH receptor agonists. TSH receptor
stimulators include TSH receptor antibodies, pituitary resistance to thyroid
hormone, adenomas of the hypothalamus or pituitary gland, and tumors
producing human chorionic gonadotropin.
http://www.emedicine.com/med/topic916.htm
3) A normally healthy, 25 year old white male who recently developed an
infection with influenza A2, develops the following:







Hemoptysis
Nausea and vomiting
Chest pain
Arthralgias
Hematuria
Tachypnea
Inspiratory crackles over lung bases
Based on the above signs and symptoms, what is the patient’s most likely
diagnosis? Please provide URL of site you used to answer this question.
Goodpasture’s disease
URL: XXX
4) Assume that you wanted to investigate for the presence of a bleeding
disorder (congenital OR acquired) in a patient. The following tests (with
results) were obtained. Based on the labs below, choose the likely bleeding
disorder from those listed.
Hematocrit
(male)
Hemoglobin (male)
Platelets
aPTT
INR
A)
B)
C)
D)
45%
16 g/dL
250 K cells/mm3
60 Sec
1.0
Hemophilia A
DIC
ITP
Vitamin K Deficiency
Prothrombin time (PT)
If the PT is over 1.5 the mean of the reference interval, suspect single or
multiple deficiencies of the "extrinsic" and "common" factors prothrombin,
fibrinogen, V, VII, or X. The factor with the greatest impact on the PT is VII.
Partial thromboplastin time (PTT)
If the PTT is over 1.5 the mean of the reference interval, suspect single or
multiple deficiencies of the "intrinsic" and "common" factors prothrombin,
fibrinogen, V, VIII, IX, X, or XI. Deficiencies of the "contact" factors XII, Fletcher
(prekallikrein), or Fitzgerald (high molecular weight kininogen, HMWK) also
prolong the PTT but are not associated with bleeding. Very prolonged PTT
results (> 200 s) are due to heparin until proven otherwise.
PT
PTT
Acquired Disorder
Long Normal Liver disease or vitamin K deficiency
Normal Long Acquired factor VIII inhibitor
Long
Long
DIC, liver disease, Lupus anticoagulant
(LA)
Normal Normal Thrombocytopenia, qualitative platelet
disorder
Congenital Disorder
Factor VII deficiency
Factor VIII (Hemophilia
A), IX, or XI deficiency
Fibrinogen, prothrombin,
factor V or X deficiency
Mild factor deficiency,
mild von Willebrand
disease, factor XIII
deficiency
DIC is generalized activation of coagulation secondary to systemic conditions
such as septicemia, carcinoma, and severe inflammation or pregnancy
complications. The presence of high concentrations of D-dimer, often > 20,000
ng/ml, is the sine qua non criterion of DIC, as it reflects increased fibrin
production and breakdown. In acute DIC, activation of the tissue factor (intrinsic)
pathway results in a decrease in factors II, VII, IX and X, prolonging the PT and
PTT. However, an increase in factor VIII production coupled with von Willebrand
factor released from the endothelium may make the PTT less useful than the PT
in laboratory diagnosis of DIC. The PT is also expected to be abnormal before
the PTT because it is highly dependent on factor VII level, which has a very short
half-life of 3-5 hours.
Assay
PT
PTT
Fibrinogen
Quantitative D-dimer
Complete blood count
with platelet count
Expected Results in DIC
Usually prolonged (even before PTT becomes prolonged)
Usually prolonged above upper limit of reference interval
Low; but may be normal or high due to acute phase reaction;
sequential measurements are helpful
Significantly above the limit of reference interval
·
Single most important assay to establish DIC
·
In compensated DIC, D-dimer may be the only abnormal test
Anemia with schistocytes
Low platelet count reflects significant consumption but count may
be near normal due to marrow response
ITP stands for idiopathic thrombocytopenic purpura. "Idiopathic" means that the
cause is unknown. "Thrombocytopenic" means the blood doesn't have enough
platelets.
http://peir.path.uab.edu/coag/article_222.shtml#a
5) The patient in the following photograph developed a painful, vesicular,
unilateral eruption on his chest (in the distribution shown below) a few
weeks after being placed on a corticosteroid regimen for the treatment of
his asthma. What is your diagnosis?
Shingles
For questions 6-8, please refer to the EKG below.
6) The ventricular rate in the above EKG is best described as ___ bpm.
A)
B)
C)
D)
60
75
90
150
7) The ventricular axis in the above EKG is best described as ____ degrees.
A)
B)
C)
D)
E)
-30
0
30
-60
90
8) In the EKG above there is evidence of hypertrophy in the
A)
B)
C)
D)
right atrium
right ventricle
left atrium
left ventricle
Program Outcome #2: Assess, evaluate and improve their patient care
practices
The evidence supporting the acquisition of this outcome is found in the answer/s
to the questions associated with outcome #6 below.
Program Outcome #3: Interpret and respond to the larger system of health
care to provide patient care that is of optimal value.
A portion of the evidence supporting the acquisition of this outcome is found in
the answer/s to the questions associated with outcome #6 below.
9) As of January 1, 1998, Medicare pays PAs' employers for medical
services provided by PAs at ___ percent of the physician fee schedule.
This rate applies to PAs practicing in all care settings including hospitals
(inpatient, outpatient, and emergency departments), nursing facilities,
homes, offices, and clinics; it also applies to first assisting at surgery. All
visits should be billed at the full physician rate; the PA's NPI number (or
PIN) will signal the Medicare carrier to implement the 15 percent discount.
What number should appear in the blank above?85
http://www.aapa.org/gandp/3rdparty.html
Program Outcome #4: Use investigatory and analytic thinking approach to
clinical situations
This evidence supporting the acquisition of this outcome is found in the answer/s
to the questions associated with outcome #6 below.
