 Hi everybody welcome to the webinar tonight we're going to give everyone a few minutes to join. So while we're waiting for everybody to hop on I'm going to get a couple things set up here so you can enjoy your evening nightcap or cup of coffee if you have to work. Hey everybody we're just going to give everyone a couple minutes to join here and then we'll get started shortly. If everybody can hear me just give me a quick thumbs up in the chat box here just so we can make sure everything's ready to roll. All right, look at that enthusiasm we're already getting started. This is going to be a good session I know it. Thanks guys, this looks awesome. All right, well it's 703 I'm sure we'll get some more people joining tonight but we'll go ahead and get started so that we can jump right into the content. So, thank you to everybody who is new to this webinar. Thank you to all who have joined last time to see me for my first session. I thought that last session was a little bit too easy for you so I made this one purposefully harder. So I hope that you're challenged and that you have a good time with us tonight we're going to make it real casual and just get to the topic here. Before we launch into the clinical case that we're going to be covering. I just want to tell you a little bit about my background so you know what I'm coming to you with in terms of education and experience as a PA and then I'll talk about advanced the clinical training to so you can understand what our company has to offer. So just to let you know, I've been a PA since 2017. I graduated from West Liberty University where I earned my master's degree there. I was a very non traditional student I had worked in sales for six years prior to going back to PA school and making an abrupt transition. Prior to that time, I earned a master's in counseling psychology. So I decided that some of you had asked last time during our webinar why I changed career paths and I learned that I'm a fixer. I don't have the patience to let people work through their concerns and I give a lot of respect to mental health professionals that have the patience to do that. I just want to jump in and start fixing problems so that clearly wasn't the right career for me. But ever since becoming a PA, I feel that I've had to help individuals in a different way. And I've really found that to be rewarding. Also, I've practiced in a variety of areas. Right now I'm working in a cardiology clinic for an academic health care setting in the outpatient environment. Prior to this, I started my career in hospital medicine working exclusively inpatient. I've also worked in hybrid roles and medical oncology and hematology, as well as outpatient women's health. So hopefully that will give you a little bit of a different perspective on tonight's topic. So my role at advanced clinical training is to be a pre physician assistant mentor, and I support pre PA students by providing virtual mentoring sessions. And we have a very good environment because it's very individualized, and I develop resource guides for students and help them to become more prepared to apply for PA schools. And we identify strengths and weakness and work through the CASPA application process so that we can get you ready to go. We also do some workshopping of personal statements. So I think that you might find that program to be really beneficial. So also advanced clinical training is an online self paced allied health certification program, and it's really designed for pre health undergraduate and post baccalaureate students. So our mission here is to provide engaging accessible and affordable clinical certification programs. And what this does is to help to prepare diverse health science students to successfully enter medical PA pharmacy and nursing programs. We have a variety of programs and they include certified medical assistant patient care technician pharmacy technician advanced medical terminology certifications, which you can access through the program. It's complete completed completely asynchronous try that for a tongue twister, and you can do it at your own pace in as little as eight weeks. We also have a really diverse and talented ambitious and smart group of students, so kudos to you. And we've certified over 500 students through this program. So if you'd like any more information about us, you can head over to our website. It's HTTPS at the clinical dot org and I'm going to post that in the chat so that you can find us there. Oh, look at that. We've got a lot of support here so someone already put it in the chat. Thank you. And yeah to answer someone's question here before yes you're automatically muted. We will do a question and answer session during our webinar tonight. So if you could hold your questions until we do the participation part that would be really helpful. And I'll get to as many questions as I can possibly do during the time that's allotted for us today. All right. So, let's talk about how today's webinar will go briefly, and then we'll launch into the case study. So just to let you know how this will be structured, we're going to talk about a real life patient case presentation, and we're going to have a clinical discussion from a PA perspective focused around that. The session is going to be very interactive, and you can use the chat feature which it looks like you're already all very comfortable with doing and I appreciate through the webinar, and I've created some polls that I'll ask you to do. And that way we can work together to try to figure out the case tonight. And it's kind of neat for me to see what you come with to. And then, like I said before, we'll have the question and answer session at the end. So, if you're ready, I'm ready. Let's get started. So today's case presentation is going to be from real DX. So what this website is it's actually HIPAA compliant. It uses real patients in clinical environments. And