By Габышев Дмитрий Николаевич (Own work) [CC0], via Wikimedia Commons

This post was inspired by one of my students who was studying from my upcoming “dreaded and feared” cardiac examination. She was completely honest with me when she said “I studied for 10 hours of cardiology and to be honest when I was done, I couldn’t tell you what I studied”. I appreciated her honesty but I found it ironic because I had given them on the first day of class a blueprint on how to approach their studies. Most students approach studying in various levels of INEFFICIENCY and they think because they study for hours that makes it useful. IT IS BETTER TO STUDY FOR 3 HOURS EFFECTIVELY THAN TO STUDY FOR 20 HOURS INEFFECTIVELY. I’m not yelling at you in caps but I want those words to stick out to you so that if you take anything away from this blog, you take away those key points. I explained the rationale to this in the blog I posted last year called PATIENT CENTERED LEARNING but to get back to the topic, the purpose of this blog is to teach you how to approach arrhythmias simple and effective. Don’t believe me???? Keep reading this blog and I promise you that you will be an arrhythmia wizard at the end of it! But first things first, you know I am a big believer in understanding basic anatomy and physiology before going into pathophysiology and management because if you don’t UNDERSTAND how something is supposed to work, what went wrong won’t make sense and how to fix it also won’t make sense since the management usually reverses the pathophysiology.



The heart has 2 upper chambers, the atria and 2 lower chambers the ventricles. That’s it



  1. WHO: the heart
  2. WHAT: does the heart have to do? Two simple functions. It has to 1) contract and 2) relax. That’s it!
  3. WHEN: hopefully all the time (because if your heart stops, you won’t be able to finish this blog).
  4. WHERE: I’m sure you know where the heart is before reading this blog so let’s move onto the why…
  5. WHY: The heart 1) contracts to send blood to the body (so you can stay alive to read the rest of the blog) and 2) it has to relax to fill with blood to start the process of contraction all over again. That’s it!
  6. HOW: The ventricles first fill passively with blood when the AV valves open by sheer gravity. At the very end of ventricular diastole (relaxation) the atria contracts the remaining amount of blood into the ventricle. The electrical conduction system of the heart is wired to allow the heart to contract effectively and then relax to allow the process to start all over again. If you understand the electrical conduction system, you can scroll down straight to the section of the golden rules of arrhythmias (but I recommend reading the whole thing so everything makes sense).



  1. Sinoatrial node: the primary pacemaker of the heart (located in the upper right atrium). The intrinsic rate of the SA node is 60-100 beats per minute.
  2. Atrioventricular node: has 3 functions: 1) it briefly delays the impulse it receives from the SA node. Why?? Because you don’t want your atria and ventricles to contract at the same time (the atria needs to contract the remaining blood into the ventricle before the ventricles contract). By briefly delaying the impulse, the AV node accomplishes this. 2) Its second job is to be a backup pacemaker of the heart. If the SA node fails to fire, it can take over as a backup pacemaker to keep you alive long enough to finish reading this blog. The intrinsic rate of the AV node is 40-60 beats per minute. The lower part of the atria surrounding the AV node, the AV node and the surrounding cells of the bundle of HIS are collectively known as the AV JUNCTION. Therefore, we often refer to rhythms originating from this area as “junctional.” Once the impulse is briefly delayed, the Bundle of HIS rapidly sends the impulse to the ventricles to ensure uniform ventricular contraction.





1) the atria 2) the AV junction or the 3) ventricles.

Atrial arrhythmias: are characterized by the presence of a P wave (since P waves reflect atrial depolarization and hopefully atrial contraction). Therefore atrial rhythms have P waves present (or flutter waves in atrial flutter and fibrillatory waves in atrial fibrillation) and are classically associated with a narrow QRS complex (reflecting normal conduction of the impulse to the ventricles). The exceptions to this rule are 1) if the beat was aberrantly conducted or 2) a bundle branch blocks is present. In those situations, the QRS will be wide (but that is for another blog and time). Take home point: In general atrial arrhythmias (expect flutter and fib) are associated with the presence of a P wave and a narrow QRS complex. P waves of SA origin are usually positive in leads I, II and avF on an ECG and negative in AVR (they can be positive, negative or biphasic in other leads).


Junctional rhythms: are characterized by the absence of P waves (since the origin of the impulse is the AV junction, it sends the impulse retrograde to the atria at the same time it sends the impulse to the ventricles so the P wave becomes “hidden” in the QRS). If P waves are present they MUST be inverted (negative) P waves in leads I, II and/or avF (reflecting retrograde atrial depolarization from the floor of the atrium to the top instead of the normal way which is from the top of atria to the floor of atria). Since there is normal conduction, the QRS is expected to be narrow (unless the beat was aberrantly conducted or bundle branch blocks are present and then the QRS will be wide). Take home point: Junctional rhythms are associated with no P wave (or inverted P waves if present) and are expected to have a narrow QRS complex.


Ventricular rhythms are always abnormal. Because idioventricular rhythms don’t use the normal, efficient electrical conduction system as its way to conduct the impulse throughout the ventricles, it inefficiently sends the impulse from cell to cell to cell (which takes a longer time, resulting in a wide QRS).


This is adapted from the AHA guidelines:

If the rhythm you are evaluating is a tachyarrhythmia, go to Golden Rule 2.

If the rhythm you are evaluating is a bradyarrhythmia, then go to Golden Rule 3



As I sat with another student during this same study session, I gave her this golden rule and it was amusing to watch her say she understood it but then went right back to not using the golden rules, leading her to inadvertently give me the wrong answer. I would tease her when she got the answer wrong and ask her “did you follow the golden rule?” she would admittedly say no and then when she did she would get the right answer. At the end of the session she was able to answer the management in less than 1 minute because she began to follow the golden rule, so I forbid you to read further if you don’t promise me that you will follow these golden rules.


STEP 1: check the patient to see if they have a pulse. If there is no pulse, then this algorithm is not used. No pulse = cardiac arrest!!!! Without a pulse there is no perfusion so you have to manually pump the heart (via manual compressions during CPR) until you can fix whatever caused the cardiac arrest. There are 4 types of cardiac arrest: 2 rhythms that are “shockable” via unsynchronized cardioversion aka defibrillation and 2 “nonshockable” rhythms. Since they all have no pulse, all 4 require CPR until a pulse can be reestablished (hopefully).

2 shockable rhythms with defibrillation (aka unsynchronized cardioversion) are: 1) Ventricular fibrillation (who would have thought right?) and 2) pulseless Ventricular tachycardia. Why pulseless V tach?? Because the natural downward progression of ventricular tachycardia is for ventricular tachycardia with a rapid pulse to deteriorate into ventricular tachycardia without a pulse and eventually into ventricular fibrillation. Since ventricular tachycardia without a pulse is essentially the pathway into ventricular fibrillation, they are treated the same. Why give them a shock?? The idea is that these rhythms perpetuate due to some of the cells in the relative refractory period and some cells in the absolute refractory period. Defibrillation puts all the cardiac cells in the absolute refractory period SIMULTANEOUSLY to terminate the perpetuation of the dangerous rhythm and allows the SA node to take back its rightful ownership as the dominant pacemaker of the heart.


2 nonshockable cardiac arrest rhythms: pulseless electrical activity and asystole.



STEP 2: If a pulse is present, then check to see if the patient is stable or unstable.

  1. If the patient has unstable tachycardia, then the management of choice is SYNCHRONIZED cardioversion. Not to be confused with unsynchronized cardioversion (defibrillation) described above. The reason it must be synchronized (the shock must be delivered on the R wave to prevent giving the shock on the relative refractory period of the T wave).  Giving the shock on the T wave can cause ventricular fibrillation to occur as a result of administering the shock. Ventricular fibrillation that occurs when an ectopic beat occurs on the relative refractory period of the T wave is known as the “R on T” phenomenon.
  2. If the patient has stable tachycardia then go to step 3


STEP 3: is the QRS narrow or wide? The reason you want to know if the QRS is narrow or wide is to determine where the problem is likely originating from. If the QRS is narrow, then the impulse is supraventricular and is conducted normally to the ventricles. Knowing this is critical in determining which is the best medication to use if vagal maneuvers don’t work. If the QRS is wide, it means the rhythm is ventricular in origin (or aberrantly conducted) which also changes the medications you would use.

