If you are reading this, you are about to begin your journey through our QBank. This experience has been designed to allow you to customize your learning and review, and also to focus on the weakest parts of your knowledge base. We have created this tool to allow you to learn, in addition to review for your exam. This experience is also perfect for practice development as you advance in your career and want to apply current concepts to your practice.
Before you jump right in and begin answering test questions, we suggest you take the following steps to familiarize yourself with the QBank, and set yourself up for success!
When you first log in to our website, you will encounter the Clinical Toolkit. This is the standard members-only page that all members of Provider Practice Essentials will see. The types and number of programs available depends on which programs you have purchased and enrolled for. Click on the name of the program you are using to see the content dropdown with that module.
Click on the dropdown content you with to access. For example, in the above picture, if you wanted to take the Emergency Medicine QBank, you would click on “Qbank”.
When you click the PPE Qbank button on the Review Dashboard, you will be taken to the Qbank Progress Dashboard. Notice that there are links for all of the other parts of the review series on the top of the screen.
You will notice several columns on your dashboard that display your personal data. Each question category is listed and ranked by the percentage of questions you have correctly answered. You will notice that before you take any practice tests, these categories are listed alphabetically. As you answer questions from each category, their ranking will change based on the number of questions you answer correctly. There will also be a bar graph next to each category that corresponds to the percentage you answer correctly. The more questions you answer from a specific category, the more accurately your performance will be ranked.
In addition to your category performance, you will easily be able to see your best and worst performing areas. We suggest you use this as a quick glance to see where you may want to focus. Finally, you will see a running total of the number of questions you have answered, the percentage you have answered correctly, and the total number of questions remaining in your QBank.
Once you have taken a question, it will be removed from the remaining questions you have available to answer. There is a menu on the top of your dashboard, where you will be able to launch any of the other board review products you have purchased.
The PPE Qbank allows you to customize your testing experience to suit your individual needs. There are two types of tests available, both of which have a unique purpose. You can create tests by clicking on the buttons at the top of the dashboard.
When you click the custom test button from the performance dashboard, you will be taken to the setup page. Simply select the categories you want to focus on for your quiz and choose the number of questions for each category. You will notice that the total number of questions appears at the bottom of your category list. You will be permitted to take a maximum of 150 questions per test.
Here are a few important things to remember when making a custom test:
1) Once you select a category, you need to enter the number of questions you want in the box next to it.
2) If you select all, you must enter a number next to that option. The questions will be evenly divided among the categories, but you will need a minimum of 1 question for each category.
3) If you encounter any problems making a quiz, go back to the dashboard and start again. You won’t lose any questions. Be sure to make your quizzes correctly next time!
The My Weaknesses TM test will automatically create a 15, 30, or 45 question test that focuses only on your weakest categories. This will allow you to let the QBank work for you. As you answer more of these categories correctly, other categories will become your weakest areas, and additional tests will always concentrate on areas that you need to improve.
Please note that a weakness test cannot be completed until you have answered at least 1 question from each category (e.g. abdominal, cardiovascular, etc)
In addition to the above choices, you will have the option to take your test in practice mode, or as a timed examination. Practice mode will show you the correct answer and the correct explanation before you see the next question. As you complete tests, the questions you have already taken will no longer be available for use. All questions from finished tests will be unavailable for future tests. You cannot answer the same question twice.
If you fail to answer 10% of the questions in any test correctly, you will not able to finish your test, and instead be prompted to re-take the practice test you created.
Clicking the flask icon brings up normal lab values for you to reference. This can be helpful if you are uncertain about a lab value as it pertains to a question.
The phone icon is a reporting link. If you have an issue or problem with a questions, click this link and a feedback form will pop up. Please complete the form and we will review the question.
Everyone studies differently, which is why we have included so many different ways to study in our review series! The Qbank is designed to expose you to questions in a board exam format. The ability to customize these allows you to arrange the review any way that you want. However, having studied for, taken, and passed literally hundreds of tests, our team has designed this to be as flexible as you want, while sticking to a proven review strategy.