you get to look at them. The provider will talk about their symptoms, the patient will actually talk about their own symptoms to so you can understand what led them to present commonly to the emergency department. And we'll go through the toll to including medical history, surgical history and other important information, which is included on the site for us. Note, they do always obtain patient consent, which is really important whenever you're using patients in the media. And we're going to approach this case in a very similar way through the lens of a physician assistant, how we're going to approach patients in real life and what we actually do in the clinic. So hopefully you'll find tonight to be really interesting. Great. So tonight's case. So, here's what we're working with just to let you know, we have got a 49 year old female. She's coming to the emergency department because of a rash that started on her legs. She contacted her primary care provider for initial treatment. But is the rash continue to spread to her arms. This worried her and she subsequently presented to the emergency department for further treatment. So I'm going to go ahead and get this case loaded up here for us. So give me a quick second to share my screen. All right, guys, give me a second here. Let me just pull this up. Okay, if you can give me a thumbs up that you can hear the audio. That would be really helpful just give me a quick second just to make sure that it's ready to go. Oh, we can't hear it. I figured this might happen. Give me one quick second. It's a funny feature that whenever you share your screen, you have to share the audio and I always forget to do it. So just give me one quick second here. All right, we should be in good shape now. Let me back this. Good afternoon. How are you doing? I'm better. I'm Dr. Moore over here at Yale Manhattan Hospital. Thanks for taking the time to do this video. You're welcome. So you came in here primarily for rash, is that right? Yes. Tell me again, how long ago it started and what it started with? It started about two weeks ago today. I just started on my legs. Actually, we'd been outside. I noticed it was, my husband noticed it was he pulled up my pant legs. And it was nowhere near like this. It was just a little pinpoint rash and kind of like this area. And by the next day it was spread. So I called my GP and she came in and I did some blood work the following day. And you said, is it itchy or painful? It was not initially like this stuff that's going on right here was how it started to look when it got bad. This is not itchy or painful right now. But this stuff that's been healed and started to show up again is pretty itchy. It almost feels like after you've had a sunburn and the skin starts to peel at raw kind of itch. All right. Wow. I don't know about you, but when I see a case like this, I start getting a little bit of hives myself. Anyway, all right. So hopefully that gave you a good insight into what this patient actually looks like in the emergency department. As you can hear in the background, it's super loud. And that's pretty typical in the emergency department environment for all of you who work in some capacity there. It's mayhem. Okay, so I'm going to show you a little bit here too on this real DX of her vital signs and what the medical assistant has so graciously collected for us in the emergency department, including her medications. And then we will talk about what we're going to do with this poor sweet patient. Okay, give me one quick second here. I'm going to reshare my screen so we can see the vitals and the demographics. Okay. So as I mentioned before, she's a 49 year old female. So when she came to us here, temperature is 98.1 degrees Fahrenheit or for those of you who thrive on Celsius 36.7 blood pressure was 108 over 77 heart rate 66 beats per minute, respiratory rate, 18 breaths per minute. Her heart rate is in normal range between 60 and 80 beats per minute. Her respiratory rate is also with acceptable parameters. And then pulse ox who want to see basically above 94% on room air is acceptable. You'll see a little bit of difference, depending on the institution you go to with that. So her vitals really are unremarkable. The other thing to note is that signs and symptoms here rash, which we clearly saw her medical history, all her medical history is significant for is high blood pressure. Now, one thing I really hate if you know me at all is when I see things like non contributory in the social history. Don't do that. Make sure you document. Is there any tobacco use is there vaping use is their snuff use. All of that is relevant and important to the tobacco part of the history you want to assess alcohol use how often how much. And then you want to talk about drugs. I also find it important to to talk about anything that's prescribed, as well as not prescribed when you do the medication review. So here, and then also as part of the social history you want to know what the patient does for a living who they're living with where they're living and what they, their occupations important because sometimes in certain situations that can click a little bit more for their occupational exposure, potentially, or risk factors. She's also on amlodipine, which is a high blood pressure medicine, which correlates with that, and she's on selection. So as you can see here, someone didn't put in the medical history depression or anxiety, which is commonly what selection is for. All right. So that's just a little bit of information there about background. From this point on, the physician assistant, it's important when you enter the room you want to start with the history and physical exam and examination which we saw this provider do. So, in this case it was a physician. You definitely want to start by greeting the patient which he did really well. You always want to introduce yourself in your job title, and