  1. Narrow regular complex tachycardia (especially if thought to SVT or AV nodal reentry): Adenosine, Beta blockers or calcium channel blockers. Adenosine is the first line management of narrow, regular complex tachycardia thought to be due to AV nodal reentry because AV nodal reentry is the most common cause of supraventricular tachycardias (SVT). In people with a normal pathway in the AV node and a second, abnormal pathway WITHIN the AV node, a premature atrial impulse will continue to go around in circles in the AV node repeatedly perpetuating that original impulse multiple times into the ventricles and the atria (causing AV nodal reentry tachycardias that can present as SVT). AV nodal blockers such as adenosine breaks the circuit, therefore terminating the arrhythmia. Adenosine has a really short half life (seconds) which is long enough to break the rhythm. Beta blockers and calcium channel blockers also block the AV node and can terminate these rhythms as well.
  2. Wide complex tachycardia: antiarrhythmics such as Amiodarone are first line management. Why antiarrhythmics and not primary AV node blockers? Because wide complexes indicate a ventricular origin of the tachycardia or aberrantly conducted rhythm in the ventricles, so AV nodal blockers won’t be helpful because the problem is below the AV junction. Other antiarrhythmics (such as procainamide and lidocaine) may also be used in specific situations.  An indication to the use of lidocaine is in patients who are having an MI presenting with wide complex tachycardias because lidocaine has been shown to reduce arrhythmias effectively in ischemic cardiac tissue.


There are 3 main exceptions to rule 3:

Exception 1: Atrial flutter and atrial fibrillation, skip adenosine and go straight to calcium channel blockers or beta blockers. Why are these exceptions to the rule? Because in atrial fibrillation, the problem are multiple ectopic foci firing in the atria. If you transiently block the AV node in atrial fibrillation it will temporarily slow down the rhythm (so adenosine may be used for diagnostic purposes to slow down the rhythm long enough to see what underlying rhythm is present) but as soon as the medication wears off, the ectopic foci that are firing through this process will speed up the ventricular rate again and you are back to square one! Beta blockers and calcium channel blockers will continue to reduce the impulses that make it through the ventricle. They are still in atrial fibrillation, but the ventricular rate will be slowed down with the calcium channel blockers or the beta blockers. That’s why we call that “rate control” instead of rhythm control. In atrial flutter, only one focus is firing but the same rules apply as I just discussed for atrial fibrillation.


Exception 2: treat the underlying cause in patients with sinus tachycardia and the rhythm usually resolves.

Exception 3: Procainamide is the preferred antiarrhythmic agent for WPW. For other rhythms thought to occur because of a second, abnormal pathway OUTSIDE the AV node (known as AV reciprocating tachycardias), blocking the AV node with AV nodal blockers may cause preferential conduction down the abnormal, fast pathway. By blocking the inhibitory effect of the AV node, AV nodal blockers may worsen the arrhythmias, so procainamide (or other antiarrhythmics) are preferred. The most common type of AV reciprocating tachycardias is Wolff-Parkinson White in which the abnormal pathway (Kent Bundle) is the issue.   Procainamide is preferred in the management of WPW over the antiarrhythmics.


All you have to do is identify the rhythm you see and plug it into the algorithm and then it’s easy to know what to do!

Don’t believe me??? Try these 3 cases:

Case 1: the nurse calls you to the floor to assess a patient. The telemetry strip shows the following:


You walk into the room the patient is unresponsive, hypotensive and there is no palpable pulse present. What do you do??

Step 1: check pulse. Since the patient has no pulse, he is in cardiac arrest. The management of pulseless ventricular tachycardia is to start CPR and compressions and unsynchronized cardioversion (defibrillation). If you got that right, you followed the rule.


Case 2: the nurse calls you to the floor to assess a patient. The telemetry strip shows the following:


You walk into the room and the patient is anxious, having palpitations and mild shortness of breath. The blood pressure is 190/110 with a rapid pulse rate.

What do you do?

Step 1: check pulse. The patient has a pulse

Step 2: stable vs. unstable: the patient is hypertensive and responsive.  They are symptomatic but stable.

Step 3: Is the QRS narrow or wide? There is a regular rhythm with a wide QRS so therefore, amiodarone is the preferred agent for a stable wide complex tachycardia.  If you got that right, you followed the rule.



Case 3: the nurse calls you to the floor to assess a patient. The telemetry strip shows the following:


You walk into the room and the patient is lethargic, hypotensive, diaphoretic but there is a palpable rapid, weak pulse. What do you do?

Step 1: Check pulse. The patient has a rapid but palpable pulse.

Step 2 is the patient stable or unstable?  The patient is unstable based on the physical exam findings

Based on the unstable tachycardia with a pulse, the management is to prepare for synchronized cardioversion to stabilize the patient. If you got that right, you followed the rule.


Notice the monitor showed the same exact rhythm in all 3 cases but there are three very different approaches to the management. TREAT THE PATIENT NOT THE ECG! If you plug in any tachyarrhythmias to the rule with the notable exceptions given to you the rule holds true in terms of which medicine to use. Unstable atrial flutter, unstable multifocal atrial tachycardia, unstable atrial fibrillation or any other unstable tachyarrhythmias with a pulse, synchronized cardioversion is the management of choice as per the AHA guideline. So all you do is plug the rhythm you see into the algorithm and assess the patient.



This algorithm has one step less than the tachyarrhythmia algorithm.

Step 1: check the patient to see if the have a pulse. If there is no pulse, No pulse = cardiac arrest!!!!


Step 2: If a pulse is present, then check to see if the patient is stable or unstable.

  1. If the patient has unstable, symptomatic bradycardia, then the first line management is atropine. Atropine is an anticholinergic drug that indirectly increases sympathetic tone by blocking parasympathetic tone (remember that acetylcholine is the chief neurotransmitter of the parasympathetic system, so by blocking acetylcholine, the sympathetic tone increases). Other medications used in the management of unstable, symptomatic bradycardia are epinephrine or dopamine (which directly stimulates the sympathetic system and increased the rate of both SA node and AV node firing, resulting in an increased heart rate). Other modalities that can be used if medical management is not effective is transcutaneous pacing (or permanent pacing) for a more definitive management.
  2. If the patient has stable bradycardia, then no immediate medical management is needed. The patient may be observed, cardiac consult or referral may be needed but you don’t need to medically manage immediately.


The exception to the bradycardia rule is third degree heart block. Temporary cardiac pacing is the preferred management. You can administer atropine or a dopamine infusion.  If the atropine or dopamine works, then the block is due to abnormal AV node conduction. Atropine is unlikely to work in third degree block below the bundle of HIS so temporary pacing will be needed until the rhythm resolves or a more definitive management can take place.


If you understand and follow these three golden rules, you will know how to effectively manage all the patients not only on the PANCE but in clinical practice! All my best!

Dwayne A. Williams is the author of Pance Prep Pearls and the PANCE and PANRE question book





By Spc. Jeshua Nace [Public domain or Public domain], via Wikimedia Commons
By Spc. Jeshua Nace [Public domain or Public domain], via Wikimedia Commons
*In my Sophia Petrillo from the TV show Golden Girls’ voice* “Picture it, Brooklyn, 2001 a young bright-eyed and bushy-tailed PA student born in Panama but raised in Brooklyn is about to start his first rotation, which happens to be surgery. He is excited to be finally out of the classroom with no windows and the grueling hours and hours (and hours) of lectures and endless torture (I mean examinations). He is also excited about the prospect of seeing all of the diseases he read about in the fables of Lange and Harrison’s. He is also petrified because he feels as if he is not quite prepared to be “out there” yet, so he calls on the powers of his senior class that is about to graduate to figure out what life vests he will need not to drown in the surgery sea. His senior tells him to buy the book “Surgical Recall” because he will be drilled by the surgeons and the more he answers right, the more he gets to participate in the operating room besides the dreaded retraction. He sprints to Barnes and Nobles to pick up the book Surgical Recall. To prepare for his first big case, he reads the OR schedule and finds out his preceptor is going to do a laparoscopic cholecystectomy. He wants in on the case, so he quickly pulls out surgical recall and learns all about the anatomy and procedure. The players of the surgical rounds consisted of him, 2 other PA students from another school on their 5th rotation, 3 medical students, 1 resident and the attending/preceptor. Anyone who has done surgery rotations know it can sometimes be the equivalent of army boot camp, so the “Surgeon General” begins to spit out questions about cholecystitis and the procedures and we are all trying to answer frantically to get into his good graces. They all give about an equal amount of right answers, all trying to get the “one up” on each other. The Surgeon general then tells the team the patient has a history of sarcoidosis and what is the management for it. Everyone was kind of stumped.  As you can probably tell by now the bright-eyed bushy-tailed student was I. I remembered a mnemonic I used in didactic year to remember that the “S for sarcoid stands for steroids”. I blurted out the answer “Corticosteroids”, brimming with pride that the lowly PA student on his first rotation had the “one up” on the other PA students, the resident and the medical students. It was like the heavenly angels were singing a melodic chorus, the birds were chirping and cherubims were playing violins. This symphony came quickly to a screeching decrescendo when the attending turns to me and asks me “How do they work in Sarcoidosis?” I remembered the buzzwords but I didn’t remember how or why corticosteroids worked. Instead of complimenting me for being the only one who knew the right answer, the surgeon general yelled at me, the poor private PA student in front of everyone for 5 minutes (which felt like 5 lifetimes) saying “It makes no sense knowing something if you don’t understand it…etc etc” there were other expletives used (anyone who has ever gotten a verbal lashing during their surgical rotation will know exactly how that convo went). Sitting in the operating room retracting, it gave me a lot of time to decide that I never wanted to be yelled at again and I needed to learn how to understand the things I had learned better. There in the operating room gave birth to the concept of PATIENT-CENTERED LEARNING.