The below recommendations are our suggestions to you to maximize this QBank as both a review and a learning tool.
We recommend beginning your QBank experience by taking a 50 question test that includes all topics. Simply select all while creating a custom test. This will give you a brief exposure to all subjects, and allow you to see where your areas of strength and weakness may be before you begin to study more and drill down your weaknesses. To truly maximize this system, we recommend you block off two hours and find a nice quiet place to take this baseline exam. Treat it as a real test to maximize your concentration.
Every accrediting agency has a blueprint for their exam content. This is basically the breakdown of the percentage of questions by category, and the commonly tested topics they typically include on their exams. While this is by no means all-inclusive, it serves as a good topic list to target your review. The ENP and PA-CAQ Blueprints can be found here:
The topics with the largest percentage of coverage on your test should be your primary focus. Look at the blueprint and identify the top three biggest percentage components of your test. For emergency medicine, as an example, you will probably have Cardiovascular, GI, and Pulmonary categories as the most commonly tested topics on your exam. We have built our tests around these percentages and you will have more questions available for these topics.
Depending on your time until the exam, this can be done in several ways. Your testing frequency also depends on the other resources you are using to study. For example, if you are using a board review series with lectures, you may want to take a few questions after you have reviewed each topic. This reinforces what you reviewed in your lectures. Our Emergency Medicine Board Review Series Module includes additional topic-specific questions after each lecture category. We recommend completing the entire Board Review Series in tandem with the QBank, and taking short (10 question) QBank tests by category after each session of hearing lectures. These will reinforce what you listened to, and also give you exposure to future topics to look out for in your next lectures.
In general, we suggest taking 20-30 QBank questions daily, with a 50 question test every 5th day of studying. These basic tests should be 50% current study category, 25% weak category, and 25% other category. This will allow for 3-4 weeks of consistent test question exposure to varying topics. In addition, we recommend taking a 30 question Weakness Test every 6th day. This will automatically drill down your weakest areas and keep them in your mind!
When you approach the final 2-3 weeks before your exam, you should be taking 50-100 questions per day. We recommend creating these based on the blueprint for your exam, and choosing the correct number of questions per category based on your blueprint. This will keep your mind active and train you to expect the unexpected with each question. If time allows, and you have enough questions left over, we also suggest a few 15 question Weakness Tests in between, every couple of days. The last week before your exam should be spent reviewing your prior questions and answers, flashcards, and stimulus pictures. These high-yield easy review techniques will continue to reinforce the materials you learned elsewhere in our program. You should also review the notes you have taken during your review. If you used our program and took notes, these can be found in the topic lists for each module.
Once you have completed your test, you will have the option to review the questions you have taken. Doing so will let you see your answer and the correct answer. You will also be able to see an explanation of why the correct answer is right, and why the other answer choices are wrong. In addition, you will see graphic summary flashcards, and audio clips to allow you to listen to a deeper explanation of the topic.
To access prior custom tests you have taken, simply scroll to the bottom of the qbank page. There you will find a list of all of the modules you have previously taken. You may also search for the name of the module you have taken to see your prior practice quizzes. For example, typing “Emergency” will display all quizzes related to Emergency Medicine.
Clicking on the notes icon in the “Statistics Column” will allow you to see the questions, answers, explanations, and audio for each prior test you have taken.
Taking and passing your certification exam is a right of passage, and while it can be stressful, it doesn’t have to be! Be proud of the work you have accomplished, and take a break the night before your test! We hope your experience with this review series will be great, and we know you are more than ready to ace your exam! Good Luck!
When you have completed all of the questions for your review, you can click on this button, which will allow you to take a brief survey and clam your CME credits for the PPE QBank. When you have finished the survey, you will receive a link to download your certificate. It will also be emailed to you on the email you have provided. You may only apply these credits one time, and application is based upon your username, which we will track and occasionally audit. We will submit your information to the accrediting agency for their filing and to ensure you are verified with their organization. Please keep your certificate in a safe place to ensure you have it for your records!