ask them what you know cause them to come to the clinic today or the clinic, or if you have a little bit of information say hey I saw that you are coming in for a rash can you tell me a little bit more about that. That way they realize you've actually looked at their chart before you walk in the room. You also want to listen to the patient uninterrupted for about a minute if you can or two minutes. I know it's busy but patients will find this is so much better for their care if you can let them tell their story. This will be the basis of our history of present onus or HPI, or what brought them to this point. All right. So, just to kind of summarize what the patient said in the video. She had an onset of a rash starting two weeks previously on her legs. It initially was not itchy or painful. Then progressed to her arms, and in the areas of her legs where the rashes started to heal it's now feeling itchy and starting to peel in a way that she describes as a sunburn. All right, now here's where you help me out. So, in the comments section tell me a little bit more about what information you want to know about the patient's course of events that will help you to figure out what's happening with her. So, type in maybe one question that you would like to ask the patient is your next step. And we'll see what you got. Ooh, recent travel. That is very good. Regular exercise out of the country, very important. Any new personal care products or sunlight exposure. You guys are thinking well, history of eczema, food allergies, yard work, skin products, what she was doing prior to the onset of the rash. Any MAO use, allergies, clinical scenario around when the rash started. Good, you guys are really, really thinking. Ooh, I like this one too. Have you been around anyone who is also having a rash? Yes. Any new body lotion or wash, ingesting new food? Someone even said Stephen Johnson syndrome. Man, you guys must be really schooled here. This is impressive. Have you touched anything dangerous? Change in laundry detergent, soaps, animal exposure. Anyone who's had shingles? Ooh, I see you guys are already starting to formulate your differential diagnosis. This is really great. Cleaners if they were mixed. Awesome. Personal hygiene. Yeah, that's a good question and that sometimes can be a little bit touchy to bring up the patients. So, that's an art for sure. Any known harmful radiation exposure. Family history with these symptoms. Ooh, for a genetic link. I like the way you're thinking. Any changes to their symptoms once the rash showed up. Lifestyle changes, new clothes. Good. You guys are all on the right track. Has this happened before? Yes, that's really important as you'll see as we move ahead. All right, so you guys are really thinking hard. So, you're all on the right track with this and I don't think any of those questions are wrong at all. I think they're right on, you know, the next step. There are some things that I'm thinking about just because I'm a little biased. I'd also like to know if the patient has experienced any fevers or chills, which you heard the provider ask in the video. Weight loss. New medications that were started recently. That's very important. I'm also thinking about any recent infections. And as we move ahead, you'll kind of see why. I'd like to know about that. I definitely want to know about drug use. That's a given when you're doing your social history, but I think that's something we really should explore a little bit more too. And then I also want to know if she's having any joint pain. Because that may help me with my differential. Okay. Based on the information collected so far. I'm going to ask you guys and I'm going to bring up a poll for us to do. I want you to think about what the differential diagnosis might be and I've I've included a couple options for you to choose from. So I'm going to throw this up on the screen. Can you guys see the poll. All right, thank you. All right, I'll give you guys a few minutes to answer it also give me a minute to rest my voice I hate listening to myself talk so much I feel like I don't even talk this much in clinic. All right. We're closing in. Oh, I see word a tight race between two of the options. Now three of the options. Oh my goodness. Okay, I'm going to end the poll because it looks like we've gotten a little bit stagnant so maybe we have an answer. Okay, so the majority of you think that what we're dealing with here is cutaneous small vessel vasculitis runner up would be thrombotic thrombocytopenic perpura or TTP and then in a close third we're thinking infectious endocarditis. Well some are thinking cellulitis. I think you guys are all really thinking on the right track here and we'll see what we can come up with. What I'd like to do is we're going to watch the video a little bit more. I want to pay attention to some notable physical examination findings that were detailed from the medical provider. So let me just pull up the video and we'll watch just a couple more seconds here of a different part of this area. Let me just get it ready. Okay. Let's take a look at this rational quick. What's do you want to see? I'll check here. So it's obviously red. It's not very raised. It's flat. When I press on it, it doesn't blanch. Oh, I'm sorry. So we'll be right back. Okay. Okay. So I'm going to back this up because I want to watch this again. Look at this rational quick. What's do you want to see? I'll check here. So it's obviously red. It's not very raised. It's flat. When I press on it, it doesn't blanch. Oh, I'm sorry. So we'll be right back. Okay. Okay. So I think the really important thing that we should be paying attention to when he's doing this exam, he just kind of breezes through it because he's super smart, super experienced. And just doing his thing has someone commented shouldn't the doctor be putting on gloves before he checks the rash. Yeah, I mean, technically, if