 So, thank you guys so much for joining again. I really appreciate your time tonight and working with me. So, just to let you know a little bit about what we're going to do tonight is we're going to have a webinar about a clinical topic and I'm going to talk to you about. A lot of different aspects of approaching the diagnosis of a patient from a physician assistant perspective. And specifically through the lens of an ear physician assistant. And we're going to talk through just some clinical topics that will be very relevant to people of all different levels in their career. So, without further ado, I'll let you know a little bit more about me. Just so that you understand the background that I'm coming to you with. I'm a physician assistant. I've been certified since 2017. I graduated at that time with a master's degree from West Liberty University in West Liberty, West Virginia, which is really close to wheeling. If you know where that area is. I was basically a non traditional student when I started PA school. I was 30 years old. I had done a sales career for six years prior to that and had a master's in counseling psychology so I took a totally different avenue in my life. And I love working with non traditional students in my mentoring role advanced e clinical training, which I'll talk a little bit about to, but just to let you know that I have clinical background in several different areas including internal medicine and associated specialty so right now I'm working in hospital medicine I'll be starting a job in cardiology. I've also worked in medical oncology slash hematology and women's health. So right now what I do for advanced d clinical training is I support pre PA students by providing virtual mentoring sessions, including personalized advising plans, and I also develop resource guides for them to help them navigate the application process and get them ready to start PA school. So, a CT is a really neat organization. So what advanced e clinical training does is it's basically an organization that is an online self paced allied health certification program, which is designed for pre health undergraduate and post specular at students. So our mission is to provide engaging accessible and affordable clinical certification programs to prepare diverse health and science students for medical PA pharmacy and nursing school. Different programs that we offer include certified medical assistant patient care technician pharmacy technician advanced medical terminology certificate, and it's completed right now. So you can do it online at your own pace and as little as eight weeks. So this is a nice option for folks that want to pursue pre med or pre PA as well because you can get your medical assistant certification, and have that in your background when you go to apply for PA school. So I'm going to put the website in the chat box, so that you can see a little bit more about our organization. And if you wouldn't mind, we'll be doing a question and answer session at the end so you can hold your questions and answers until that time. I'll address them. We have a lot of people on this webinar tonight. So we'll probably only get to a couple but we'll address them at the end of the call. So the structure of today's webinar will include a patient case presentation as I alluded to as well as the clinical discussion. It's going to be an interactive session. And you can use the chat feature in the webinar and participate in the polls whenever I mentioned them as we go along. And the last part of it as I said before will be the question and answer session. So, without further ado, let's get going with the presentation today. All right. So, keep in mind as we go through this we're going to approach this way as we were an emergency department physician assistant working there, and we have a patient that's coming into the ER. And we're going to evaluate them kind of starting from the beginning and go the whole way through to the diagnosis phase. And I'm going to let you guys know a little bit about kind of what we need to do as a physician assistant. Before we go in the patient's room, it's really important to review the patient's chart, and know a little bit about past diagnosis the patient has clinical conditions, any surgeries they've had in the past, you know, just a little bit about them, because that will change the way you look at them when you go to do a physical exam and to talk to them a little bit more. So, the patient that we are doing our case today. She's 69 year old female. She presented to the emergency department with three days of acute onset edema, which is swelling and era theme, which is redness of the left upper extremity. So that is the chief complaint that is being provided to us by the triaging folks in the emergency department. So, when the patient comes to the ER vital signs are going to be obtained by the medical assistant employed in the emergency department. And I'm going to show you a little bit about what this patient walked in with. So let me share my screen here. And I'm going to pull up the vital signs for you to see. So just give me a quick second. All right. So this is what we have. So the patient as I mentioned female 69 years old. She weighs 62.6 kilograms, which is 138 pounds in the US equivalent here. Her height is 64 inches, which equates to 162.6 centimeters. And the medical assistant collective vitals the temperature is 98.5 degrees Fahrenheit, which is totally normal. Her blood pressure is 130 over 