10) If the entry hemo* is entered into the search box of a database that
recognizes truncation, a search will be conducted for all of the following
except
A) hemorrhage
B) hemorrhoid
C) hematuria
D) hemostasis
11) Words such as "AND", "OR", and "NOT" are referred to as
A) descriptors
B) operators
C) indicators
D) regulators
Program Outcome #5 - Display interpersonal and communication skills that
result in effective information exchange with patients, their patients’
families, physicians, professional associates, and the health care system
12) Provide a brief, one paragraph interpretation of the answer to question
question #2 above in a manner that would be understandable to a high
school student with no medical background.
Grader, please use your own judgment regarding whether or not the “translation”
is 1) accurate and 2) appropriately worded for a young, lay person.
13) Find and paste the types of information that should be included in the
documentation of a history of present illness (HPI)? Please provide URL of
site you used to answer this question.
1. Duration: How long has this condition lasted? Is it similar to a past
problem? If so, what was done at that time?
2. Severity/Character: How bothersome is this problem? Does it interfere
with your daily activities? Does it keep you up at night? Try to have them
objectively rate the problem. If they are describing pain, ask them to rate it
from 1 to 10 with 10 being the worse pain of their life, though first find out
what that was so you know what they are using for comparison (e.g.
childbirth, a broken limb, etc.). Furthermore, ask them to describe the
symptom in terms with which they are already familiar. When describing
pain, ask if it's like anything else that they've felt in the past. Knife-like? A
sensation of pressure? A toothache? If it affects their activity level,
determine to what degree this occurs. For example, if they complain of
shortness of breath with walking, how many blocks can they walk? How
does this compare with 6 months ago?
3. Location/Radiation: Is the symptom (e.g. pain) located in a specific
place? Has this changed over time? If the symptom is not focal, does it
radiate to a specific area of the body?
4. Have they tried any therapeutic maneuvers?: If so, what's made it
better (or worse)?
5. Pace of illness: Is the problem getting better, worse, or staying the
same? If it is changing, what has been the rate of change?
6. Are there any associated symptoms? Often times the patient notices
other things that have popped up around the same time as the dominant
problem. These tend to be related.
7. What do they think the problem is and/or what are they worried it
might be?
8. Why today?: This is particularly relevant when a patient chooses to make
mention of symptoms/complaints that appear to be long standing. Is there
something new/different today as opposed to every other day when this
problem has been present? Does this relate to a gradual worsening of the
symptom itself? Has the patient developed a new perception of its relative
importance (e.g. a friend told them they should get it checked out)? Do
they have a specific agenda for the patient-provider encounter?
Program Outcome #6: Show care that is effective, patient-centered, timely,
efficient and equitable for the treatment of health problems and the
promotion of wellness
14) You suggest to a patient that they should consider taking a drug to
lessen the likelihood that they will experience an MI. The major side effect
of the drug is that it can cause alopecia. Your patient strongly “resembles”
the patients in the study in all ways. You attempt to assess how the patient
“feels” about the risks and benefits of the treatment using a disutility scale
(as shown below) and find that the patient assigns a disutility score of 0.8
for the alopecia and 0.2 for the MI? Taking these disutility scores into
account, calculate the likelihood of being helped and harmed (LHH)
assuming that the NNT is 16 and the NNH is 48. Show your work, but no
source documentation is required!
Disutility Scale (0 = Death and 1 = Full Health)
The Severity (S) Value = DA / DO = 0.8/0.2 = 4
The S value tells us how many times worse the patient feels the MI is compared
to the adverse reaction of alopecia, i.e. an MI is 4x worse than the alopecia.
LHH = (1/NNT) * S / (1/NNH)
= (1/16) * 4 / (1/48)
= 12
Program Outcome #7: Display a high level of responsibility and sensitivity
to a diverse patient population
15) When dealing with patients from a culture different from your own,
which of the following would be LEAST appropriate to do?
A)Consider asking the patient, “What did you hope to get from today’s visit?”
B)Be aware that cultural or folk medical practices may be incorporated into a
care plan (with or without your knowledge) and inquire about the use of such
practices.
C)Consider asking the patient, “What would typically be done for you in a
clinic in your country?
D)Support incorporation of cultural/folk practices if there exists good scientific
evidence that to do so would be harmful to the patient.
Program Outcome #8: Conform to high standards of ethical practice and to
legal/regulatory requirements
16) Find and paste answers to the questions, “What is the role of a PA?
What do PAs do?” Please provide URL of site you used to answer this
question.
Q. What is a Physician Assistant (PA)?
A. Physician assistants are health care professionals licensed, or in the case of those
employed by the federal government they are credentialed, to practice medicine with
physician supervision. As part of their comprehensive responsibilities, PAs conduct
physical exams, diagnose and treat illnesses, order and interpret tests, counsel on
preventive health care, assist in surgery, and write prescriptions. Within the physician-PA
relationship, physician assistants exercise autonomy in medical decision making and
provide a broad range of diagnostic and therapeutic services. A PA's practice may also
include education, research, and administrative services.
http://www.aapa.org/geninfo1.html
17) Find and paste Indiana code IC25-27.5-4-4 below. Please provide URL
of site you used to answer this question.
Committee may grant temporary certification to an applicant who meets all
qualifications for certification except for the taking of the NCCPA exam or has
taken the exam and is awaiting the results. A temporary certification is valid until
the results of the examination are available or the committee makes a final
decision on the applicant's request for certification. A physician assistant
practicing under a temporary certificate must practice with on site physician
supervision and may not dispense drugs or medical devices.
IC §25-27.5-4-4
http://www.aapa.org/gandp/temprov.html