you're doing rashes and dermatologic issues, that's not a bad idea because who knows, it could be contagious. And you can definitely do this part of the physical exam with gloves on. But you know, I think he just wanted the full effect here. So because I think he already knows what it is. So here's the key physical examination finding I really want to highlight for you. So he says, Oh, and take a look at the rash here. It's non blingable. Yeah, it's non blanchable. So that is whenever you see a rash, the one thing that you want to start with to try to help narrow down your diagnosis is saying, is it blanchable so what in heck does that mean. If you press on the affected area of the skin, you put apply some pressure, and then you pull it away. If the skin underneath, like where you where your finger was that turns lighter, it blanches. So that will help to differentiate what's going on with the patient. So in this case with this patient, the rash does not blanch it stays the same color no matter if you apply pressure or not. So what I would describe this rash to is it looks particular. So particular is where you have very, very tiny looking hemorrhages or bruises that are on the skin. And that is also a key part of this exam. Another thing that a lot of dermatology PAs will do and probably isn't a bad idea to do even in a general setting like an ER or primary clinic is to have a roller with you, because in they make disposable rollers to by the way that you can just toss after you see a patient. So what happens is if you have a rash and you have a lesion to look at a specific area, you can measure it. You can typically it's done in millimeters. If it's large enough, then maybe we're talking centimeters, but typically it's millimeters, and that will also assist with your differential diagnosis. And then another thing you want to do is look and see is the rash raised or not. Is it flat with the skin or does it come in a 3D way out of the skin. In that case, I would say this rash is not raised so it's flat. It's particular non blanchable. And then if we're measuring it we'll talk a little bit more about what we would expect here. Lots of information in a fast amount of time. So I want to do another poll for you because I really want to see what you think about this so we've done our history and physical exam. It's a pretty good job. You want to do more organ systems than just the focus skin exam like listening to heart and lungs checking pulses, checking orientation status, etc. But you know, for the purpose of today we're a little bit focused, but I want to know what you think at this point will make the definitive diagnosis for this patient. If your thinking caps on, let me get our poll activated. Alright, here we go. So our poll question what do you need to do to make the definitive diagnosis in this case and I need definitive in capital letters. What is the one thing that's going to say 100%. This is what it is without a doubt. Last choice punch biopsy second choice shape biopsy third choice lab studies with inflammatory markers such as Aretha site sedimentation rate and C reactive protein ESR or CRP for short. And then the last piece or the last choice would be x ray of the tibia or fibula. So she said that the rash started on her lower extremity so I just picked on that area will give you guys remember I said definitive. Alright, so let's end this poll looks like you guys think that the lab studies are the key the ESR and the CRP. Let's see if you agree as we move on forward here. Alright, thank you guys so much for participating by the way I really appreciate such an interactive crowd I think we have a really nice group of people on here. I know I can't see you or hear you but you guys are awesome and I can see your comments and I appreciate everything you do here. Alright, so last poll. My question for you here is going to be. Now that we have so much information here. Do you think the diagnosis is going to be. Let me give you a second to put your thinking cap on and we'll launch our last poll. Are we still thinking it cellulitis. Are we thinking it's thrombotic thrombocytopenic perpura or TTP. Are we thinking it's cutaneous small vessel vasculitis, or are we thinking it's infectious endocarditis. Alright, well looks like the majority of people have gone with cutaneous small vessel vasculitis. Let's see if you're right ding ding ding you're right it is it's cutaneous small vessel vasculitis. So in this case more specifically it's called leukocytoclastic vasculitis. Another tongue twister for everybody. Alright, so you might be thinking what in the heck is this what is this vasculitis, and I can tell you what from my clinical experience this is the one condition that makes people really nervous, really fast, and you'll see why so I'm going to share my screen I'm going to pop a PowerPoint for you. I know don't fall asleep it's only a few slides. We're just going to go through a couple clinical meet of the matter on cutaneous small vessel vasculitis, and so that you can understand a little bit more about what goes into diagnosing this and how do we treat it and that's the most important how are we going to help somebody. So let's do this. Wait, hang on one second let me get this slide show up and run in just give me the thumbs up again if you can see my slideshow. Alright, thanks guys. Alright, here we go so cutaneous small vessel vasculitis. What in the heck is it. So it's a condition here where blood vessels and the skin become inflamed. It's a very inflammatory process so inflammation in our body when it affects anything. What can damage tissue. So what happens is the blood flow gets impaired here because the vessels are inflamed. And anytime something's inflamed typically the area swells to so you can think about the vessel swelling or becoming a little bit more narrow, and it leads to impaired blood flow and subsequent tissue