90. And that is a very normal blood pressure. We want it to be less than 140 over 90 based on current guidelines. And the heart rate, which is 84. So pretty close to normal. We want it to be between 60 and 80 and the respiratory rate of 10, which is normal. And they didn't collect her pulse symmetry. You want to do all of that to get a comprehensive view of the patient. So really that doesn't, you know, stand out to me as being abnormal in any shape or form. I'm going to walk into the patient's room and we'll collect a little bit more data. So when you walk into the room you want to knock on the door, you want to greet your, greet the patient and introduce yourself. You also want to make sure that you let them know what title you have so that they know if you're a physician provider or non physician provider that's pretty important so they know who is leading their care. And it's also important to listen to the patient in an uninterrupted way if you can, for a couple minutes to empower them to tell their story. An old adage is that patients will tell their diagnosis exactly what's going on with them in the first couple minutes that you talk to them so it's very important to listen. This information that we collect will be the basis of our history of present illness, or basically what's going on with the patient. So you knocked on the door you introduced yourself you greeted the patient. You asked the patient so what brings you into the emergency department today. Patient says, so I have swelling of my left arm. It first started about three days ago. It started as a swollen lump around my elbow, and then the swelling started to move down from my elbow toward my wrist. The elbow was red and painful, and it started to really go up into my left forearm. I was really worried that I had an infection, and that it was getting worse. So I came to the emergency department to get checked out. So, that's pretty good. Sometimes patients, you know, have different levels of cognitive ability and don't always have the means to tell you what's going on. So it's nice when you can get someone that tells you a clear picture. So at this point, what additional information might you want to find out about the patient to kind of help in your diagnostic process. What might you ask them in terms of a question, you can put your response in the chat box. And I'll give you about 30 seconds to mention, you know, what you want to ask the patient. So go ahead. Someone said the chat is disabled. Okay. Well, let's see if we can get it working. Technology is always great whenever it works, but when it doesn't, it's a bear. And it's always the worst when your EMR goes down, and you're working in the hospital, and you have to do everything on paper. Oh, thank you very much. I appreciate that. Oh, good question. Have you fallen recently? That's a good one. Absolutely. Any kind of allergies, involvement in sports? Have you been bitten by an animal? Awesome. Any recent travel in the past 30 days? Similar symptoms in the past. Any allergies to medications? New medications? Trauma to the elbow? I don't see. Hmm. How long have your symptoms persisted? Have you changed your laundry detergent? Oh, that's a great one. People get a lot of contact dermatitis. We do see that a lot. Anything that makes it better or worse? Awesome. You guys are already starting to learn a little bit more about how to elucidate your HPI and, you know, really ask all these questions. Symptoms? Good. On a scale of one to 10, how painful? I like that. Have they been hiking recently? Different body washes? Family history? Awesome. You guys are killing it. You must have studied before you came. I really appreciate that. Great. Well, let's get back to the case because you guys have done so well. And, you know, some questions I was thinking about and someone actually mentioned this on a scale of one to 10 with one being the most minimal to 10 being the worst. How bad was your pain when the symptoms started? And then it's also good to ask how about now? Because you want to see if their pain level has changed. Is the pain getting worse? Is it getting better? Also, you can ask them how would you describe the pain that you're feeling? A lot of times people will say it's burning, it's aching, it's stabbing, it's shooting. That will help to let you know as a clinician, is this neuropathic? Is this organ kind of pain? Is this visceral? That will help you to make your diagnosis. And then you definitely want to know if there's anything that worsens or improves the pain. And someone mentioned that in the chat. So I'm basically preaching to the choir here. Also, it's important to ask if they've noticed any fevers at home. Sometimes when patients come to the ER, they don't have a fever when they get their vitals because they took ibuprofen or Tylenol an hour before they came for the pain. And it also made their fever go away. So they may not be febrile when they come in. You also want to ask if they had any chills, nausea, vomiting, or diarrhea, which are associated symptoms that are definitely someone mentioned in the chat. I saw falls or recent trauma. You guys already covered that. The only other thing I would add, too, is do you have a history of diabetes? The reason I want to ask that is because people with diabetes are definitely more susceptible to infection and also serious infection. So that is something that you definitely want to get when you go through the rest of the process. So in addition to understanding