Preparing to recertify (or certify for the first time) is an arduous process for which there is never enough time to practice and test one's knowledge. The Quick Recertification Series (QRS) is one way PAs who are preparing to take the exam can meet their informational needs. In a condensed review format, the QRS addresses critical topics included on the exam. It also provides practice questions, answers, and their explanations. Successful completion of the NCCPA examination requires a variety of tactics. The QRS offers one more to add to your test-taking armamentarium.
PREMENSTRUAL DYSPHORIC DISORDER (PMDD)
GENERAL FEATURES
• PMDD involves physical and behavioral symptoms that occur regularly in women in the luteal phase (days 14-28 of the menstrual cycle) and interfere with normal activities.
• PMDD is thought to be the most severe form of premenstrual disorder occurring along the spectrum from PMS (premenstrual syndrome) to PMDD. In PMDD, anger, irritability, and tension are the predominant symptoms.
• The incidence of PMS is between 10% and 90% of women; PMDD affects approximately 3% to 8% of PMS sufferers.
CLINICAL ASSESSMENT
• Symptoms are associated with the menstrual cycle beginning during the luteal phase and resolving with the onset of menses; patients are symptom free during the follicular phase (days 1-14) of the menstrual cycle.
• The most common symptoms involve psychological effects (labile mood, tension, irritability, depressed mood, forgetfulness, anger, tearfulness); abdominal bloating, GI upset, heart palpitations, headache, acne, and breast tenderness.
• Hyperthyroidism/hypothyroidism and underlying major psychiatric disorders should be ruled out. A CBC, thyroid-stimulating hormone, and serum chemistry tests should be ordered to rule out other disease.
DIAGNOSIS
• Patients will report symptoms; for PMDD psychological symptoms will predominate.
• DSM-IV-TR criteria for PMDD include depressed mood, feelings of hopelessness, or self-deprecating thoughts; anxiety, tension, or feelings of being “keyed up” or “on edge”; marked affective lability; anger, irritability, or increased interpersonal conflicts; decreased interest in usual activities; difficulty concentrating; lethargy, easy fatigability, or marked lack of energy; change in appetite, overeating, or specific food cravings; hypersomnia or insomnia; a sense of being overwhelmed or out of control; and physical symptoms such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” or weight gain.
• The timing of symptoms is essential and must be determined for diagnosis; patients must exhibit a symptom-free interval during the follicular phase. Consider providing a menstrual calendar so the patient can track the timing of symptoms.
• Symptoms must be severe enough to interfere with daily living.
• PMDD is a diagnosis of exclusion, including the absence of hormone or drug ingestion that could explain symptoms.
TREATMENT
• Nonpharmacologic interventions include exercise, relaxation, and stress reduction.
• Pharmacologic treatment includes the following:
• Vitamin B6 to relieve breast tenderness and depression; calcium, magnesium, and vitamin D
• Oral contraceptives to suppress ovulation; 28-day regimens of active drug more effective than 21 days of hormones
• Selective serotonin reuptake inhibitors, including sertraline (Zoloft), paroxetine (Paxil, Pexeva), or citalopram (Celexa) given daily or cyclically during the luteal phase
• Diuretics (eg, spironolactone [Aldactone]) may relieve symptoms related to fluid retention
• NSAIDs to relieve symptoms associated with pain.
QUESTIONS & ANSWERS
1. Your 35-year-old female patient complains
of severe PMS symptoms that are affecting her ability to work and stressing her relationships with family members. You suspect PMDD and ask about the timing of her symptoms. In order to be considered PMDD, her symptoms must begin
a. With the onset of menses
b. During the follicular phase
c. During the luteal phase
d. At ovulation
Answer: c
Explanation: Premenstrual symptoms are associated with the menstrual cycle and begin 1 to 2 weeks before the onset of menses and end within the first few days after the onset of menses. A symptom-free interval during the follicular phase (days 1-14 of the menstrual cycle) must also occur.