damage. So that's pretty dangerous when you think about that. What causes it. Well, this is always the one idiopathic. So what does that mean, that means, I don't know. It's, it's what we always joke about in P.S. school and said it's the idiot diagnosed it's the idiot ideology because nobody really knows. How does it come how does it form I don't know. Now there's a lot of hypothesized mechanisms of how this happens so there's a lot of research in this area, but it's a very complicated process so there's not a complete consensus about how this happens. It really is thought to be immune mediated to some degree that your immune system causes an overactive response. And it can be triggered by medications, it also can be triggered by infections. A lot of viral infections can trigger this which you'll see to, and that whole that trigger which we can look at almost like an allergy. So people that have environmental allergies walk outside, they get triggered by an antigen which sometimes is pollen, and that creates a response in your body to kind of a similar thing that's going on here you've got an antigen or something that is exposed to, and then an immune system response is stimulated. And then what happens is these immune complexes that form in your body, and get dropped into the vessels and that's where they sit, and they start reacting. So, that's contributory to the rash to it's actually immune complexes, or what are thought to be in the vessels and that's what you can feel when you're feeling that rash. So, common medications that are triggering this issue would be antibiotics and the beta lactam class so penicillins are a big trigger for this cephalosporins like your Keflux, potentially could also be a trigger. Phenosulfonamides, so loop diuretics like Lasix or the generic furosamide. Thiazide diuretics are also a potential trigger like hydrochlorothiazide phenatone and allopurinol. Allopurinol is a gout medication phenatone is used for seizures. A lot of times, and some other things too but so we have to always think about medications that people are starting whenever you see something like this. Infections triggers so hepatitis B and C can trigger this problem. Bacteremia. So we're thinking more like infective endocarditis, like a strep viridens potentially shunt infections, other viral infections that can be implicated would be HIV or just generic viral infections. Yeah, virus, viruses are no good, neither a bacteria. Boo. All right. So symptoms and how this looks in real life. You've actually seen this through the video, but here's the technical way to talk about it. So this is palpable perpura. It's 0.3 to 1 cm in diameter. So if you think about this, it's like less. It's about three millimeters, they can be larger with or without PTKI. So these PTKI are like the little pinpoint hemorrhages that you saw in that patient's arms and legs. Those ones are small. So if they're palpable, they're going to be larger. So palpable just means they're like more raised and you can actually feel them as a lesion on the skin. The PTKI are more flat, and they're really small. So that's where I say the ruler helps because who, you know, no one's really great at eyeballing sizes of these lesions. And if you are a kudos to you because I'm not. So that can come in handy there. As we mentioned before, non blanching. So the skin is not changing color when you're pressing down on it. This rash can be in clusters. As you saw in that patient's arms and legs, it was pretty diffusely spread. And it can be ulcerated so it can look really, really gross. Or be located around Boulay, which are raised clear fluid filled sacs on the skin. In this case, they would be hemorrhagic, so they'd be filled with blood. If triggered by this medication or a virus, you definitely want to find out when the medic or the rash started and if they had an infection, how close the infection was to the sort of the rash. That's key in your diagnosis because you're going to see this rash start seven to 10 days approximately after they've been exposed to either this medication or the virus. So it's really cool to kind of talk about the timing of that a little bit and you have to get really detailed in your history. But the key in why this is so difficult to figure out and to treat potentially is because you've got to see if this is limited to the skin, which it can be, or if it's affecting the body in a widespread way, which is what I mean by systemic, or if there's an underlying condition, condition present that could be even causing the vasculatus to begin with. So it's either primary or secondary local or systemic. And the systemic kind is really dangerous and can actually kill somebody pretty fast if it's not identified and treated appropriately. So this is where something you want to be able to recognize this, get the diagnosis started so you can get this work up underway and get them treated. You don't want to wait. So your review of systems that's going to be really important here. So here's the picture of it up close. We saw it on the video, but here's what it's looking like. A little bit more detail. So as you can see down here, these are the fatigue I in the bottom, and then the perpura or the palpable part which is here where you can actually see it's raised up off the skin. It's a little bit of a tragic belay to a bit because it's filled with blood. Poor patients, I hate vasculatus. All right, so part of the mix here is just evaluating for systemic disease so why widespread organs that are affected by this and underlying disease. So how do we know if it's more widespread. Well, clues would be through the review of systems if you're asking questions like, or you have in, you know, bloody sputum because it can affect the lungs and cause what's called an alveolar hemorrhage or bleeding in the alveoli that carry gas exchange throughout the lungs. It can also affect the kidneys and