the active concern for what the patients being evaluated for today, redness, pain, swelling of the elbow, you want to complete the rest of the history taking process and understand their past medical history, or what factors may be contributing to today. So some of it you may have in your EMR, but it's always very good to double check, ask the patient, you know, do you have any history of diabetes, as we mentioned. So this patient's actually going to tell you have a history of osteoarthritis, hypertension or high blood pressure, and cervical degenerative disc disease, which is basically arthritis of the cervical spine in the neck. You're going to ask about surgical procedures. This patient has had none. You're also going to ask about social history. So the key of that is tobacco alcohol drug use and any herbals that they're taking at home as well. This patient denies tobacco use and none of that. She consumes alcohol on an occasional basis, basically one to two drinks per month. No drug use. That's important as well. She is employed as an author of nursing textbooks. So she clearly has a little bit different of a lens coming to the ER than an average patient that does not have a medical background. She's married with two children and exercises two to three times weekly in terms of allergies to medications. She doesn't have any known drug allergies and no latex allergy. All right. So here's where you get to participate again. Based on the information that we have collected so far, I'm going to do a poll and you can let me know what you think is going on with the patient or your first impressions of a diagnosis. I'll give you about 30 seconds to a minute to answer. Can you guys see the poll? Okay, good. Yeah. I know that some of it was a teaser from the title of the webinar. So you may already have been ahead if you read that. But if not, let's just play devil's advocate and come up with some ideas. You guys are doing so well. I feel like you could teach me. So when I take students under my wing and we do some shadowing in the hospital, I feel like I learned so much from my students every time I take them and it's just such a rewarding experience. And it looks like you guys, you know, are really definitely moving in group in here. So let's end this poll because you answered so quickly and it's really not changing much. So most people think that what's going on with this patient preliminarily is left upper extremity or left arm cellulitis and a lecronon bursitis. Okay. I'd say the next one would be left upper extremity osteomyelitis. Cool. So those are the results in the poll. All right. So what we want to do is get a little bit more information because I just don't feel like we have enough to really get this differential diagnosis near or down. So what I'm going to do is I'm going to put on this video for you from real DX and real DX is a system that uses actual patient videos, and it is a neat program because it obtains consent from the patient. And they agree to let their video be posted on this website to teach medical students and pre-PA students and other folks about what's going on. So let's share this screen with you so you can see. All right. And if for some reason you're having trouble hearing the audio, I want you to let me know in the chat. I'm going to double check though and make sure that the audio is shared. All right. So let's watch the short video and it's basically going to pick up from the physical examination and a little bit afterwards. So it'll be about a minute long. It was about a three to four centimeter lump on a posterior aspect of the hang on one second. Let's get this bigger. There was about a three to four centimeter lump on a posterior aspect of the proxmoal period of forearm, which was non-tender and there's no rhubor. Then over the lecheron bursa got swollen with a little bit of redness. And then the swelling proceeded down the forearm to midway and later involving the hand and a little bit up approximately above the elbow joint. And as this video is being done, the redness and swelling has diminished slightly overnight. She's had a lot of range of motion. And what did you do yesterday? I made sure her arm was elevated, had an ace wrap and started her on a mox of 7500 milligrams initially and then Okay. Let me get out of this and then we'll get back to business. Okay. So the most notable things to look at in that video is the provider had mentioned a couple of things about what's going on with this exam. So what they saw is you see the elbow was very, very swollen, but it was swollen and kind of a ball around the elbow. There's also redness that was extending around the elbow and also on the forearm. And it hurt when you touched it or palpated the elbow area. The arm itself was red, warm, and swollen. And the patient was having trouble moving her left forearm. So she basically had a decreased range of motion. Likely due to the pain, but it improved after the arm had been elevated and after starting some additional treatment. So the thing about this video is the patient came in earlier in the evening and she stayed in the ER overnight, got some treatment and already had started to see a little bit of improvement when they did the video. So it likely she would have been in a lot more pain when she first came in. The elbow would have been redder and probably more demerits. But you get a good idea of how that really looks in real life. Poor thing looked absolutely miserable. So at this point, you've