Dermatology Essentials
Definition
Cellulitis: infection of dermis and subcutaneous fat
Impetigo: superficial purulent lesions, esp. on face and extremities. Commonly with bullae and/or golden crust
Erysipelas: raised erythematous lesion with clear borders
Folliculitis: hair follicle inflammation. Superficial and limited to the epidermis.
Furunculosis: hair follicle infection that extend to dermis. Multiple = carbuncle
Necrotizing Infection: Deeper SSTI that involve fascial and/or muscle compartments
Etiology
Microbiology
At risk: athletic teams, military, prison, MSM, communities with MRSA infxn, Diabetic
High risk for more aggressive infection: splenectomy, immunocompromised
Differential Diagnosis
Patient History
Physical Exam
Work Up
Note: Diagnosis is largely clinical
Laboratory:
Imaging:
Triage
More serious presentations of skin and soft tissue infections:
Treatment
Purulent (furuncle/carbuncle/abscess):
Nonpurulent (necrotizing infection/cellulitis/erysipelas):
Duration of Therapy: 5-7 Days
Treatment Notes:
– Erythema may initially worsen with antibiotics 2/2 local bacterial killing.
– For cellulitis, elevation of the affected extremity is essential to treatment.
– For Staph aureus infections (eg suppurative cellulitis) in 2014 at Hopkins susceptibilities were: TMP-SMX 87-88%, Tetracycline 89-91%, and Clindamycin 46-60%.
– For Beta-hemolytic Strep infections (eg non-suppurative cellulitis) all strains are susceptible to penicillin. At Hopkins there are high rates of resistance to TMP-SMX and tetracyclines and variable rates of resistance to Clindamycin.
– If you are concerned for a necrotizing infection, CONSULT SURGERY. Empiric antibiotic treatment with vancomycin (or linezolid) PLUS zosyn (or carbapenem) should be initiated. Clindamycin can be added to inhibit toxin production.
References
Resources
Cardiology Essentials
Definition
Syndrome characterized by impaired myocardial performance and progressive maladaptive neurohormonal activation of the cardiovascular system leading to circulatory insufficiency to meet the body’s demands.
Systolic heart failure or heart failure with reduced ejection fraction (HFrEF): Clinical diagnosis of heart failure and an EF of less than 50%.
Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF): Clinical signs and symptoms of heart failure with evidence of normal or preserved EF and evidence of abnormal LV diastolic function by Doppler echocardiography or cardiac catheterization
Right heart failure: Majority of cases are a result of left heart failure, although isolated pulmonary diseases can also cause this syndrome.
Etiology
Pathophysiology
Progressive disorder initiated by a form of myocardial injury either sudden (MI or myocarditis) or chronic insults (familial, metabolic, HTN, valve disease, shunting) that result in maladaptive compensatory mechanisms.
These mechanisms include activation of the sympathetic nervous system and activation of the RAS system which overtime lead to pump dysfunction and circulatory collapse.
Differential Diagnosis
Other entities that may look like acute decompensated heart failure:
Patient History
Ask about the signs and symptoms:
Ask about triggers of acute decompensation:
Physical Exam
Work Up
Laboratory
Imaging
Other imaging and diagnostic modalities that can be considered based on the patient’s history:
Triage
Strongly consider step-down or ICU if evidence of decompensation with hypoperfusion (cold and wet):
Altered mental status, Cold extremities, evidence of organ hypoperfusion: increasing lactate or rising creatine, narrow pulse pressures
Risk Stratification
The American College of Cardiology/American Heart Association (ACC/AHA) Heart Failure Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment.
The four stages of heart failure in the ACC/AHA classification are:
Stage A: At high risk of developing heart failure due to underlying conditions or risk factors such as hypertension, diabetes, or coronary artery disease.