In the didactic year, most students survive by making up useful mnemonics, and cramming the information just to pass they myriad of exams that come at you like tidal waves while you are trying to swim out of the whirlpool of all day lectures. They cram, memorize and regurgitate the information and move onto the next test. They make it through the didactic year but then the clinical year poses a new, daunting challenge. Not only do you have to recall the information of the didactic year but also you have to now apply it clinically. This is where most PA students (often even the brightest ones in the class) have difficulties. Think of our brains as a computer and it will make total sense and then I will go into the PATIENT CENTERED LEARNING technique.

You don’t have to be a computer whizz to understand defragmentation, RAM and ROM

RAM: is our short-term memory, where information is crammed, stored temporarily and regurgitated. Most of us put the things we learn here. The problem with that is that although easier to access, the memory stored here is loss after the computer is turned off (meaning an after the exam or after that course).

ROM: is our long-term memory, where information is stored and retained. Ideally this is where we want most of the material to go because it leads to greater retention. This stays even after our computer is turned off (after an exam). What is not lost in RAM is then placed in ROM in many fragments and unrelated bits.

“DEFRAGGING OUR BRAIN”. A computer has to go through the process of defragmentation to work faster and more efficiently. The process of “defragging” your computer physically organizes the massive amounts of information into smaller regions of knowledge blocks (fragmentations), arranging them in a sequence for faster access to the information. It “fine tunes” and reorganizes it. A lot of what we learn in the didactic year is learned in these fragments but then are stored all over the place.

To make it real for you, we learn hypertension in cardiac lectures, we learn about pulmonary hypertension in pulmonary, causes of secondary hypertension (such as Cushing’s syndrome, hyperaldosteronism and pheochromocytoma) in endocrinology.   We learn about hypertensive emergencies in emergency medicine lectures, preeclampsia in OB/Gyn etc. But these are not learned at the same time, so we store them as individual fragments when we learn them, often not connecting the dots.   Faced with this unique problem of having to reorganize the information for the clinical year, I had to figure out: how can I learn this information so I don’t have to receive any verbal lashings, pass the end of rotation exams, pass the PANCE, be able to an efficient practitioner and be able to explain the diseases to the patients so they feel more knowledgeable about their own diseases and retain as much information over the long haul. My technique “Patient-centered learning” combines all of that into one process so it’s an efficient way to learn. If these diseases are difficult for us to learn despite having the extensive training we went through, imagine how much harder it is for our patients to comprehend their diseases.   I can’t tell you how many times in the emergency room I tell patients they have a fracture and then they make a sigh of relief and say to me ‘Ok. At least its not broken” and then when I tell them it is broken, their mouths drop until I explain to them it’s the same. So to help you and our patients, I will explain to you the patient centered learning concept in 3 easy steps:


  1. BREAK DOWN the disease first by explaining the disease (including the pathophysiology) IN YOUR OWN WORDS in one (maximum 2) sentences whenever possible. The sentence should be constructed as if you were explaining it to your patient for them to understand the disease. By breaking it down in your own words you are processing the information and relating it to your previous baseline of knowledge, which promotes retention. Make sure with this step that you understand the basic anatomy and physiology and pathophysiology pertaining to the disease as this is critical for this concept to work or else it is more memorization and less understanding. Remember that you want to limit rote memory and clogging up your RAM to more understanding to store it in your ROM.
  2. EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions of the medications pertaining to the diseases. Relate each of those things back to the sentence in rule 1. Relating it back one reinforces the sentence, your understanding and the connections between all the things about the disease to each other.
  3. CONNECT if possible to other disease with similar processes or the exact processes for comparison and contrast to allow the fragments to be grouped for easier access. Thus also helps you to understand medicine in a broader perspective and over a broad range of topics.

Now that you have the three golden rules I will give you two examples to drive the point home.

Example: Gastroesophageal reflux disease:

STEP 1: BREAK DOWN the disease first by explaining the disease (including the pathophysiology) IN YOUR OWN WORDS in one (maximum 2) sentences whenever possible.

If you have my book Pance Prep Pearls then I have pretty much already done the first step for most of the diseases in the book but if you don’t have the book, fear not. I can easily show you how to do it

Gastroesophageal reflux disease (GERD): decreased lower esophageal sphincter pressure due to relaxation, leading to reflux of the acidic contents of the stomach into the esophagus.

STEP 2: EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions pertaining to the diseases relating it back to the sentence in rule 1.


  1. heart burn (pyrosis) hallmark: burning sensation in the chest or upper abdomen due to reflux of acidic contents into the esophagus.
  2. Regurgitation & water brash: due to reflux of acidic contents into the mouth
  3. Cough especially worse at night: reflux of acid into the esophagus and mouth with aspiration of acidic contents stimulating the cough irritant receptors. This also explains the development of possible aspiration pneumonia and asthma-like symptoms (bronchospasms also limits further damage from acidic contents).
  4. Hoarseness: due to reflux of acidic contents causing inflammation of the vocal cords


  1. Esophagitis: due to reflux of the acidic contents into the esophagus, leading to inflammation.
  2. Esophageal stricture: the damage from the refluxed acid and chronic inflammation can lead to narrowing of the esophagus
  3. Barrett’s esophagus: the esophagus tries to compensate for the chronic exposure by the migration of gastric cells proximal esophagus. This chronic exposure can lead to metaplasia and eventually esophageal cancer.
  4. Adenocarcinoma of the esophagus: (see Barrett’s).


  1. Clinical diagnosis
  2. Endoscopy: used to evaluate persistent symptoms, look for complications listed above
  3. Esophageal manometry: used to see if lower esophageal pressure is present.
  4. Ambulatory pH monitoring: used to see if the pH lowers throughout the day (acid has a low pH). Currently the gold standard. Note all the diagnostic studies are still related to the original sentence you created.


  1. Lifestyle modifications: all used to reduce reflux and speed up GI transit (ex. elevation of the head of the bed, avoiding recumbency for 3 hours after eating, eating small meals, decrease fat and alcohol intake etc).
  2. H2 receptor blockers: reduces acid production by blocking histamine-induced gastric acid production
  3. Proton pump inhibitors: reduces acid secretion by blocking proton hydrogen ion release
  4. Nissen fundoplication: surgical procedure to reinforce the closing function of the lower esophageal sphincter.

Again note all the management is still related to the original statement.

For step 3, you can tie the information to Peptic Ulcer disease, another disease that may present with epigastric pain and that H2 blockers and proton pump inhibitors are used in that disease as well.

Now you see that with the one (or two) original sentences, the basics of GERD can be remembered easier because you tie it all to one or two sentences. Your brain can package and organize the information so that you can do less memorization/regurgitation and more retention because you tie all the details to a bigger picture as opposed to small tidbits of information.

Now let’s try one more to make sure you have the concept.   Asthma


STEP 1: BREAK DOWN the disease first by explaining the disease.

Asthma: reversible (1) hyperirritability of the airways, leading to (2) airway narrowing (bronchoconstriction) & (3) airway inflammation obstructing the movement of air out of the lungs.

STEP 2: EXPLAIN as much of the history, physical exam findings, diagnostic studies with expected findings, treatment options, medications and mechanisms of actions pertaining to the diseases relating back to the sentence in rule 1.


  1. Dyspnea: shortness of breath due to airway narrowing and inflammation increasing the work of breathing.
  2. Wheezing: sounds made as air moves through the narrowed airways. Also explains the chest tightness
  3. Cough: hyperirritability of the airways stimulates the cough irritant receptors.