seen the patient, you've gotten some history, what laboratory or diagnostic imaging studies do you want to order? Go ahead and put it in the chat and I'll give you about 30 seconds to a minute to write it in there. Let's see what you guys can come up with. And look at you, you're rolling it. X-ray, blood test, CBC, biopsy, skin test, bacterial culture, CBC, ultrasound. I like it. MRI, CT, chemistry test, X-ray, CBC and MRI, blood cultures. You guys have a lot of really good ideas and I think that the thing about medicine is, remember this, there's not really one right answer. And a lot of times you're doing, especially in the ER, you're doing tests simultaneously where you're ordering multiple things at once. So thank you for letting me know what you would order. You guys definitely are on the right track. So let's talk a little bit more about what I would order here if this is why I'm patient that I was taken care of. I definitely would get a CBC with differential or a complete blood count. And what that is important for is that's going to assess the white blood cell count. That's the key thing that I'm looking for there. And also within the white blood cell count, what kind of cells are involved? Is it neutrophils? Is it monocytes? Those are the infection slash first responders to inflammation, which would be very interesting to me. Or if there's eosinophils that would kind of keep me into this a little bit more of an allergic situation. I definitely would order a comprehensive metabolic panel, a CMP. And really this is not so much essential for the diagnosis as it is for, you want to look at a patient's electrolytes when they come in any way. Their kidney function and their liver function in case that we need to prescribe any medications. Because sometimes medications need to be dose adjusted if they have some degree of liver or pedic impairment or renal impairment to. So you need to know that information. It's also good to know, you know, if they're severely infected, you want to see if they're dehydrated, if their kidneys have been impacted and we can talk a little bit more about that. Other things I would order are an arethrocyte sedimentation rate, which is abbreviated as an ESR and a CRP, which is a C reactive protein blood test. Both of those are non specific blood tests that assess for inflammation. I would also get a uric acid from the blood to assess for gout, even though this is less likely, I think just based on the way it looks in her history. And I would start with a three view x-ray of the left elbow. So why three view, well, it's going to do an anterior to posterior view, a lateral which is from the side and an oblique view which is at an angle. So that gives the radiologist the best time to look at all these different views and say, is there a really a fracture here? You do want to see, you know, sometimes even though patients don't have trauma to the arm, they can get, you know, they may bump it and not even realize it and get a fracture, particularly if they are a 60 year old woman postmenopausal osteoporosis. There's got to be, you know, cognizant of those things. And that will also help you to decide if there's any kind of involvement if there's infection, if there's involvement of the bone, osteomyelitis, that's your first stop. That's not always enough, but it's where you want to start. Now if the patient had a fever, so we want to think temperature of 100.4 or 100.5 or higher, or if she has sustained tachycardia, a heart rate of 100 beats per minute or higher. So you definitely want to get blood cultures from two different sites to roll out a systemic body wide infection like bacteremia. Those would also clue you in that maybe she has sepsis if she started having fever and tachycardia. And then you definitely would want to get blood cultures there. That would really tell you how long you need to treat the patient for how serious of an infection you're working with. It almost sounds a bit silly to ask this question again, but we're going to do it. So based on all this information, what do you think is going on with the patient? I'm bringing the poll back up. All right, guys, I'll give you a few minutes here. All right, what do we come up with? All right, we're doing good. So let's share the poll. Most people think it's left upper extremity cellulitis and a lecronombusitis. So your diagnosis has not changed from the first poll that we did. Interesting. I like that. So also, some people are a little bit more concerned though that it is osteomyelitis. I saw the poll number jump up to 17% previously was a little bit lower. So that's also something that really can look like osteomyelitis. All right, let me get this crazy poll to stop. All right. Thank you guys so much for participating in that to really helps to keep this engaging and exciting. And I think that, you know, your participation is awesome. Based on the information that we've obtained diagnosis actually is going to be B, left upper extremity cellulitis and a lecronombusitis, but you knew that already. So let's talk a little bit about what this means, because these are some topics that are pretty interesting and can be complicated, depending on how severe you have, you know, a bursitis and cellulitis. All right, so I'm going to share my screen with you and we're going to go through a couple clinical topics. Give me two seconds. All right. Hopefully you guys can see my PowerPoint. So if you can't just write it in the chat and I'll see it. All right, so