Stage B: Structural heart disease is present, but there are no symptoms of heart failure. This stage includes patients with a history of myocardial infarction (heart attack) or left ventricular remodeling after a cardiac injury.
Stage C: Structural heart disease is present, and there are symptoms of heart failure such as fatigue, shortness of breath, and decreased exercise tolerance. This stage includes patients with past or current symptoms of heart failure who are responding to treatment.
Stage D: Advanced heart failure that is refractory to standard treatments. This stage includes patients with severe symptoms of heart failure at rest, despite maximal medical therapy. Patients in this stage may require advanced interventions such as heart transplant or mechanical circulatory support.
The ACC/AHA Heart Failure Classification is based on a combination of factors, including clinical symptoms, physical examination findings, imaging studies, and laboratory tests. This classification system is useful for guiding treatment decisions and predicting outcomes in patients with heart failure. It can also help clinicians identify patients at high risk for developing heart failure and initiate preventive interventions to improve outcomes.
The New York Heart Association (NYHA) Functional Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment. The classification system was developed in 1928 and is still widely used today.
The NYHA Functional Classification is based on the patient’s subjective symptoms and limitations related to physical activity. It is often used in clinical practice to assess the severity of heart failure, guide treatment decisions, and predict outcomes. Patients with more severe symptoms are more likely to have poorer outcomes, and may require more aggressive treatment or consideration of advanced interventions, such as heart transplantation or mechanical circulatory support.
It’s important to note that the NYHA Functional Classification is just one aspect of the overall assessment of heart failure and should be used in conjunction with other clinical and diagnostic findings.
The MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) risk score is a prognostic model that is used to predict mortality in patients with chronic heart failure. It was developed using a large international database of over 39,000 patients with heart failure from 30 different studies.
The MAGGIC risk score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of mortality in heart failure, including age, sex, systolic blood pressure, NYHA functional class, heart rate, serum sodium, serum creatinine, ejection fraction, etiology of heart failure, and use of certain medications such as ACE inhibitors, beta blockers, and diuretics.
The MAGGIC risk score assigns points to each of these variables based on their estimated contribution to mortality risk. The total number of points is then used to estimate the patient’s probability of mortality at 1 year and up to 5 years. The MAGGIC risk score has been shown to have good discrimination and calibration in predicting mortality in patients with heart failure.
The MAGGIC risk score is useful for identifying high-risk patients who may benefit from closer monitoring and more aggressive treatment, as well as for guiding clinical decision-making and communication with patients and families about prognosis. However, it is important to note that the MAGGIC risk score is just one tool among many that can be used in the management of heart failure, and it should be used in conjunction with clinical judgment and other diagnostic and prognostic tools.
CHA2DS2-VASc score: The CHA2DS2-VASc score is a tool used to estimate the risk of stroke in patients with atrial fibrillation. Since atrial fibrillation is a common comorbidity in heart failure, this score can be useful in managing heart failure patients with concurrent atrial fibrillation.
The CHA2DS2-VASc score is a clinical prediction rule that is primarily used to estimate the risk of stroke in patients with non-valvular atrial fibrillation. It is not specifically used in the management of heart failure, but rather in the management of comorbidities that may be present in patients with heart failure.
Patients with heart failure are at an increased risk of developing atrial fibrillation and other cardiovascular diseases, such as stroke, myocardial infarction, and peripheral vascular disease. As such, the CHA2DS2-VASc score can be used in the management of heart failure as a tool to identify patients who are at an increased risk of developing these conditions, and to guide clinical decision-making regarding the use of prophylactic therapies such as anticoagulation.
The CHA2DS2-VASc score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of stroke and other cardiovascular events, including age, sex, history of stroke or transient ischemic attack, hypertension, diabetes, heart failure, and vascular disease. The score assigns points to each variable based on its estimated contribution to the risk of stroke or other cardiovascular events.