  1. Peak flow meter: assesses the level of obstruction of the movement of air out of the lungs. Most objective noninvasive way to assess severity.
  2. Pulse oximetry: measures oxygenation and level of obstruction of airflow
  3. Metacholine challenge test: a test done to cause bronchoconstriction (you have to remember from basic physiology that acetylcholine/parasympathetic stimulation leads to bronchoconstriction and sympathetic stimulation leads to bronchodilation). This concept will also be helpful in understanding the medications. Metacholine is an acetylcholine-like drug.
  4. Pulmonary function test: gold standard to look for reversible


Remember the 3 components of the disease from the stem sentence:

Bronchodilators (addresses the bronchoconstriction)

  1. Beta 2 agonists (Ex albuterol): Beta-2 activation stimulates the sympathetic system, leading to bronchodilation of the lungs, increasing airflow. Side effects are due to sympathetic stimulation (including the beta 1 receptor of the heart) leading to palpitations tachycardia CNS stimulation.
  2. Anticholinergics (ipratropium/Atrovent): central acting bronchodilator that blocks acetylcholine-mediated bronchoconstriction. Acetylcholine activation causes increase bronchoconstriction, salivation, lacrimation, urination, digestion and pupillary constriction. Side effects are the opposite of those including: dry mouth, urinary retention, dry mouth, and exacerbation of glaucoma.
  3. Theophylline: bronchodilation
  4. IV magnesium: Magnesium antagonizes calcium-induced contraction of the muscles in the airway leading to bronchodilation.

Anti-inflammatories: addresses the inflammation and hyperirritability:

  1. Corticosteroids, mast cell inhibitors, leukotriene modifiers: inhibit inflammation at different levels

STEP 3: CONNECT if possible to other disease with similar processes. There are many connections that can be made from this but to give you an example:

Anticholinergic atrovent sounds like atropine (an anticholinergic used to increase the heart rate in bradycardia.

You can even connect it to glaucoma by remembering acute glaucoma can be exacerbated pupillary dilation, which is why anticholinergic drugs (that cause pupillary dilation) can exacerbate glaucoma and why cholinergic drugs (such as pilocarpine) can be used to treat glaucoma and Sjrogen’s syndrome (by increasing salivation).

You can also connect it to benign prostatic hypertrophy by realizing that anticholinergic can promote urinary retention in patients with BPH and can exacerbate the symptoms.

You can also connect anticholinergics to why they work in urge incontinence by decreasing bladder detrusor muscle contractions, improving the symptoms as well as why tricyclic antidepressants m ay also be used (due to their anticholinergic effects).

You can connect the magnesium sulfate used in asthma by remembering it is used in seizures, to treat torsades de pointes, ventricular tachycardia, and for tocolysis (anti-contraction to prevent premature birth). Why the same drug for these very different diseases??

Asthma: Magnesium antagonizes calcium-induced contraction of the muscles in the airway leading to bronchodilation.

Torsades de pointes and ventricular arrhythmias: antagonizes calcium-induced heart muscle contractions and blocks neurotransmission of cardiac neuromuscular impulses, prolonging conduction times and stabilizing cardiac membranes.

Eclampsia: blocks neuromuscular transmission producing anticonvulsant effects reducing the seizure potential as well.

Tocolytic: antagonizes calcium-induced uterine contractions, decreasing labor contractions, preventing premature labor.

Laxative: promotes osmotic retention of fluid in the colon, causing distention, leading to increased peristalsis and bowel evacuation.

Now you have tied that drug and how it works to cardiac, pulmonary, obstetrics, gynecology, neurology and gastrointestinal. So your brain can now make those stronger, more lasting connections.

You can use this technique for almost all medical diseases and the more you start to do it the faster that you will become at doing it. It takes a little while to get used to doing it this way but you will find that when you review it this way, you will retain more each time you review it. It is also helpful to use that one-liner (sometimes simplified) to explain the nature of the condition to your patient, why they develop certain side effects and symptoms. Which symptoms to look out for that are considered “alarm” symptoms. Why they are taking the medications you prescribe to them and some side effects they should look out for.  This will make the patient feel empowered because they know more about their condition and things they can do to improve it and why they are doing it. You become a better clinician, you will pass your PANCE/PANRE, you will become more effective at communicating with your patients and increase their understanding and you will do less memorizing and more understanding and retention of the material. A win-win for all!!!

All my best

Dwayne A Williams

Dwayne A. Williams is the author of Pance Prep Pearls and Pance & Panre Question Book  .  He is also author of the Medical Mnemonic Comic Book.





By Fraxinus Croat (Own work) [CC-BY-SA-3.0 (], via Wikimedia Commons
By Fraxinus Croat (Own work) [CC-BY-SA-3.0 (, via Wikimedia Commons




As a professor and lecturer of PA board reviews, I am around students who voice their concerns to me all the time about passing the PANCE.   As a practitioner that has take the recertification (PANRE) twice, I also understand the unique concerns of a practicing clinician.  Some of the concerns are similar and some are unique to each. For example, both the student and the practitioner  are prepared enough.

Practitioners taking the PANRE who specialized in specific fields are concerned if they can retain the information even though they don’t use most of it clinically anymore. Students wonder if they have studied enough and did enough questions to be truly ready or are  often confuse that what they saw and learned on rotations aren’t what the exam questions seem to reflect.  My mother and I hope to answer some of these concerns in part 1 of Studying Tips for the PANCE and PANRE.

First, about my mother. She is a retired beautician.  6 years ago I signed up for my first recertification and told my mother in passing conversation. With the busy life I led, I completely forgot about it.  But what we find trivial, our parents tend to remember in great detail (thank goodness).  So I am home on the day of my exam and she calls me to wish me good luck on my exam.  I ask her what is she talking about and she reminds me 3 months ago, I told her I had to take the exam on that day.  I jumped out of bed, got dressed, tried to study on the way to the testing center and took my first PANRE.  I was lucky that my background in internal medicine and emergency medicine helped me to  pass.  But it made me realize that I took a great chance by not studying.  Despite not having any medical background, things my mother taught me throughout the years are helpful in studying for the PANCE & PANRE using her quotes from song, the bible, things she made up on the spot while yelling at me, etc.…..

I came home from school in the winter and wanted to play outside. And since the sun went down faster during the winter, my mother would say:

Your money is time, so spend it wisely and your play time is up when the streetlights come on”

After graduating and before taking the PANCE, PA students have all the time in the world to study (though many of them argue against that notion). For practicing PA’s, free time is like a Pink Star Diamond, extremely precious and exceedingly rare!!  So when you do find the time to study, you have to maximize that time so that you get the most out of the study time.

“By failing to prepare, you are preparing to fail” – literally!!

She may have stolen that one from Ben Franklin, but she loved to say it.  You have to spend some time studying in order to pass the PANCE or the PANRE, especially for what I call the “Silver-Star PA’s” – those who have been practicing over 20 plus years or close to retiring but still have to pass the PANRE to continue practicing (even if its only for a few more years).  The earlier you start, the more time you have to prepare.  Even if it means studying for that half an hour that it takes you to get to work on the commuter rail, or during down time at work etc.

“Look both ways before you cross!!”  

Just as important as it is to set aside time, learning how to divide that study time is important to maximize the effectiveness of your studies.  Most people are aware of the PANCE blueprint and for those of you who aren’t,  the NCCPA website has graciously provided us with a blueprint which breaks down the exam percentage by organ systems.   They even go one step further as to provide us with all the details of the things that comprise that organ system.  So your study time should reflect that.   Your goal is to be comfortable with at least all the topics within each organ system  with at least 80-85% to ensure a pass rate.  You should study all of them, but if you are limited on time, then you should use the percentage to help govern how you spend the allotted time, spending more on the topics or organ systems that have a higher percentage.   If you have an understanding of most of the major topics, then you can focus the time on the stuff you don’t feel comfortable with.


You should be the most comfortable with what I call the “Fabulous 5” otherwise known as the topics that take up a passing percentage of the boards: 1. Cardiology (16%), 2. pulmonary (12%), 3. Gastrointestinal/nutritional (10%) Musculoskeletal/Rheum (10%), and 4.  EENT (9%).  This accounts for 57% of the material on the boards, so in studying, your time should be maximized on studying these topics to ensure a passing score.  Now I know you are thinking that is the fabulous four instead of five and you are right.  The fifth one is the one I call the silent giantInfectious disease. I call it the silent giant because in the percentage, it only comprises 3% (which seems like barely nothing) but in reality, there are many infectious topics in all of the other organ system areas that are classified under the organ systems that deal with infectious disease: ex. Influenza in pulmonary, meningitis in neurology, viral exanthems in dermatology, bacterial gastroenteritis in GI etc.  So infectious disease takes up a bigger bulk than the percentage the blueprint describes.

Once you feel comfortable in those topics, then you can use the time to study the other topics as well to boost your score and better your chances of passing.