let's talk a little bit about a lecronombusitis. So to understand what this is you really need to understand what a bursa is first. So what's a bursa? A bursa is a sack. It's lined by a membrane. So kind of a gelatinous substance. It contains fluid and it's located in between structures that move in the musculoskeletal system. So why do we care about that? Well, they're important because they reduce friction. So if you think about joints moving all the time up and down, it's going to create friction, which is going to create irritation. It is going to start eating at the cartilage. So you need some cushioning there for all of that movement. So you have bursas deep to the tissue, very, very deep, and you have them more superficially. The elbow or the lecronon, which is the medical term for the elbow, is a superficial bursa. So when you see bursitis in this arm in this location, it is going to be a lot more prominent. Versus if you had a bursitis that was very, very deep in the tissue. So what's bursitis? Well, bursitis has a misnomer a lot of times that people always think it's infectious, not always. Really all bursitis means is tenderness or inflammation in the bursa. It doesn't have to be infected. It can be infected, inflamed, and tender all at the same time, which is what we're seeing with this patient, but it doesn't have to be. So what does this happen to people? Well, injury is a big reason or trauma to the area that causes a process called hemorrhagic bursitis, which basically is going to result in, you know, like a bloody collection in there that's not just fluid. You're going to have causes because of sustained pressure on an area over use of the arm or a crystalline process like gout, which is why I was talking about that uric acid level earlier. It also can be inflammatory in nature. So people that have rheumatoid arthritis, which is an autoimmune process or psoriatic arthritis can have an inflammatory process that can happen anywhere in their body specifically in the joint. Or this can be infection mediated and it can actually be septic. So that joint can be completely infected and it can spread to the body and cause bacteremia, which can lead to sepsis as well depending on your body's inflammatory response to that infection. Another key thing about bursitis is that it can be acute. So that is short term, or it can be chronic going on for a long time. The difference between that is really acute is going to be more painful because that bursa has not had enough time to expand for the fluid. And it's going to just kind of push on those pain sensors and the nerves very fast and cause the pain when you touch it. Well, chronic the swelling has been there for a while that bursa has gotten used to expanding to that fluid, and it's less painful because there's more room for the fluid. All right, let's look at this elbow. So the elbows really cool. There's a lot more going on than, you know, what meets the eye when you look at it. So the electronon is this area here in the corner, which you can see from this little skin overlay that's where the elbows at. So there's bony structures right there. And the bursa is kind of like right under that bone. So you can see why if somebody has bursitis and it's actually turns into septic arthritis, it could be very dangerous to get into the bone because of the close proximity of that bursa to the bone. There's also, you know, a lot of bones here. So depending on if a patient has trauma to that area, you know, they could fracture to. And that's why I was alluding to that because sometimes fractures, you know, present is redness, even if they're not displaced, you know, they could be completely in alignment and just read. Unfortunately, our patient did not have a fracture. So let's take a look at this. You saw it in the video, but I wanted to show you a picture up close. This is bursitis of the electronon. And as you can see here, it's just so pronounced. It almost looks like a golf ball. It's just living in this person's elbow and that's what it'll look like in real life. So let's talk about evaluation and treatment. So in terms of diagnostic evaluation, what up to date says, and that's not the only resource but that's a good word is pleased to start to kind of know what people are doing in the medical community. You want to aspirate the fluid. Once you figure out it's bursitis, you want to aspirate the fluid or inject like a little syringe in there and pull the fluid out from that bursa and send it for fluid analysis. What this does is it rules out infection. This is particularly important with septic bursitis and it'll look at crystals to and tell you if the person has gout beyond what a serum uric acid level will do. So you can have bursitis without infection or crystalline disorder and the essence of that fluid will look like non bloody. I mentioned it might look bloody if it's hemorrhagic before, but if it's just plain old bursitis non bloody fluid and white blood cell count is less than 500 per millimeters cubed. And that would be a lot higher if it was infected. So white blood cell count driver of infection if it's low, not infected. Pitching is actually not typically indicated unless you suspect infection or crystal disease. So in our case we ordered an x-ray because we wanted to see if there was osteomyelitis, which I think is important because her arm looked infected. You also may need ultrasound for guidance during your aspiration just to make sure you don't hit any nerves or