cause glomerulonephritis or inflammation of the glomerulus, which is the main function functioning part of the kidney. It can cause mesenteric ischemia, which is basically if you think about vessels getting affected here and narrowed, you have arteries all through your body. The mesenteric area is in the abdomen and it carries blood flow to, you know, a lot of key organs in the abdomen. So it can cause a lack of blood flow, which can also be potentially fatal. Mononuritis multiplex, which I've never seen in real life, which, you know, would be really interesting and probably unfortunate for the patient. Or it can also be triggered from an underlying malignancy or cancerous process. So you can see how this is really something you want to get narrowed down really fast. So relevant questions to ask that really can help you to figure out if this is affecting more than just the skin would be systemic signs and symptoms of potentially malignancy, which would be your typical unintended weight loss or weight loss that you didn't try to lose. Excessive fatigue, chills or night sweats. Those are all your kind of generalized malignancy cancer symptoms that you definitely want to check for. Myalgias, which are muscle pain, arthralgias, joint pain. That could be a clue that you have an underlying rheumatologic process or autoimmune disease going on here that might be contributing to this. T-colored urine or frank blood in the urine, which we call gross hematuria. That could be a sign that you have the glomerulin arthritis. Abdominal pain or dark blood in a stool known as melanin, which could be signs of mesenteric ischemia or an issue in the colon there. Chest pain, dyspnea, which is difficulty, shortness of breath, trouble breathing, cough or coughing up blood could be a sign of the alveolar hemorrhage. And then new development of asthma or worsening asthma condition in nasal symptoms that could also signify lung involvement. Perforal neuropathy, which is basically numbness and tingling of your upper or lower legs or arms. And then here's the other thing we need to think about too. You're always going to want to do further testing. Number one, if you suspect it's more than just limited to the skin. Number two, if you suspect there's something going on underneath, it's more serious. Or number three, if it's persistent, if this lasts more than four weeks or they have signs of systemic infection, vasculitis, you need to do further testing. You cannot just say, oh, it's only limited to the skin. No, it's been going on for more than four weeks. Like there's something bigger here. If in doubt, you can always get other professionals involved. So you can talk to hematologists and oncologists, which are blood and cancer doctors and providers. You can also talk to immunologists, which deal with allergic related conditions or rheumatologists, which deal with autoimmune disease. They're more than willing to help, especially if you're in the hospital setting, because you can get a lot of resources. No, not every service comes to the hospital, but you can definitely get oncology and hematology to help you. Okay, so let's look at a CT scan. This is actually a CT scan of the lungs. So this one, the lung is the black here on both sides, and this is the middle of the chest. The lungs are going to be black because they're supposed to have air in them. As you can see here, there's a lot of junky white stuff that looks like big patches here. This is a sign of an alveolar hemorrhage or bleeding in the alveoli. So you can actually see that in the lungs and it shows up almost looks like a cloud. So a radiologist who's very astute and knows what they're doing can see this and say, uh-oh, this looks like an alveolar hemorrhage. So that could give you a clue that there's, you know, lung involvement. So when you want to think about diagnosing these patients, the main way to definitively diagnose this once you've done your clinical exam, history and physical exam are always first, is four millimeter punch biopsy. All right. So what is a punch biopsy? So a shave biopsy, which we'll say first is basically when you just kind of skin the top of the skin using a very superficial way to do it. A punch biopsy is when you get a special tool that looks like a circle or a hole punch and you put it on the skin and it takes out a four millimeter. There's all different sizes available, but in this case you want to use a four millimeter size and you press it down on the skin after you've anesthetized the skin because it's painful. And it will basically punch a hole in the skin and you'll get it in your collection device and you can flick it out in a jar and send it to the lab. In the lab, we'll look at it under the microscope and do a histopathological diagnosis. So those of you who work in the lab and think it's, you know, maybe not that relevant in real life, it is so relevant in real life. This is actually going to make the definitive diagnosis for you when someone looks at it under a microscope and here's what it looks like. So these are the purple part of the vessels. In that picture, the peach part is this person's skin. It's a dermis. And you can see here that there's just all these like deposited dark purple spots in these vessels. So the person, you know, the pathologist looks at it in the microscope and says, uh oh, this is it. This is vasculatus. The ideal lesion because if you saw on the legs and arms, there's just so many, which one do you choose to biopsy? The ideal one is going to be there for about 24 to 48 hours and it's kind of early in development. If you really just, you know, don't have a clue if it's been just biopsy, whatever you can get. I mean, I don't know that anyone's going to be super picky about that. So, you know, the key findings here that the pathologist would see under the microscope would be necrosis or death of the cell wall, leukocytoclasis, which has damaged