Now this does not mean that poor little hematology that only accounts for 3% should be forgotten about because for those who failed by a few points, that small hematology section could have pushed them over to the pass section, so the little subjects count as well to provide you with a protective passing cushion.

Many people are well aware of the breakdown by organ systems and look for it but then get hit by the “task-area” truck coming from the other direction because they failed to look both ways. The truck is the other component that many people either forget to look at, ignore or don’t even know exists when looking at the blueprints.  I can’t tell you how many times students tell me they didn’t look at pharmacology because they “weren’t good at it” and they figured they would do well on the PANCE/PANRE without it. Pharmacology makes up a whopping 18% of the exam!!! How do I know this??? Because when you “look the other way” you realize the NCCPA also gives us another gem in our preparation arsenal: the exam breakdown by task areas.


The site also breaks down what comprises each of the task areas. The exam is broken down by specific topics, which is crucial for maximing your studies.  So when you are studying the organ systems this is how you should focus your studies in those particular systems. Pharmacology has the highest percentage when it comes to task areas.


Everyone is completely different and so your study techniques should reflect your personal level of retention, style of learning or preference.   Whatever your technique is, it should involve some sort of  1) reading/viewing and  2) practicing questions as an active way to test what you are retaining.

1. Reading is important because most students and practitioners fail to read enough and that is the foundation to passing. In reading, the goal should be to memorize what you need to. What I have found fundamentally true is that the more that you understand, the less memorization that it takes to understand concepts and it also helps you to cross reference other topics. For example understanding that acetylcholine in the neuromuscular junction promotes nerve conduction transmission,  promotes digestion in the GI tract, promotes urination in the GU tract and  promotes constriction of the pupil in the eyes will help understand the drugs better.  Acetylcholine muscarinic receptors cause SLUDD-C (Salivation, Lacrimation, Urination, Defecation, Digestion, Constriction of the pupil).  This helps to understand a myriad of diseases or use of medications.   For example: cholinergic drugs can be used in Sjrogen’s (a disease that causes dry eyes and dry mouth) by promoting salivation and lacrimation, anticholinergic drugs can cause glaucoma (by dilating the pupil and closing off the angle), anticholinergic drugs can be contraindicated in BPH (because it promotes urinary retention), &  anticholinergic drugs can be used to treat diarrhea (they slow down the GI tract).   It explains that increased activity of acetylcholine can cause tremor in Parkinson’s (due to decreased dopamine), so anticholinergic can help with the tremor.   All based on a simple understanding of the basic physiology you can make connections across organ systems.  So don’t only read to memorize, also read to understand!

2. Questions are helpful because they allow you to apply what you have learned so that you are able to see what you understand and what you still struggle with. Another reason why questions are so beneficial is in understanding the explanation of the correct answers. Sometimes we pick the right answers for the wrong reasons, which may have gotten us a correct answer, but could lead to a wrong choice selection where it counts most, on the exam. So when you get an answer right, still read the explanation to solidify the material you already know and to see if your train of thought was in line with the thought of the question writer, which will enhance your exam taking techniques. Also reading the explanation of the wrong choices gives you a studying  snippet of the other 4 wrong choices. So in essence, with reading the explanation to that one question,   you just studied five diseases.   Most people just look to see if their answer was right and then move on.  It is much more effective to read it even if you got it right.  Repetition promotes retention.   In writing questions, some of the choices are easy to eliminate and then some can be eliminated with some minor thought.  However, there is often times when you left with what I call “the dreaded duo.”   Those are the two final choices you are left with where you are unsure which of the two is the correct answer.  Understanding the similarities in diseases and the critical differences are one of the main things the exam questions are looking to see you are able to elucidate. For example:

A 65-year-old patient has a harsh systolic crescendo-decrescendo murmur that radiates to the neck and is best heard at the right upper sternal border.   The murmur decreases with inspiration and the valsalva maneuver.  Which of the following is the most likely diagnosis?

a. pulmonic stenosis

b. aortic stenosis

c. mitral stenosis

d. aortic regurgitation

e. hypertrophic cardiomyopathy

In trying to answer this question we can already eliminate choice C (Mitral stenosis) and choice D (aortic regurgitation) because we remember by our cardiac mnemonic “AR MS rest” that aortic regurgitation and mitral stenosis are diastolic murmurs and the vignette says the murmur is systolic.  What the remaining three choices have in common are that they are all systolic murmurs. So now you have to look at the clues in the stem to start weeding out the incorrect answers. With more consideration, we can weed out Choice E (hypertrophic cardiomyopathy) despite the fact that the murmur of HCM sounds very similar to aortic stenosis because we know that decreased venous return (ex. performing the Valsalva maneuver) decreases all left and right sided murmurs (with the exception of hypertrophic cardiomyopathy). So valsalva would increase the murmur of hypertrophic cardiomyopathy (even if you didn’t remember that the murmur of HCM does not radiate to the neck).   Now when left with the dreaded duo, you use the clues to determine the answer. Both aortic stenosis and pulmonic stenosis can sound similar but you remember from physiology that inspiration increased blood flow to the right side (so the blood can get oxygenated) so inspiration would increase the right side flow and thus the murmur of pulmonic stenosis (decreasing the murmur of aortic stenosis) as well as the fact that pulmonic stenosis would be most commonly be maximally heard in the left upper sternal border.  This rules out choice A, making choice B (aortic stenosis) the best answer to this question.  Often, there is more than one clue in the question stem that can help you to get to the right answer. Taking many questions gives you the skill on honing into them and picking those things out.

  1. BOOKS: My favorite book study book is PANCE PREP PEARLS  on not only because I wrote it, but also I really believe the format of it maximizes learning. The other two books that my students say are great are the DAVIS BOOK   and the COMPREHENSIVE GUIDE  (which is endorsed by the AAPA).
  2. WEBSITES there are many good websites out there.       One that I have found particularly useful (and also gives you much more details on the available sources) is the PALIFE In addition they have practice questions and other great advice for both the student and the practitioner as well as awesome resource information on all the tools available to you.
  3. Review courses: The RUTGERS review course   is one that many of my students  have said has been a big help to them.  My personal favorite review course is CME4Life because of their philosophy of gaining an UNDERSTANDING of medicine and MAXIMIZING your mind.  CME4LIFE
  4. Exam Questions: the NCCPA has great questions, the link above to the palife, exam master and Kaplan just to name a few.

(Please note, I do not have any affiliations with the above organizations but just mentioning the ones that I get the most positive feedback from my students).



“Don’t be afraid of the lions, tigers, bears and ZEBRAS”

The PANCE/PANRE exam is not an exam based on clinical experience. It is based on the exam content and standards of practice.  I think this is one of the hardest concepts for already practicing PA’s like myself because we get tested on diseases we don’t see like smallpox (despite the fact the last case of smallpox in the United States as in 1949).  So for practicing PA’s, don’t use the strategy that the Zebras (the diseases that are rare in compared to the horses) are not important to study.  There are certain high-yield topics that come up a lot on exams and you will begin to notice the pattern once you start doing questions.

“Just because your friends do it doesn’t mean you can do it too!”

Although it infuriated me when my mom would tell me that (I really wanted a unicorn at my party after seeing Johnny had one at his).  What we see and do in clinical practice can be different than what is on the PANCE/PANRE.  The PANCE/PANRE is based on standards of medicine. In clinical practice, I rarely ever tell someone to come back in 3 days for suture removal on the face but the guidelines say that suture removal in the face is done in 3-5 days, so know the standards that will be tested.  It is also hard for practicing PA’s because our drug of choice that we use for a disease based on our personal experience, hospital policy etc. may not be the standard drug of choice.

A caveat to that concept is to  remember that the boards are also behind when it comes to changes in standards, so any new standard changes used in clinical practice that occur this year (for example) will not show up on the boards for at least a couple of years. The take home point is to know the standards   of what will be on the exam. Again very important for the practicing clinician taking the PANCE/PANRE.

“Learn those books like you learn those songs.”

My mother refused to accept that I couldn’t master trigonometry since I knew all the words to the every single one of the top 100 songs on the countdown. Learn the buzz words because they are often the deciding factor when you are left with two choices with a relatively similar presentation or similar exam findings.  Also when learning them, know all the different disorders that buzz word is related to so you can look for the differences to help find the right answer.

Ex: A 22-year-old female with no prior medical history presents with diplopia and  generalized muscle weakness that worsens with repeated use of the muscles.  There is no history of night sweats or weight loss. There is no crepitus on palpation of the chest wall.   A chest radiograph shows mediastinal widening.  Which of the following is the most likely diagnosis?

