PANRE Prep: High-Yield Clinical Knowledge Refreshers for the Recertifying Physician Assistant

PANRE Prep: High-Yield Clinical Knowledge Refreshers for the Recertifying Physician Assistant

by

Recertifying means you already know how to care for patients. PANRE success comes from sharpening pattern recognition, recalling key numbers, and choosing the safest first step. The exam rewards clear thinking: what is it, how do you prove it, what do you do now, and what can’t you miss. Use these high-yield refreshers to tune up the clinical details you use every day.

Exam mindset: pattern → test → treat → safety-net

  • Pattern: Name the most likely diagnosis from age, risk, and a few classic clues. This saves time because most exam vignettes lean toward one best answer.
  • Test: Choose the least invasive, most confirming test. The exam rewards tests that change management.
  • Treat: Know first-line therapies and what actually reduces mortality (e.g., GDMT for HFrEF).
  • Safety-net: Spot red flags. If a patient could crash, stabilize first and call for help. The exam prioritizes patient safety.

Cardiology: chest pain, rhythms, and heart failure

  • ACS basics: New crushing chest pain with diaphoresis is ACS until proven otherwise. Get ECG within 10 minutes and high-sensitivity troponin. Why: early reperfusion and antiplatelet therapy save myocardium and lives.
  • STEMI vs NSTEMI: STEMI = contiguous ST elevation or new LBBB with ischemic symptoms → activate cath lab. NSTEMI/UA = non-ST elevation with positive troponins or dynamic changes → admit, dual antiplatelet, anticoagulation. Why: STEMI needs immediate reperfusion; NSTEMI needs early invasive strategy.
  • Immediate meds in suspected MI: Chewable aspirin 162–325 mg now. Sublingual nitro for pain (avoid in RV infarct or hypotension). Beta blocker within 24 h if no shock, heart block, or asthma. High-intensity statin. Why: aspirin and statins reduce mortality; nitrates relieve ischemia.
  • Heart failure (HFrEF): Start GDMT: ARNI (or ACE/ARB), evidence beta blocker (metoprolol succinate, carvedilol, bisoprolol), MRA (spironolactone), and SGLT2 inhibitor. Why: each class independently lowers death and hospitalization.
  • Atrial fibrillation: If unstable, cardiovert. If stable, rate control (beta blocker or diltiazem; avoid diltiazem in HFrEF). Anticoagulation when CHA2DS2-VASc ≥2 in men or ≥3 in women; consider at 1 (men) or 2 (women). Why: stroke prevention is the key outcome.
  • Hypertension: Target <130/80 for most adults. First-line: thiazide, ACE/ARB, or CCB. Black patients without CKD: thiazide or CCB. CKD with albuminuria: ACE/ARB. Why: these choices reduce CV events in the studied groups.
  • Murmur must-knows: Aortic stenosis = harsh systolic, radiates to carotids, older patient with syncope/angina. Mitral regurg = holosystolic at apex radiating to axilla. Why: these patterns guide echo and urgency.

Pulmonology: dyspnea, wheeze, and clots

  • Asthma: Controller therapy centers on inhaled corticosteroids; ICS–formoterol as needed is preferred for mild disease. Why: ICS reduces inflammation and exacerbations better than SABA-only.
  • COPD: Start LAMA or LAMA/LABA for symptoms. Add ICS if frequent exacerbations or eosinophils high. Oxygen if resting SpO2 ≤88% or PaO2 ≤55. Why: LAMA/LABA reduce exacerbations; oxygen improves survival only in severe hypoxemia.
  • Community-acquired pneumonia:
    • Healthy outpatient: amoxicillin high-dose, doxycycline, or macrolide if local resistance is low.
    • Comorbidities: amox-clav or a cephalosporin plus doxy or macrolide; or respiratory fluoroquinolone monotherapy.

    Why: coverage should match likely S. pneumoniae and atypicals while limiting resistance.