the vessels due to neutrophils that have moved into the scene. So, neutrophils are white blood cells are first line of infection support from the immune system, and they just infiltrate these vessels because that's the immune complex that's depositing there. And you see that under the microscope. Holy cow. All right, so treatment. Woohoo. How do we help people? First episode of limited vasculatus, meaning it's only affecting the skin and it's their first time. And you don't suspect that there's any kind of systemic involvement or underlying condition going on based on the review of systems you've performed. So what do you do? Well, you find out if there's any new medications that have been started, and you remove them, if you think that it is contributing. Usually, if it's due to the medication, it's going to stop in days to weeks. You want to also check to see if they're actively infected with a bacterial infection. You want to avoid any kind of immunosuppressant infection because that can impair their body's ability to fight this bacterial illness can make them really sick. You want to have them rest, compress, and elevate the affected extremity, whether it be an arm, a leg, or all four. When feasible, people have to live to, you know, can't just play on a couch all day. You also can do some pain management with NSAIDs. So you're a leave ibuprofen, Motrin, naproxen to try to help because it's also inflammatory. So that should help to have an anti-inflammatory benefit. And then you can use emollients, which are basically lotions to help with any dry skin and itching, particularly as the area is kind of fading off. It can get real itchy. And then there's also some other things you can try to like Benadryl to try to help them out a little bit with itching. But you want to make sure you treat if they have an bacterial infection like those lesions ruptured and became infected in their cellulitis in the area like redness or swelling. You want to treat that with antibiotics or if they have like a widespread systemic infection, you want to make sure they're obviously treated with antibiotics because that itself can be the trigger for this condition. And you want to try to avoid antibiotics that are going to make this worse based on the list that I shared with you. And then treat viral infections that they may have like HIV, hepatitis with antivirals if possible and available. If it's a recurrent issue, then you can do corticosteroids. So prednisone is a commonly used agent here and you're going to dose this by body weight. So it's going to be 0.5 milligrams per every kilogram that they weigh per day. You're going to do it for one to two weeks, then you're going to taper it down gradually by reducing the dose over a three to six duration instead of abruptly stopping it. If you abruptly stop somebody's steroid therapy and they've been on it long term, it can actually cause adrenal insufficiency where the glands on top of the kidneys just stop making cortisol production and it can make people really sick. So you definitely, if they're on it for a while, you want to taper them down. If you give somebody prednisone or steroids for a short course, you don't always have to do that. So, and that's key too, because that's definitely going to help to stop this immune activation if it is due to an overactive immune system. Okey dokey. Well, that was a lot of information that we covered in a short amount of time. I do want to thank you all for being so attentive to today's presentation. So now we can open up our Q&A and I'll get to as many questions as I can. And we will go from there. Alright, so you can either type your questions into the question and answer section here or you can just do it into the chat and I'll get to as many as I can do. So someone asked if it's painful. Not usually whenever it starts people don't typically have too much pain for it with it. Sometimes, you know, it can get a little bit itchy as the lesions kind of start to heal a bit. If they do have any pain you can try to treat it with NSAIDs. Oh, someone so sweet they said will there be more shadowing opportunities like this I really enjoyed it well thank you. Yes, I tried to do these and there's also other health care professionals that offer shadowing opportunities through advanced clinical training. So, why did you choose PA over another type of medical provider really good question. There are so many different options you can do in medicine you know there's nurse practitioners that you know a lot of times start as a nurse, gain a lot of clinical experience on the job and then take additional courses to become a nurse practitioner have similar responsibilities as a PA with a different governing board you know so the nursing board instead of the medical board would regulate their profession. But you know similar privileges. And then obviously we have physicians and we have pharmacists what really drew and physical therapist occupational therapist mental health professionals I mean I could just go on and on. What drove me to choose PA is I met a PA, who was the wife of somebody I worked with in my sales job and she loved it. And that you know she had a lot of responsibilities, but she always felt that she could work in a team environment with other health care professionals like nurses and physicians. She didn't feel like she was alone practicing medicine. It was a very streamlined program where I could get a master's degree in two years, and be, you know which included clinical rotations and come out working in medicine because I had science prerequisites done before that too. And, and a bachelor's degree. So it was nice because I could get out and work in medicine, and a pretty fast way and start helping people instead of, you know, going back to medical school which could be four years for that residency on top of that which is at least three depending on what you choose to