A. Inhalation anthrax

B. Thoracic aortic aneurysm

C. Cardiac tamponade

D. Thymoma

E. Small cell lung carcinoma

So you highlight widened mediastinum as a buzz word, only to your chagrin when you read the choices and realize all of the choices can cause a widened mediastinum. Since all of the following disorders can potentially cause a widened mediastinum and many can cause fatigue or weakness, you have to use the additional “buzz words” to help you to figure out the answer.

Choice A (inhalation anthrax) is a rare disease and may be associated with a cutaneous presentation so a buzz word for that would have been a “painless black eschar on the skin” or exposure to cattle, sheep swine etc.

Choice B (thoracic aortic aneurysm) buzz words would include a “history of uncontrolled hypertension” “severe chest pain that radiates to the back or neck”.   The omission of those in the vignette would make this choice less likely.

Choice C (cardiac tamponade) buzz words would often include one or more of Beck’s triad (muffled heart sounds, systemic hypotension, increased jugular venous pressure)

Choice D (thymoma) buzz words would include an “anterior mass” or may present with Myasthenia Gravis (which is due to antibodies against POSTsynaptic acetylcholine receptors at the neuromuscular junction).   This leads to generalized “weakness that WORSENS” with repeated use.

Choice E (small cell lung carcinoma) can cause Eaton-Lambert syndrome (which is the development of antibodies against the PREsynaptic calcium-gated channels responsible for acetylcholine release.   The buzz words would include  “generalized weakness that IMPROVES with repeated use.”

Based on the buzz words given or “denied” in the vignette, choice D would be the best answer.

“Six of one, half a dozen of the other”

When I would try to delay doing a chore until later, she would tell me “ If you do it now or later, you are still going to have to do it before the day is done.  Six of one, half dozen of the other”.  Many people remember the buzz words but often will forget what it means or don’t take time to understand the meaning of it.  For example, may people remember whenever “Bamboo spine” like a Pavlovian dog, we are trained to say ankylosing spondylitis.  Sometimes on the boards, they may put down Bamboo spine, but be aware of the fact that they may describe it in words such as “vertebral body fusion of marginal syndesmophytes” or more commonly “squaring of the vertebral bodies” which all allude to the “Bamboo spine.”  Another way they may describe the pulse of aortic stenosis besides the pulsus parvus et tardus is a “weak delayed carotid upstroke” so don’t just memorize the buzz words, but to be able to recognize them in all of their forms.

“Drugs are good for you”

In Panama, for every change of season, we would have to take a laxative or what she would call a “purge” of Castor Oil to clean out our systems. Besides Buckley’s cough syrup, that was the worse thing I ever tasted.  I tried to get out of it by saying “Mom you told me to never take drugs” and she would tell me some drugs are good for me.   Remember, pharmacology is 18% of the boards and many students and practitioners alike tend not to do well on this topic.  They stress this on the PANCE/PANRE because one of the benefits of being a PA is our ability to prescribe medications.  We have to understand how the drug is working for the disease we are using it for, side effects to warn the patients about (which often are related to the mechanism of action), contraindications and drug interactions so that we don’t cause harm to our patients unknowingly.  She loved Willie Nelson so she would often sing:

  • “You gotta know when to hold them.”   Know generics! Some medications have multiple brand names but there is only one generic name of a medication, and often times (not always) the ending of generic drugs can help you with the class of the drugs. Such as “pril” ending for ace inhibitors, “artan” for angiotensin receptor antagonists, “tidine” endings for the H2 blockers etc.


  • “You gotta know when to fold them.”   You also need to know when the endings may mislead you. For example metronidazole is an antibiotic that is not in the same class as fluconazole (an antifungal) or that because many antibiotics were derived from Streptomyces, some drugs can have similar endings but are in different classes, such as streptomycin, vancomycin, clindamycin, erythromycin.


  • “Know when to walk away.”   You need to know what are some of the precautions when using certain drugs, such as beta blockers can mask hypoglycemia.


  • “Know when to run” – you need to know absolute contraindications of medications.




“Eat all of your veggies”

In doing exam questions, never leave any questions unanswered.  Answer all of your questions.  Because the PANCE/PANRE is a timed exam, you should practice doing questions in a certain amount of time, leaving yourself about a minute for each questions to assure that you answer  questions sufficiently.  If you think you have an answer but you spend 10 minutes perseverating on which one is right, then you have lost valuable time to answer other questions for that one question, forcing you to rush your thought process in answering the remaining questions.  So put an answer down and flag it so that you can come back to it at the end of the exam and then have all the remaining time to spend on the flagged questions now that you have given an answer to all of the other ones.  I have also found that, if I am lucky, some other similar question in that question block may have given me the clue or jarred my memory enough to remember the answer to a flagged question.


“When in a rut, trust your gut”

This is also crucial in time management tool when you are stuck on a difficult question. Many people will have a right answer and then change it to a wrong one because they falsely doubted their choice.  Changing it may work if you were initially unsure of the choice you made and, through further reading, you now feel there is a better answer.  But if you strongly believe an answer is right based on material that you feel you understand, then chances are your gut was right.  Although this method doesn’t work for everyone, I am a firm believer in reading the stem and the question and then predicting what the answer would be before even reading the choices.  If I am fairly confident in it based on the stem buzz words, inclusion and exclusion factors, then that will be my default answer when I am not sure which of the two to pick. I may still flag it and then come back to it later if I have time left over to make sure I am not missing anything.  If there isn’t anything compelling when I re-read it to make me change my answer, then I will stick with it.  And by compelling, I will give you this example.  Let’s say I didn’t follow my own advice and I spent 5 minutes on one question and now I have 5 questions left and 6 minutes so I fly through the last few questions and flag them.  Now with the last 2 minutes, I go back to the question that states:


A 42-year-old male presents with right leg swelling, pleuritic chest pain, tachypnea and shortness of breath after a 10 hour drive from Georgia to Connecticut. Labs show a Creatinine of 1.8, Sodium of 140, with a negative troponin and creatine kinase levels. ECG shows an S1Q3T3 pattern. Which of the following is the next most appropriate diagnostic test in the management of this patient?

A. D-dimer levels

B. Pulmonary angiography

C. Helical CT scan

D. Ventilation-Perfusion Scan

E. Coronary angiography


My choice when I read this was choice C but I admittedly read this fast. I used all  the stuff from above.  I used my “buzz words’ to know that this sounds like a classic pulmonary embolism presentation and that the ECG shows a classic (not common) ECG finding of S1Q3T3, making my best initial test in this vignette Choice C (Helical CT scan).  But now rereading the question with more time, I realized the patient has an elevated creatinine, so the administration of IV contrast may worsen the kidney function in this patient.  That qualifier now makes choice D (ventilation perfusion scan) the better option.  Had it not been for that, I would have kept my answer as C.  So if I reread it and I knew my answer was C and there were no factors to change it, I would have kept C but that qualifier does change the answer in this specific instance.  Here, the test writer wanted to see if you knew how the person’s medical history would change your management.

This brings me to another important point. My mother would often say:

If I ask you about the moon, don’t answer me the sun”

She would always say that to me when she asked me a question and I was stalling to find the answer I thought she was looking for by replying about something else.  Always answer what the question is asking you.

Giving those same choices, if the vignette said or alluded to a  low suspicion of PE and there were no compelling findings for DVT or PE, then D-dimer would have been correct. If the question asked “Gold standard” or “Definitive diagnosis” then the answer would be Pulmonary Angiography.  This becomes important in questions that say “NEXT appropriate” etc.  because sometimes you know the disease but you answer wrong because you didn’t answer what the question was asking.   Remember that gold standard tests  are often (not always) invasive and so are usually done to definitively diagnose someone with a high suspicion and a negative (often less invasive) test.  Or if they specifically want to know what is the definitive diagnosis, don’t answer what you think you would be the next step.   Many students tell me well isn’t the “the most appropriate” test the gold standard and in question form that usually does not equal to  “six of one, a half dozen the other”.

Remember that classic doesn’t necessarily mean common. For example the “classic migraine” is with an aura but most patients with migraine “common migraine” present without an aura.  Or the classic chest radiograph finding in pulmonary embolism is Hampton’s hump or Westermark sign but the most common chest radiograph finding is a normal chest X ray.  So read the question carefully to make sure you are answering what they are asking of you.

“Sometimes you avoid choking when you realize you have bitten off more than you can chew.”

Be honest with yourself. If you are not ready to take the exam, don’t go into it “hoping for the best”.  This is different than being nervous or apprehensive about the exam.  Deep inside, you know when you are not ready and you have an objective way of telling if you are not consistently falling above that 80-85% range on the “Fabulous 5” organ systems.   Again “Failing to prepare is preparing to fail”.  So if you are not doing well in your studies, then delay the exam until you are ready.   You won’t magically pass if you are not ready.  Many  students just hope for the best and end up with the worst.