2. The patient from Question 1 is treated with oral contraceptive pills, exercise, and stress reduction, but her symptoms persist. You recommend treatment with
a. Paroxetine
b. Olanzapine
c. Lithium
e. Divalproex sodium
Answer: a
Explanation: Selective serotonin reuptake inhibitors have been shown to be effective in some women with PMDD. These drugs may be taken during the luteal phase or during the entire menstrual cycle. Antipsychotics are not recommended for the treatment of PMDD.
PSORIASIS
GENERAL FEATURES
• This chronic skin disorder is characterized by rapid epidermal cell turnover and proliferation of keratinocytes, resulting in formation of scaly plaques, pruritus, and inflammation.
• Approximately 2% of the world's population has some form of psoriasis, with men and women affected equally.
• There are guttate, pustular, and arthritis variants of psoriasis.
CLINICAL ASSESSMENT
• The characteristic psoriatic lesions are well-defined erythematous plaques and papules with a loosely adherent silvery scale; removal of the scale results in pinpoint bleeding (Auspitz sign).
• While patches can be found anywhere on the body, they are most commonly located on the elbows, knees, scalp, fingernails, and toenails.
• Nail involvement demonstrates pits and ridges, nail separation from the nail bed, and oil spots.
• Patches can develop from physical trauma such as sunburn or scratch¬ing (Koebner phenomenon); pruritus is common.
• Psoriatic arthritis can be present in persons without skin lesions; joints involved are most commonly the dis¬tal joints of hands and feet.
• Guttate psoriasis develops following a streptococcal pharyngitis infection and is characterized by disseminated lesions that spare the palms of the hands and soles of the feet.
• Pustular psoriasis (Zumbusch's psori¬asis) is characterized by fever, mal¬aise, and leukocytosis along with disseminated pustules that join to form lakes of pus.
DIAGNOSIS
• Diagnosis is made by history and physical examination; skin biopsy is rarely necessary.
TREATMENT
• Nonpharmacologic therapy includes sun exposure, elimination of triggers (such as beta-blockers, lithium, antimalarial therapies), and emollient moisturizers applied daily following a warm water bath.
• Mild cases may be treated with topical corticosteroids or coal tar preparations.
• Topical vitamin D preparations (calcipotriene), coal tar or salicylic acid preparations, or retinoids (also effective for pustular psoriasis) are used for moderate disease.
• Treatments for generalized disease may include PUVA (psoralen plus ultraviolet A), methotrexate, and cyclosporine.
• Systemic corticosteroids can be effective but may result in exacerbations after treatment is stopped. JAAPA
QUESTIONS & ANSWERS
1. You are seeing a 45-year-old male patient for “a rash” and notice erythematous plaques and papules covered with silvery scales on his elbows and knees. You remove one of the scales and notice pinpoints of bleeding. This bleeding is known as
a. Ackerman's sign
b. Auspitz sign
c. Zumber's sign
d. Capillary sign
Answer: b
Explanation: Auspitz sign refers to the specks of bleeding that occur when a scale is removed from a psoriatic lesion.
2. You diagnose the patient in Question 1 with psoriasis. Because his symptoms are mild, you decide to treat him with a. Topical corticosteroids
b. Methotrexate
c. Retinoids
d. PUVA
Answer: a
Explanation: Mild symptoms of psoriasis may be alleviated with topical corticosteroids. Methotrexate, retinoids, and PUVA are reserved for moderate to severe disease.
The QRS is not meant to replace in-depth studying for the recertification exam and should be used only as an adjunct. The information contained here may not be sufficient to provide diagnosis and treatment in the clinical setting.
Amy Klingler practices in primary care at the Salmon River Clinic, Stanley, Idaho. Ms. Klingler and Dawn Colomb-Lippa, PA-C, are department editors for the Quick Recertification Series and members of the JAAPA editorial board.