While the CHA2DS2-VASc score is not specifically designed for use in heart failure, it is an important tool that can be used to guide clinical decision-making in the management of patients with heart failure and comorbidities. It can help identify patients who may benefit from prophylactic therapies and other interventions aimed at reducing the risk of stroke and other cardiovascular events.
Heart failure with reduced ejection fraction (HFrEF) is a condition where the heart muscle weakens and can’t pump blood effectively. Treatment for HFrEF usually involves a combination of lifestyle changes, medication, and other interventions.
The HFrEF therapy calculator is a tool that can help healthcare professionals determine the most appropriate treatment plan for patients with HFrEF. The calculator takes into account the patient’s age, sex, blood pressure, kidney function, and other factors, and recommends medications and doses that have been shown to be effective in treating HFrEF.
The calculator is based on guidelines developed by the American College of Cardiology, American Heart Association, and Heart Failure Society of America. These guidelines recommend a combination of medications that target different aspects of heart failure, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, and aldosterone antagonists.
The HFrEF therapy calculator takes into account the patient’s current medications and adjusts the recommendations accordingly. It also provides guidance on when to start or stop certain medications, and how to titrate the doses to achieve the maximum benefit while minimizing side effects.
The Renal Risk Score is a tool that helps predict the risk of developing acute kidney injury in patients with heart failure who are undergoing intravenous diuretic therapy.
The renal risk score is a tool that is primarily used to estimate a patient’s risk of developing acute kidney injury (AKI) after undergoing cardiac surgery. However, the risk of AKI is also a concern in patients with heart failure, particularly those who are hospitalized or receiving treatment with certain medications.
In patients with heart failure, the risk of AKI is often related to factors such as low cardiac output, fluid overload, and the use of medications that can affect kidney function. Some of these medications include diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), and nonsteroidal anti-inflammatory drugs (NSAIDs).
Several studies have looked at the use of the renal risk score in patients with heart failure. One study, published in the journal Circulation Heart Failure in 2014, found that the renal risk score was able to predict the risk of AKI in patients hospitalized with heart failure. The study also found that patients with higher renal risk scores were more likely to require dialysis or have a longer hospital stay.
Another study, published in the Journal of Cardiac Failure in 2018, evaluated the use of the renal risk score in patients with heart failure who were receiving treatment with sacubitril/valsartan, a medication used to treat heart failure with reduced ejection fraction. The study found that the renal risk score was able to predict the risk of AKI in these patients and could be used to guide dosing of the medication to minimize the risk of kidney injury.
Overall, while the renal risk score was developed for use in patients undergoing cardiac surgery, it may also be a useful tool for predicting the risk of AKI in patients with heart failure. By identifying patients at higher risk of AKI, healthcare providers can take steps to minimize the risk of kidney injury and improve outcomes for these patients.
Treatment
IV diuresis:
Determine home regimen and try to give an increased dose. Patients with anasarca DO NOT ABSORB ORAL MEDS. Remember patients who are naïve to diuretics may not require high doses for good urine output. As a rule of thumb, the furosemide dose can be initially calculated at 40 (mg) X serum creatinine. Titration will be performed according to initial response. Common diuretics include furosemide, torsemide, metolazone, and Chlorothiazide. For ESRD patients who no longer make urine, volume removal will be via ultrafiltration and may need to be done more aggressively as tolerated by BP. Be sure to check electrolytes twice a day and aggressively supplement (keep K around 4 and magnesium around 2.4. Check daily weights (standing if possible) and monitor Ins and Outs.
Afterload reduction in systolic heart failure:
If no kidney injury is detected you can consider an ACE-Inhibitor, otherwise hydralazine with/or without nitrates. In more severe cases, one may consider sodium nitroprusside
Inotropy: Usually in severe cases or if effective diuresis is not achieved despite other efforts.
Dobutamine or milrinone
Remember to hold beta blockers in acute decompensated heart failure
Mortality reducing agents:
References
Resources