“Hope for the best, plan for the worst”

Make sure if your certification is up soon, don’t wait until the last minute to take the exam. In the worst case scenario that you fail, you have to wait 3 months to take it again, which can put your career in jeopardy if you are a practicing PA.   Give yourself enough time cushion so that you can retake it, take another course, study more etc. to ensure you pass the second time around.

Speaking of knowing when to fold them, I hope that these tips or techniques in terms of studying and approaching exam questions are helpful. Good luck, and make sure to thank my mother when you pass!  🙂

Dwayne A Williams is a clinical professor at two PA programs and the author of Pance Prep Pearls, a study guide for the PANCE and PANRE available on   He is also the author of the Medical Mnemonic Comic Book as well as the FlipMed medical app.

Winifred Williams is the author of Dwayne A. Williams 🙂




By LaurMG. (Cropped from "File:Frustrated man at a desk.jpg".) [CC-BY-SA-3.0 (], via Wikimedia Commons
By LaurMG. (Cropped from “File:Frustrated man at a desk.jpg”.) [CC-BY-SA-3.0 (, via Wikimedia Commons


As a professor for both clinical and didactic year at 2 PA schools for 12 years, I have seen a lot of students come and go.  PA school is one of the hardest things I have done in my life, but if I had a better roadmap when I was a student, the task would not have been as daunting.  I started undergrad with 4.0 average and upon starting PA school, I quickly learned that what I did to get the 4.0 had to be DRASTICALLY remodeled for PA school or I would have kept drowning.  Here are some tips to help new PA students stay afloat and survive the medical monsoon that is PA school.  Before jumping into tips, one must have a complete understanding of the unique problems of PA school…




COME TO TERMS WITH IT!!! Many people can cram, study and just regurgitate memorized material & many other skills to get a 4.0 in undergrad however, won’t get MOST people far in PA school because:

  1. You a learning A TON OF INFORMATION IN A SMALL AMOUNT OF TIME.   You are constantly learning new material while being tested on old material – there isn’t just one focus on one area.
  2. You have more time & less material in undergrad so it didn’t require a lot to get a lot (in terms of good grades).
  3. MOST of PA school is application learning:

Classes like anatomy may be heavy on memorization but many core classes require learning how to apply the information in a clinical scenario, not just pure memorizing the material.  This requires a much deeper understanding of the material compared to undergrad.


  4.  THE CLASS SCHEDULE IS USUALLY NOT STATIC:  Classes easily change day to day & week to week so you must adapt more often to changes and lengths of class.


   5.  There isn’t much FREE TIME:

  •          Schedules are hectic with little breaks.  Sometimes have multiple in exams in the same week while learning new material.


  • You can easily fall behind & hard to catch up.  Many students have the false notion that, like undergrad, it will be easy to catch up to speed with a little hard work.  Once you fall behind it becomes harder and harder to catch back up without compromising learning and retaining new material.
  • A lot of the material is CUMULATIVE:  Unlike undergrad, it is not about learning for an exam and then forgetting it.  You have to maintain a working knowledge and retention of the diseases .  “Old” material is never “old”  disease processes or diseases will come back in other classes = what I call the  OVERLAP phenomenon.


I hope by now that I convinced you that PA school is different.  But chances are if you are already in PA school, you have already learned the hard way.  Now that you realize it is different, MOST of you will  have to approach it DIFFERENT than you did  in undergrad.   Again, what you did to get a  4.0 in undergrad often will not work (or may not be enough to get a great grade in PA school).  So how do you alter or rearrange your once useful or semi-useful techniques to make you a stellar PA student??

  • The most fundamental principle of efficient studying  – the best use of your limited time – requires ACTIVE not passive learning.


  • ACTIVE LEARNING: requires MAKING ACTIVE, INTUITIVE  DECISIONS about the material.  Questions you must ask yourself is:
    • “WHY Is this important?” 
    • “What is the BIG PICTURE?”


                  What is the LITTLE PICTURE ?”

    • “WHERE have I seen this before?? (to make connections with things you have learned before).    
    • “Where does this fit into the ‘BIG PICTURE?”    How to organize material?



The LITTLE PICTURE  are the necessary components and details of a disease or group of disease.  This requires:

    • Understanding basic anatomy & physiology:   STUDENT MYTH: IF I AM NOT STUDYING FOR AN ANATOMY OR PHYSIOLOGY TEST AND IT IS CLINICAL MEDICINE, I CAN SKIP THIS BECAUSE IT’S “NOT NECESSARY.”    REALITY:   This is a critical mistake PA students make in an attempt to figure out when studying what should the focus on and what can fall by the wayside.  Now, I am not saying to remember every single page of anatomy and physiology from the book but you do need to know the basics of that to apply to the disease.  This is because when you understand the basic anatomy and physiology.  You can make sense of the pathophysiology of the disease.  Understanding the pathophysiology often will explain clinical manifestations and (9 times out of 10) the medications used to treat the disease, the mechanism of action of the medications as well as some of the side effects of the medications used or why some medications are first line for a disease where it isn’t in other diseases that it may be used for.  For example: understanding that heart failure is a condition where the body tries to compensate for the failing heart by stimulating the renin angiotensin system, which over time leads to decompensation and heart failure.   ACE inhibitors are first line for heart failure because they directly inhibit the effects of the renin angiotensin system.  Side effects of ACE inhibitors are they can cause hyperkalemia (because from physio you remember that if you block aldosterone, you get rid of sodium but you hold onto potassium and hydrogen ions – which also explains another possible side effect of ACE inhibitors, metabolic acidosis).  Understanding this also helps you to understand other disorders.  For example, the disease hyperaldosteronism (meaning that too much aldosterone action is occurring) will present with hypertension, hypokalemia (since aldosterone holds onto sodium in exchange for potassium and hydrogen ions) and metabolic alkalosis (since you are getting rid of hydrogen ions).  And why patients with Addison’s disease (a condition that you don’t produce enough aldosterone) will have hypotension and hyperkalemia as presenting symptoms.  Again different diseases with the same connecting principle.  Often students learn these thoughts in isolation and focus on these little details because in getting the little picture (of the details) they miss the big picture – but I am getting ahead of myself!  Back to the little picture:  Understanding the basics takes a little more time initially but the pay off is when you understand it, the other details make more sense and you don’t have to memorize as much because you can talk it out as to what is going to happen so it is easier to retain. The more you understand, the less you have to memorize!  This means that you don’t have to study as much and the time that you do use to study is used more efficiently!


    • Also understand the basic terminology used: I can’t tell you how many students can tell me that they see Kussmaul’s sign in certain diseases but when I ask them to describe it they can’t.  Often on exams, they may either write out the name of the terminology or describe it, so it is good to be able to understand the terminology you are using in a disease.  If you don’t know it, make sure to look it up!
    • STUDENT MYTH: ” IF I UNDERSTAND ALL THE LITTLE DETAILS THEN I WILL MASTER THE TOPIC”.  Wrong!  There is no little picture if you can’t see the big picture!!!



The BIG PICTURE is making the connections of all the little details to see the underlying theme of that disorder and how that concept can apply to other disorders.  This is the one of the hardest part for students because they concentrate so much on memorizing the little details they can’t pick their head up to see the connections, so they learn everything in an isolated bubble.  It is like driving to a destination.  if you just look at the road of the highway without looking at the signs, you will eventually get lost.  The big picture is like the GPS.  it tells you how the little roads that you learn are connected to get you to the destination.  Rather than aimlessly drive and ending up in detours, you take the fastest route to the end destination while maximizing your retention.   Why is the big picture Important??? Funny you should ask, well I am here to tell you!

    • Knowing the big picture helps to understand the little details moreFor most students this concept seems counterintuitive.  But when you understand the big picture, you understand the purpose and the principles of all the details you learned


    • Knowing the big picture helps you to relate other diseases to a common theme: For example Sinusitis (sinus openings get blocked and the flora that is already there along with the mucus builds up,  leading to an infection), Appendicitis (fecalith blocks the appendix leading to infection/inflammation), Cholecystitis (stone blocks the cystic duct, leading to infection/inflammation), Diverticulitis (fecalith blocks the diverticulum leading to inflammation/infection), Saliolithiasis (salivary stone…well you get the picture now).  Also other diseases that have the same processes are connected.  For example: atherosclerotic disease in the coronary arteries happen throughout other arteries in the body not just the coronary.  Whenever there is decreased blood flow we call it ischemia, when there is death due to prolonged ischemia, we call it infarction.  Ischemia in the coronary artery is called angina, cell death is called a myocardial infarction.  Atherosclerosis in the carotid arteries of the neck can lead to brain ischemia (TIA – Transient Ischemic Attack) or brain cell death (Cerebrovascular accident/Stroke).  Atherosclerosis in the arteries that supply the leg can lead to ischemic leg pain (claudication) or cell death (gangrene).  Atherosclerosis in the arteries of the GI tract can lead to ischemia (Chronic mesenteric ischemia often called intestinal angina) or acute ischemia that can lead to bowel gangrene, etc.