important structures. That's just a little side note. So how do we treat this? Treating bursitis by itself without cellulitis, you want to do joint protection. So an orthosis, kind of like the one I showed you here, you can actually buy these on Amazon or other retailers, get them in pharmacies, and that stabilizes the joint and helps it to not move so much, which is good because a lot of times this causes from overuse. You also want to provide them with NSAIDs if there's no contraindication to that. So NSAIDs are basically your ibuprofen, your alve, your Advil, your aspirin. Ibuprofen or naproxen is technically the most preferred regimen for these patients and you want to do 600 milligrams to 800 milligrams of the ibuprofen three times daily or naproxen, which is the generic name for alve. You want to do 375 milligrams to 500 milligrams twice daily. You want to do it for a couple days. NSAIDs would be contraindicated if they have chronic kidney disease. So that's why I said order that CMP. Also, you could, you know, do an NSAID but maybe just really dose reduce it. And also consider aspirating it one time for decompression because swelling causes pain. So if you decompress that area to be a lot less painful, you want to avoid a repeat though, because if you keep doing it, it can introduce new infection from the skin into the joint. Also, it's painful. So you don't want to do it too many times. So that is olecranon bursitis in a nutshell. Let's, since we're really dealing with two diagnoses here, let's look at cellulitis. So cellulitis in our case affecting the upper extremity. What cellulitis cellulitis is a very common situation you're going to see in the emergency department or is a hospitalist in the inpatient setting. And this really just means infection of the skin and soft tissues. So cellulitis is different than osteomyelitis osteomyelitis is basically, you have cellulitis generally and then it goes into the bone cellulitis excludes the bone. How does this happen to people. Well, bacteria enters the skin, and it can be through such a small tear that you don't even know you have. And some of the genetics come a lot of times to the ear with cellulitis because you know their skin is fragile and the bacteria get in and they get infected. So once the bacteria get in, they can cause infection. The skin barrier is disrupted. Also, IV drug use is a risk factor because you're inserting needle into the skin and breaking that barrier down. Risk factors also include inflammation of the skin because of eczema or radiation treatment for your cancer patients edema due to venous insufficiency, because when fluid builds up, it tends to be stagnant and get infected. If the lymphatic system is not draining, or it's compromised because they've had a procedure. Obesity is another risk factor and being immunosuppressed. As we mentioned earlier, physical exam findings are going to be erythema, redness edema swelling and warmth, and can be painful if you're talking about a, you know, a pretty bad cellulitis when you touch the area. Common pathogens or microbes that are responsible for cellulitis are including the beta hemolytic streptococci group, most commonly group a strap or strap pyogenes. Staff is another pathogen that's been implicated in cellulitis. So this is MRSA, which is methicillin resistant staff aureus or methicillin susceptible staff aureus or MSSA. But it's a little bit less common as strep species that I mentioned, unless IV drug use is involved or they've had prior colonization from MRSA or have been hospitalized recently. These are your MRSA risk factors. Ooh, lots info. Let's look at it. This cellulitis is really more pronounced than the patient we had in the video. I mean, this is just right and angry and beefy and everything terrible. Very swollen. That hurts. So, you know, cellulitis is one of those things you'll get used to looking at as a dermatologic condition and you'll say, oh, that cellulitis without a doubt. Diagnosis. Funny I say that it's clinical. It's all up to you. Do a good history and physical exam. You can diagnose it without any other tests. Amazing. As I mentioned, diagnostic imaging not typically needed unless you are worried for an abscess, which is when the infection gets walled off in a little pocket, or if it goes into the bone. And you won't know if it goes into the bone just by looking at it. So you're going to have to do something because if you miss it, it's really serious and you know they might need to amputate it. Or just an extended course of antibiotics. So as we mentioned in our discussion before start with the x-ray. If that is inconclusive and you're still like really I think this is osteomyelitis, get an ultrasound to look for an abscess, or an MRI. MRI is so much better than anything else at looking at the soft tissue so that'll really give you some good info. Labs you don't really need if it's uncomplicated. If it's complicated, fever, tachycardia, looking bad. You want a CBC, the ESR, the chemistry panel, all of those things that I mentioned before. You also want to check for blood cultures in that situation if it's complicated. The inflammatory markers can help with the assessment of the severity of this cellulitis too. So if the numbers are higher, guess what, it's more severe. That'll also let you know kind of prognosis to how the patient's going to do. So treatment. Yay, let's fix them. Acute uncomplicated cellulitis. No abscess is involved. If it's an adult, non-diabetic, non-immunocompromised