  • Pulmonary embolism: Use Wells score to guide D-dimer vs imaging. If high probability, anticoagulate first, then CT-PA. Why: delays in anticoagulation increase mortality.
  • Pneumothorax: Tall, thin young person with sudden pleuritic pain → get CXR. Tension physiology (hypotension, tracheal deviation) = immediate needle decompression before imaging. Why: treat life threats first.

Endocrinology: glucose, thyroid, and adrenal pearls

  • Type 2 diabetes diagnosis: A1c ≥6.5%, fasting glucose ≥126, 2-h OGTT ≥200, or random ≥200 with symptoms. Why: these thresholds predict microvascular risk.
  • T2DM treatment: Metformin unless advanced CKD or intolerance. Add GLP-1 RA for ASCVD/obesity, SGLT2 for HF or CKD. Insulin if symptomatic hyperglycemia, A1c very high, or catabolic signs. Why: outcome-driven therapy beats A1c-only strategy.
  • DKA vs HHS: DKA = high anion gap acidosis and ketones (type 1 or insulin-deficient). HHS = severe hyperglycemia with osmolality, minimal ketones. Treat both with fluids first, then insulin, and fix K+. Why: volume depletion kills; insulin without K+ can trigger arrhythmias.
  • Thyroid: Low TSH/high free T4 = hyperthyroid; high TSH/low free T4 = primary hypothyroid. Thyroid storm = fever, tachyarrhythmia, AMS → beta blocker, thionamide, iodine (after thionamide), steroids. Why: block hormone effects and synthesis.
  • Thyroid nodules: Get TSH and ultrasound. Low TSH → radionuclide scan (hot nodules are rarely malignant). Ultrasound patterns and size guide FNA (typically ≥1 cm if suspicious). Why: avoids unnecessary biopsies.
  • Primary hyperaldosteronism: Resistant HTN or HTN with hypokalemia → screen with plasma aldosterone/renin ratio. Why: targeted treatment (adrenalectomy or MRA) improves BP and CV risk.

Infectious diseases: when to cover and when to culture

  • Cellulitis vs abscess: Fluctuance means abscess → incision and drainage. Nonpurulent cellulitis → cover strep; purulent → add MRSA coverage (TMP-SMX, doxy, or clindamycin). Why: drainage cures abscess; antibiotics alone often fail.
  • UTI: Cystitis first-line: nitrofurantoin, TMP-SMX (if local resistance low), or fosfomycin. Pyelo: oral fluoroquinolone if local resistance allows, or ceftriaxone then step-down. Why: tissue penetration differs by site.
  • Meningitis empiric therapy: Adults <50: ceftriaxone + vancomycin. ≥50 or immunocompromised: add ampicillin for Listeria. Give steroids before/with first dose for suspected pneumococcal. Why: early appropriate therapy improves survival and outcomes.
  • Sepsis: Suspect with infection + organ dysfunction (hypotension, lactate ≥2). Start broad antibiotics and 30 mL/kg fluids promptly. Why: each hour of delay raises mortality.
  • Endocarditis prophylaxis: Only for highest risk (prosthetic valves, prior IE, certain congenital heart disease) undergoing dental work with gingival manipulation. Why: limits unnecessary antibiotics.
  • Adult vaccines, quick hit: Tdap once, then Td/Tdap every 10 years; annual influenza; shingles (2-dose recombinant) ≥50; pneumococcal: single PCV20 dose (or PCV15 then PPSV23 later) depending on prior status. Why: prevents severe disease in high-risk adults.