    • Finding the “big picture”  will help keep you on track during the lecture This is a fine tune skill that not all students will subscribe to because they will say that they don’t have time.  But if you read a lecture a few 5 minutes before class, it won’t be the first time you are hearing the material and then you can begin to formulate questions to ask your professor during the lecture of the material which is needed to effectively learn the lateral.
    • Knowing the big picture can maximize your study of the material later while reducing the time you have to study for it to make it stick:  it helps you to rewrite your notes in an outline form (which is very helpful for a quick study especially before an exam.  So is creating flow charts, lists or diagrams that organize the needed material in a visual way.  Not all of us are visual learners but you will be surprise that you remember that some information you needed to answer a question was in the upper left section of your chart or you can visualize your simplified chart in determining which way to go to treat the person.  Actively memorizing these flow charts are a quick way to review the material and then when you add the little picture to your big picture, you can see the work of art you created.


Here is an example of the big picture study strategy and how it helps you understand the disease better. Click on this for a sample:  BIG PICTURE.


Now that you have created your work of art, how do you know study it?



1.  MEMORIZATION: Some things need to be memorized and most students handle that part okay.  Difficult things that you need to memorize can sometimes be made simple with a mnemonic.  For example, I tell my students that Multiple

Myeloma is the main hematological malignancy that directly affects the bone.  So I teach them Bones “BREAK” with multiple myeloma to help them remember the cardinal findings in patients with Multiple Myeloma.

Bone pain – due to calcium remodeling.  This also helps them to remember the “punched out” lesions of the bone on the skull in patients with Multiple Myeloma

Recurrent Infections –  the plasma cells that make up the malignancy crowd out the bone marrow that the marrow can’t make other cell lines such as red blood cells

Elevated Calcium – Hypercalcemia due to bone remodeling

Anemia – the plasma cells that make up the malignancy crowd out the bone marrow that the marrow can’t make other cell lines such as red blood cells

Kidney Failure  – due to increased protein excretion damaging the glomerulus.  This also helps them to remember to look for Bence Jones Proteins in the urine

    •  Don’t put off memorizing material until just before the exam!      NOOOOOO CRAMMING!!!  Remember that tactic helped us in undergrad but it won’t help us here because you can’t commit things you cram into long term memory and remember medicine isn’t about forgetting what you learned and moving on, it is cumulative knowledge.  You won’t remember everything but you have to remember a lot of it or be able to recall it from your long term memory.  If you cram the night before, you won’t remember it in a week.
    • Frequent review of the material leads to more retention.  The more you review a packet over and over again, the more things will start sticking or making sense and you get an idea of what you know and what you don’t know.



Another Student MYTH: “I JUST DON’T HAVE ENOUGH TIME  TO GET IT RIGHT”.   I get it.  The hours are long, there isn’t much time to study, you need to sleep… yada yada….(insert violin player and sad woe-is-me music).  But this is what you signed up for.  You can’t learn all of medicine in a couple of years without time and sacrifice.  It is all about maximizing the little time you do have.  A few tips on how to do so…….

    •  Set aside adequate time for studying: Even with study tips, they are tips to help you STUDY (the operative word here).  You have to put in the time.
    • PRIORITIZE AND ORGANIZE TO MAXIMIZE  the time you have by using it more efficiently.  In other words if you decide you have 6 hours of study time  (I know I know how often does that happen) and you have 4 exams that week and you are going to study every day, do 2 hours of the exam coming first  and then an hour for the other exams.  As the exam passes and you have new material, then always re prioritize which should get more of your time.  A big mistake students make is using all 6 hours to study all the material in one exam and that will hurt your scores in the other exam.  Some people prefer to set aside the most important topics in the beginning when the brain is freshest or some at the end (because they retain what they look at last better).  You have to figure out which type you are to maximize the learning.  Now you didn’t hear this from me, but for those who are caught in a hairy predicament.  the have fallen  behind and you have 4 exams this week but 3 of them counts for the same class and you have lets say 6 exams in that course that count to your final grade but the 4th exam you have that week is for a  course that only has 2 exams and you didn’t do well on the first one (and if you don’t pass the second one, you will have to take a remedial or fail the course), then you need to prioritize that exam so that in the long run you are in better academic standing.  If you don’t do as well on an exam where getting a bad grade in the long run won’t affect your overall score then you have to think about the long-term.  Again you didn’t hear it from me and if you did all the things that I mentioned before, you wouldn’t find yourself in that dark, dark place.


    • BREAK UP THE STUDY WITH SOME BREAKS Another big mistake students make (especially those who found themselves in that deep dark place of academic issues) is they study for hours on end, thinking that the chunk of time will allow them to learn it.  I sometimes teach my students for 7 hours straight.  The first 45 minutes they are into the lecture and then close to the  hour, they  begin to nod their heads, look at me with puppy dog eyes to have mercy on their souls, some snore loudly, some snore silently but drool a lot, and their brain starts shutting down etc.  So I give them a break every hour and I do activities where they move around or do case studies or presentations just to get the brain to learn a different way and to give the brain a rest.  You won’t learn if you are completely tired or if you don’t give yourself a break!  Students fail to realize those breaks make those 45 minutes in between much more efficient.  For example, lets say you have those 6 hours as above and you are studying for Pharmacology, Infectious Disease, Anatomy and Pathology (the dreaded test you didn’t do well on the first one and there are only two for that course)  and you are one of the ones whose brains are fresh in the beginning.  then your study should look like this:
  • Pathology 12p -1p (break 1:15-1:30p)
  • Pathology 1:30 – 2:30 (break 2:30 – 2:45p)
  • Pharmacology 2:45p- 3:45p (break 3:45p-4:00p)
  • Infectious Disease 4p- 5p (break 5p – 5:15)
  • Anatomy 5:15-6:15p


And when you take a break, walk away from the study area, take a walk, catch up on your social website, pet your dog, cat or pet tiger, listen to music, call and cry to a fellow student that I am making you study for 6 hours.   But do something to temporarily take your mind off the material and that is relaxing.


    • GET SOME ZZZ’S TO GET SOME AAA’S: Another big mistake students make  is to study all through the night and go to the exam with only 2 hours of sleep.  While this strategy may work for very few and far between, fatigue means you are more likely to make smaller mistakes and your brain won’t function at its peak when you are sleepy.  Do you want a sleep bus driver driving you to PA school??? Probably not (unless you want to use the excuse the bus accident delayed you from taking the exam).  You should be well rested so you can perform at your best on the exam.


    • STUDY GROUPS ARE NOT THE TIME TO STUDY…WELL SORT OF:  Study groups are not for everyone.   Many people do better studying on their own.  But if you decide that study groups are good for you (which many are, you also have to maximize what you get out of that.   Though it is called a study group, most of your studying should have been done before you go to the group.  You want to be able to contribute to the group and if someone doesn’t understand a concept, you may be able to explain it in a way that they can get it.  in you explaining it, you reinforce that concept in your head.  Also since you studied, you know which issues you need help with to pinpoint your focus in the group.  And no one likes that person who is slowing down the group because they are trying to write down everything being said because they have no clue what is going on.  Make sure the socializing is limited.  It is a study group not a social group.    No talking about TV or who is hottest guy or girl  in the PA class etc.  That cuts into study time.  Quiz each other, break up tasks areas and assign each person so they can tackle a subject and quiz each other make up some scenarios to apply the information you learned clinically.  When a question is answered wrong, try to help explain why it was wrong to help each other learn.    Sometimes you think you understand a topic until you get a question wrong sand you realize that you may not have totally understood a key concept that you thought.  Plus, students discussing topics may have made you realize there was key area that you missed but them discussing it brings your attention to that detail.



    • Not all technique works for all people – find which ones works for you
    • If you try a technique and it works, use it
    • If it doesn’t work, assess if it needs to be utilized better, altered or changed
    • Don’t become too discouraged, it takes time to get an effective


With this information you can cruise and soar above the waves instead of sinking into the deep abyss!  And have a blast learning medicine at the same time!


Great Studies to you!!!!

Dwayne A Williams is a clinical professor at two PA programs and the author of Pance Prep Pearls, a study guide for the PANCE and PANRE available on   For more information, visit