patient with no medication allergies, by the way, which never happens in clinical practice. You want to consider Dicloxacillin, blue-coxacillin, cephalexin, or cephydroxyl. I highlighted cephalexin, which is Keflex because that is the most common medication I see prescribed for this. So a typical dose for uncomplicated infection is going to be 500 milligrams every six hours for five days. You can increase the duration of 14 days if the infection isn't looking better. Also, as I mentioned before, though, when to suspect MRSA because you want to do a little bit different of a treatment for that. If there's pus, purulent drainage or exudate coming from the skin. If they have a history of MRSA infection in the past. If they've been on antibiotics recently or if they use IV drugs. So treatment for MRSA would be trimethoprim, sulfamethoxazole, which is Bactrim, and a lot easier to say, or amoxacillin plus doxy or Linazolib is a single agent. I see Bactrim most commonly, although there are some contraindications with renal function and it's not always tolerable on the elderly. Linazolib is also one I'm seeing more and more often in the hospital. And then this is just a little caveat for you because oral antibiotics aren't always going to be effective. So when do you do IV antibiotics when you if anticipate that the infection is body wide or systemic so the fever, tachycardia, if the redness is just rapidly progressing, if there is a lot of swelling, or if they have that red streak going up the arm, then you kind of suspect that the lymph nodes are involved. If they have been prescribed an oral antibiotic in the outpatient setting and failed it, if they can't take oral treatments or if you're worried they won't be able to absorb the antibiotic. Holy cow, that's a lot of info. Well, I think we covered a lot of stuff though so let's get out of that. And let's open the floor for the question and answer session. And I'm also going to give you guys a special treat. So advanced clinical training is giving a code for everybody here in the webinar to receive $300 off an online certification program or a mentorship program through AZT. I mentor pre physician assistant so you could potentially get me as your mentor. All you need to do is when you check out at AZT put in this code in the checkout and you'll be able to get some money off which is really great because everybody wants to save money. All right friends, I'm seeing the Q&A blowing up so let's take a peek on this. Oh sweet somebody said congrats on being a physician assistant. Yay. I wanted to know is someone as a pre-PA with getting virtual shadowing hours be accepted in PA schools would this make me competitive. That's a great question. So, virtual shadowing is something that has become invoked because of COVID. And, you know, it was getting really hard for pre-PAs to get into the hospitals and the offices to CPAs in person and the patients. So virtual shadowing is something that is never a bad idea. You're actually going to get an hour from spending time with me today, and you're going to get an email that'll send you a digital certificate for an hour of virtual shadowing so you can include that in your application process. And I think, you know, it's important to try to do in person if you can, because that always requires a little bit more effort in schools like that. And because things look different in person and they do online and online you're going to be interviewing a PA and not always seeing the patients to so I think it's good if you could get both that definitely looks good. And we always tell people that 10 to 40 hours of shadowing experience preferably in person are would be making you a competitive applicant. So that is huge. Good question. All right, let's see what else we've got here going on. Regarding the information I provided about the patient so temperature blood pressure respiratory rate will the information be already provided by their nurse or physician or well that you are doctors attending PA have to take care of that great question. So, usually when a patient walks into the door in the ER, the medical so they'll get triage by triage team they'll walk up to a desk and they'll say why are you here and the patient will say, my arm is swollen or my arm hurts, and they'll take them into a room and a medical physician who is resistant typically will do a full set of vital signs, and that information will get put in the computer. So when the ER PA, or ER physician, you know, sometimes ERPs are seeing patients on their own and physicians are seeing their own patients, but can be available for supervision is needed. That information will be in the computer and you can review it before you walk into the room and I always make a point to do that, because that'll clue me in on additional questions to ask the patient. Excellent. So, let me see. Are there situations when you've done all the patient history intake in order labs but still cannot come up with a diagnosis or not sure what is causing the present illness. That happens. I don't want to say a lot because that'll make us some bad but you know I've seen physicians that we look at each other and say, what is going on with this patient, you know either the medical history is just so complicated and they have so many conditions that could be causing this problem you really don't know is this an arthritis flare up. You know is this gout is this cellulitis is this something else is this a fracture. Really, sometimes