Gastroenterology: pain patterns and bleeds

  • RUQ pain: Positive Murphy sign + fever/leukocytosis → ultrasound for cholecystitis. HIDA if US equivocal. Why: US is fast, noninvasive, and accurate for stones and inflammation.
  • RLQ pain: Migratory pain, anorexia, rebound → CT in adults; ultrasound first in pregnancy/kids. Why: imaging reduces negative appendectomy.
  • LLQ pain: Uncomplicated diverticulitis may be managed outpatient; antibiotics if systemic signs, immunosuppressed, or significant comorbidity. Amox-clav is common. Why: not all cases need antibiotics; treat higher-risk patients.
  • Upper GI bleed: Resuscitate first. PPI infusion for suspected peptic ulcer bleed; octreotide and antibiotics in suspected variceal bleed. Early GI consult for endoscopy. Why: hemodynamics and acid suppression reduce rebleeding risk.
  • H. pylori: Bismuth quadruple therapy is preferred first-line in many areas due to clarithromycin resistance. Confirm eradication. Why: rising resistance lowers triple therapy success.
  • Pancreatitis: Epigastric pain radiating to back + lipase ≥3× ULN. Early aggressive fluids and pain control; CT only if unclear diagnosis or no improvement. Why: most cases resolve with supportive care.
  • LFT patterns: AST/ALT >> ALP/Bili = hepatocellular (viral, toxins). ALP/Bili >> AST/ALT = cholestatic (stones, stricture). Why: pattern narrows differential and guides imaging.

Renal and electrolytes: AKI, CKD, and potassium

  • AKI categories: Prerenal (hypoperfusion), intrinsic (ATN, GN), postrenal (obstruction). FeNa <1% suggests prerenal; >2% suggests ATN. On diuretics, FeUrea <35% supports prerenal. Why: directs fluids vs further workup.
  • CKD: Stage by eGFR and albuminuria. ACE/ARB for albuminuria (ACR ≥30) unless contraindicated. SGLT2 inhibitors slow CKD progression even without diabetes. Why: reduces ESRD and CV events.
  • Hyperkalemia emergencies: Peaked T waves/widening QRS → calcium gluconate to stabilize myocardium, insulin + dextrose to shift K+, consider albuterol and bicarbonate, then remove K+ (loop diuretic, zirconium, dialysis). Why: arrhythmia risk is immediate.
  • Nephrotic vs nephritic: Nephrotic = heavy proteinuria, edema, hyperlipidemia. Nephritic = hematuria, HTN, some protein, RBC casts. Why: different pathophysiology and treatment.
  • BPH: LUTS → alpha-blocker first (tamsulosin). Add 5-alpha-reductase inhibitor if enlarged prostate. Red flags (retention, UTIs, hematuria, elevated creatinine) need further workup. Why: symptom relief vs disease modification.

Musculoskeletal and rheumatology: joints you can’t miss

  • Septic arthritis: Hot, swollen joint with fever → urgent arthrocentesis; WBC >50,000 with neutrophil predominance suggests infection. Start IV antibiotics. Why: delays cause joint destruction and sepsis.
  • Gout: Sudden monoarthritis of first MTP; negatively birefringent needle crystals. Acute therapy: NSAID, colchicine, or steroid (not together NSAID + steroid). Start urate-lowering if ≥2 flares/year, tophi, or CKD. Target urate <6. Why: prevents flares and joint damage.
  • RA vs OA: RA = symmetric small joints, morning stiffness >1 hour, improves with activity; treat early with DMARDs (methotrexate). OA = pain with use, brief stiffness, bony enlargement; treat with exercise, NSAIDs, injections. Why: inflammation vs degeneration guides therapy.
  • Back pain red flags: Cancer, infection, trauma, neuro deficits, saddle anesthesia, urinary retention → immediate imaging and referral. Why: risk of cord compression or cauda equina.
  • Ottawa ankle rules: X-ray if malleolar pain plus bone tenderness at posterior edge/tip of malleoli or inability to bear weight. Why: reduces unnecessary imaging without missing fractures.