do, and then getting out and practicing and you know granted the autonomy for a physician is unmatched I mean you are the boss you're making the decisions you're leading the care team. But it's also a big financial and time commitment and just for me you know being 30 years old and going back to school. I really didn't want to put my husband through, you know me being in school and residency for seven years I just thought it would impact our relationship and impact our quality of life and sometimes you just have to look at that and make decisions based on where you're at in your life and I don't regret a day of being a PA it's one of the most rewarding professions that I think you can be a part of and I love my patients and I really love learning from them and seeing what they bring to the table. They're just awesome. Yeah, so somebody asked what do we do if patient can't take NSAIDs due to a blood condition. Ah, look at you thinking yes, some people can't take NSAIDs because they have platelet count that is too low. They're bleak they have GI bleeding history ulcer disease, or basically a number of conditions. You don't have to use them. I mean they're an anti inflammatory medicine sometimes we do culture scene for these patients to which is a type of acute gout. Medication different than allapurinol because that's a potentially a trigger medicine here. That's been shown to help with this too and we can also you know choose Tylenol if we're able to help with some of the pain control. All right. So somebody else had a really good point here which I think would be really nice. I would ask the oncology rheumatologist if possible since I think the CD4 CD8 is important. Yeah, so that is key because that if you're really suspecting somebody has an immunodeficiency or they have each IV, you definitely want to, you know, start with your testing there. I mean you want to try to get the test for the HIV right away. You want to get the Western blot to confirm the diagnosis and you want to start looking at cell counts after that point if that's what's going on. If you have a concern for another immunosuppression. Yeah, get get somebody else involved to help with that because those tests are expensive and not always users are screening. But if you really suspect something you can order a test and you know in real life I'm ordering a CBC to look at blood counts I'm ordering probably a CMP comprehensive medical or metabolic panel to look at kidney function. We're looking at liver function because that can also give you a clue that maybe an organ is bothered by this condition a urinalysis you know to look for microscopic blood in the urine or an infection too. If you're worried somebody has an infection in the bloodstream you're going to be ordering blood cultures to look for the bacteria culturing that culturing any wounds that are present. If you're concerned that's where the infections coming from. You know so in real life, it's a very multifocal approach you're not just going to necessarily look at it. You're not going to do a punch box biopsy and say okay my work is done. You're going to be ordering labs you're going to be ordering a lot of different tests to kind of help beef up what you're doing and making sure that you're covering all your bases but that's the most streamlined information that we can do you know to get this started and to get a definitive answer. All right well this webinar is planned to end at 8 so I could probably get to about one more question and then what we'll do is so after this session you're going to get a survey of sort that will allow you to get a certificate to claim that you participated in this event. So that'll be how you get your certificate, but I'm also going to share a promotional code for you so that you can get some financial savings if you choose to join advanced clinical trainings, pre PA or pre healthcare mentorship program or other programs that we can offer. So, oh, I like this one. How long do the lab results take to come out good question. It depends on your institution that you're working with so if you're sending a biopsy, a punch biopsy to the lab, and you want to see what that shows you know sometimes that can take five to seven days to come back, which is a long time but you know in some organizations that have access to be able to get pathologists on call. You know and sometimes in surgeries there's pathologists that are actually there in the hospital waiting for samples to come in, and they are looking at them under the microscope in real time. So if you want to move a little bit faster depending on you know if you're working in the community hospital if you're working in a clinic if you're working in academic hospital or an academic institution. Everything's a little bit different depending on the environment that you work with. So, all right everybody. So let me put a coupon code in here for you. Let me just write it in here. And then this will be relevant for you if you choose to participate in our programs and just to recap a little bit about advanced clinical training. This is an organization that offers pre health care programs certification programs for students to become more prepared for pre health care careers. And we cover a lot of different areas and have mentorship programs for pre physicians and pre PAs and nursing students. So here's the code for tonight that you can use its webinar 300 and what this will get you is $300 off a mentorship package with advanced clinical training. Alright, and then just to remind you there is a website. Alright everybody thank you so much for your time I really enjoyed working with you and thank you all for your participation for your efforts for your diligence. I really hope to do this again with you sometime soon. This made my whole night, and maybe I'll see some of you in the pre PA mentoring program as well. Great everybody have a good night. Thanks.