you just need to order more tests, ask the patient more questions, or ask somebody else. So sometimes it just asks, you know, asking for help is never a bad thing and our situation is a PA. We can always ask for help. So if you are, you know, have done everything you have done, and you're still not sure, ask a physician there's your physicians in there, other physicians in the offices and they're more than willing to help you. What else can we talk about here. Well a non traditional candidate have any leverage over traditional candidates. Now that's a good question. Every school is a little bit different from PA programs, some people only have a spot for one non traditional student because some schools tend to like more traditional students better. It is just how they, you know, what their preferences, and you won't know that you won't know how a PA school is going to select how many spots they have for you know, candidates that are a certain way if they're non traditional traditional. You just have to basically beef up your application the best that you can go in with confidence, rock the interview, and hope that you get selected and apply to, you know as many schools as you can. Let's see what else people are asking. We'll do a couple more minutes of this. I love this one I have to read it. How do you ask a patient if they're drinking or taking drugs without sounding rude. Okay. It really, you can ask people, anything, if you come off in a way that is non threatening. So, you know, a lot of times, I just, I make my voice soft with people. And, and I don't want to say that I'm the best at doing this but I can get people to tell me a lot of crazy things. And it's really fun. What I want to say is, I'm not asking this question because I'm putting any judgment on you, I have to ask this question because it may influence the medical situation that we're dealing with today. You know, have you consumed any alcohol in the past week it's so how much. Have you used any drugs in the past or you using now. A lot of times people will respond to that, and they won't get upset, you know if they get upset they get upset. I always do a urine drug screen, because, you know, I hate to say it because I work with a lot of people that do have addictions and it's a very complicated situation with every single person, and not everybody's the same. And please don't walk into the room and have prejudgment in your head because you never know why somebody becomes addicted, you know they could have been raped in the past and have a lot of trauma, and that's how they're coping with it. Which is just really sad actually did see that in real life. But anyways, you can ask people questions if they get upset, or they don't lie to you sometimes just get a urine drug screen and see if they're, if they have any drugs in their system at that time it's not 100%. Because you know if they've used a week ago and haven't used in the last couple of days it won't get it, but always. I know it's a good start. You basically have to trust the person but then back it up with data. So I never see anything wrong with getting urine drug screen a blood alcohol level. I'll do that a lot of a lot of times people are coming in and they're kind of weird they're, you know, not knowing what day it is what year it is. Those are things that are really important. I never hesitate to add to order the test, you know they can always decline it. If they decline it, then you can't get it but at least you ordered it and you documented that you did. All right guys we have time for one more question. These are also good I wish I could answer your questions all night. I live in a small town. So I have only shattered doctors so far. We barely have PAs. And if we do most are not open to shattering. I don't like that. Okay, I am not able to shadow a PA but we'll meet that make me less competitive. This is a good question shadowing physicians is great. You know if you can get in with a physician that's amazing it's not the same as a PA but at least it's shadowing a medical professional and that'll give you some background and that'll show the selection committee that you do care. That's fine you know if that's what you can do that's what you can do. If you, you know sometimes you just have to do the virtual shadowing route in that situation or try approaching PAs a different way, creating a LinkedIn profile. I'm going on the website for the practice and finding their email address and emailing them stopping into the office almost like you were going in and trying to sell them something but not just yourself. I'm asking, you know, I'm a student, I'm looking to shadow a PA. Can you please help me out. A lot of times people will do it. So that is something that, you know, you just have to ask. All right, folks. Again, so many good questions, I wish I could answer this all night but zoom is going to kick us out if we stay here more than an hour. I don't have to call in the night but I want to thank you from the bottom of my heart for joining this webinar we have had over 200 people join this and that is just phenomenal. I wish all of you the best of luck in your careers. You're going to do great. And you're a wonderful crowd. You answered these polls so well. Again, thank you, thank you, thank you, thank you. Hopefully we'll do some more of these in the future and I'll get to see all of your names again and we'll get to talk about some fun clinical topics. Have a great evening and it was a pleasure.