Neurology: time is brain

  • Stroke: Check last-known-well. Noncontrast CT first to rule out bleed. Thrombolysis up to 4.5 hours in selected patients; BP must be <185/110 before tPA. Large-vessel occlusions may get thrombectomy up to 24 hours with favorable imaging. Why: early reperfusion improves outcomes.
  • TIA: Neurologic deficit resolved <24 hours still needs urgent risk stratification and imaging of carotids and heart. Start antiplatelet and manage BP, lipids. Why: high short-term stroke risk.
  • Seizure: First seizure → check glucose, electrolytes, and consider imaging. Levetiracetam is a common first-line due to fewer interactions. Status epilepticus: benzodiazepine first, then antiepileptic. Why: prolonged seizures cause neuronal injury.
  • Headache red flags: “Worst ever,” new neuro deficits, fever/neck stiffness, age >50 with new headache, cancer/HIV → image ± LP. Why: must exclude SAH, meningitis, mass, or temporal arteritis.
  • BPPV: Brief positional vertigo with positive Dix-Hallpike; treat with Epley. Why: canalith repositioning fixes the cause.

Dermatology: rashes that matter

  • Cellulitis vs erysipelas: Erysipelas has raised, well-demarcated border (usually Group A Strep). Cellulitis is deeper and less defined. Why: helps choose narrow strep coverage when appropriate.
  • Drug eruptions: Morbilliform rash 1–2 weeks after new med; stop agent. Red flags: mucosal involvement, blistering, systemic signs → suspect SJS/TEN and hospitalize. Why: SJS/TEN can be fatal.
  • Psoriasis: Well-demarcated plaques with silvery scale on extensor surfaces; treat with topical steroids/vitamin D analogs, escalate to phototherapy or biologics for severe disease. Why: immune-driven disease needs anti-inflammatory therapy.
  • Skin cancer: Melanoma ABCDE (Asymmetry, Border, Color, Diameter, Evolution). Basal cell = pearly with telangiectasias; SCC = scaly, indurated, may ulcerate. Actinic keratosis is premalignant; treat with cryo or field therapy. Why: early treatment prevents progression.

Hematology: anemias and clots

  • Iron deficiency: Microcytosis, low ferritin, high TIBC. In men/postmenopausal women, evaluate for GI blood loss. Why: iron loss is usually from bleeding, not diet.
  • Anemia of chronic disease: Low iron, low TIBC, normal/high ferritin. Why: iron is sequestered in inflammation.
  • B12 vs folate: Both macrocytic; neurologic deficits point to B12 deficiency. Replace B12 before folate to avoid worsening neuropathy. Why: folate can mask hematologic signs.
  • Hemolysis labs: High LDH, high indirect bilirubin, low haptoglobin, reticulocytosis. Why: confirms increased RBC destruction.
  • VTE treatment duration: Provoked DVT/PE usually 3 months; unprovoked often extended if bleeding risk is low. Cancer-associated VTE: DOACs or LMWH. Why: prevents recurrence driven by ongoing risk.
  • Transfusion: Restrictive threshold in stable adults is Hb <7 g/dL (higher if active ischemia or symptomatic). Why: reduces transfusion risks without worse outcomes.

Women’s health: from screening to emergencies

  • Ectopic pregnancy: Pain + bleeding + positive hCG → transvaginal ultrasound. Discriminatory zone ~1500–3500 mIU/mL. If no intrauterine pregnancy above zone, suspect ectopic. Why: rupture can be fatal.
  • Preeclampsia: New BP ≥140/90 after 20 weeks plus proteinuria or severe features (thrombocytopenia, elevated LFTs, renal dysfunction, pulmonary edema, headache/visual changes). Severe HTN (≥160/110) needs urgent control and magnesium for seizure prophylaxis. Why: prevents maternal stroke and eclampsia.
  • PID: Cervical motion/uterine/adnexal tenderness with STI risk. Outpatient: ceftriaxone IM plus doxycycline ± metronidazole. Inpatient if pregnant, severe illness, abscess, or cannot tolerate PO. Why: early therapy prevents infertility.
  • Contraception cautions: Avoid estrogen in migraine with aura, smokers ≥35, uncontrolled HTN, VTE history, or breast cancer. Why: estrogen increases thrombotic and stroke risk in these groups.
  • Cervical cancer screening (average risk): Start at 21. Ages 21–29: cytology every 3 years. Ages 30–65: HPV testing alone every 5 years, or cotesting every 5, or cytology every 3. Stop after 65 if adequate prior screening and low risk. Why: balances early detection with overtesting harms.

ENT and eyes: don’t miss the airway or the angle

  • Strep pharyngitis: Centor features (fever, tonsillar exudate, tender anterior nodes, no cough). Test before treating in adults to avoid unnecessary antibiotics. Why: viral pharyngitis is far more common.
  • Otitis media: Bulging, erythematous TM with decreased mobility. First-line high-dose amoxicillin unless recent antibiotics or purulent conjunctivitis (then amox-clav). Why: targets S. pneumoniae and H. influenzae.
  • Epiglottitis: Rapid sore throat, drooling, muffled voice, stridor. Keep patient calm, do not use tongue depressor, secure airway emergently. Why: manipulation can precipitate obstruction.
  • Acute angle-closure glaucoma: Severe eye pain, halos, mid-dilated fixed pupil, high IOP. Treat with topical beta blocker, alpha-agonist, acetazolamide; urgent ophtho. Why: prevents optic nerve damage.
  • Orbital cellulitis: Painful EOM, proptosis, decreased vision → IV antibiotics and imaging. Why: risk of cavernous sinus thrombosis and vision loss.

Emergency must-know doses and cutoffs

  • Anaphylaxis: IM epinephrine 0.3–0.5 mg of 1 mg/mL (1:1000) in lateral thigh; repeat every 5–15 minutes as needed. Add antihistamines and steroids after epi. Why: epinephrine is lifesaving and time-sensitive.
  • Hypoglycemia: If alert, give 15–20 g oral glucose; if altered, IV dextrose (D50 adults) or IM glucagon. Why: rapid correction prevents seizures and coma.
  • Opioid overdose: Naloxone 0.4–2 mg IV/IM/IN; titrate to breathing, not full arousal. Why: avoids acute withdrawal while restoring ventilation.
  • ACS aspirin: 162–325 mg chewable at first medical contact. Why: early platelet inhibition lowers mortality.
  • Status asthmaticus: Repeated SABA via neb, ipratropium, systemic steroids early; consider magnesium sulfate. Why: bronchodilation and anti-inflammatory therapy reverse airflow obstruction.

Numbers that often show up

  • BNP: Elevated supports HF in dyspnea; low level argues against HF. Why: high negative predictive value.
  • D-dimer: Use only in low/intermediate probability for VTE. Why: high sensitivity, poor specificity.
  • Lactate >2 mmol/L: Signals hypoperfusion; higher levels correlate with mortality. Why: guides resuscitation intensity.
  • Troponin kinetics: Rises 2–4 h, peaks ~24 h, remains elevated days. Why: helps time infarct vs reinfarct.
  • TSH recheck: 6–8 weeks after dose change. Why: hormone axis needs time to equilibrate.

Last-week strategy and test-day tips

  • Focus on first steps: Stabilize ABCs, get the right confirmatory test, then choose guideline-backed therapy. The exam rewards safe sequencing.
  • Memorize short lists: ACS initial meds; meningitis empiric regimens; hyperkalemia sequence; anaphylaxis dose; stroke tPA rules. These recur often.
  • Use age and risk as shortcuts: Older smoker with hemoptysis → image lungs. Young woman with pleuritic chest pain on OCPs → think PE. Patterns save time.
  • Eliminate unsafe answers: If a choice delays lifesaving care or ignores red flags, discard it—even if the diagnosis is uncertain.
  • Keep it simple: Prefer tests that change management. Avoid shotgun labs or duplicate imaging when a single best test exists.

You already practice this medicine. The PANRE asks you to prove it under time pressure. Lean on pattern recognition, pick targeted tests, start proven therapies, and never miss the safety-critical steps. That approach will carry you through the toughest vignettes.

Leave a Comment

PRO
Ad-Free Access
$3.99 / month
  • ✓ No Interruptions
  • ✓ Faster Page Loads
  • ✓ Support Content Creators
Subscribe Now