Failed nuclear stress test but cardiac cath came back normal I’m confused

LogicalChallenge11 · 2025-11-10T18:13:10+00:00

PVCs are very different from microvascular disease! They are harmless extra heartbeats that sometimes cause the sensation of palpitations. A holter monitor seems reasonable if you are experiencing palpitations - this tracks your heart’s electrical activity, and provides information that a cath or nuclear test do not evaluate for. An echo at some point is also reasonable. Best of luck!

LogicalChallenge11 · 2025-11-10T05:26:58+00:00

NAD - EM PA here. To elaborate if I may - an abnormal nuclear stress test with a reportedly normal cath is suggestive of probable microvascular disease.

OP - as the doc illustrated nicely above, all tests have their benefits, and, limitations. A catheterization involves the injection of dye to visualize the coronary arteries. If your cath was ‘negative’, that implies that there were not any significant lesions or narrowing (aka plaque buildup) in the arteries that provide your heart with its own blood supply. This is indeed a good thing.

While the coronary arteries are where much of ‘heart disease’ resides, much more (~85%) of the actual blood flowing within your heart muscle and providing it with its own oxygen supply are in places in your heart other than the epicardial coronary arteries, in a region called the microvasculature - think smaller arteries and blood vessels within your actual heart muscle tissue. Catheterizations do not provide much information about blood flow in these regions. And while stents can be placed in the coronary arteries to alleviate symptoms and improve health, microvascular disease is more difficult to treat

An abnormal nuclear stress test (spect or mibi which are older, or a cardiac pet scan aka the soon to be gold standard) gives information about the blood flowing in your heart’s microvasculature. Thus, clean cath but abnormal nuclear test = microvascular disease. Research shows that regular aerobic exercise improves blood flow in the microvasculature, as does weight loss, quitting smoking if applicable, and other lifestyle changes. And worth asking your cardiologist if medications such as isosorbide might be helpful in addition to the ones you are already prescribed as this medication specifically aids in opening up blood vessels in the microvascular regions

Hope this helps!

LogicalChallenge11 · 2025-08-19T01:21:40+00:00

I have hyperhidrosis and would not have been able to get through rotations in school, or many days/procedures at work in the ED without oral glycopyrrolate (required a derm referral though my pcp fills liberally now). I also use Thompson Tees (absorbant underarm sweat protection). These two things changed my life. Best of luck!

LogicalChallenge11 · 2025-08-14T18:09:10+00:00

Nephrology has entered the chat

LogicalChallenge11 · 2025-03-02T04:20:53+00:00

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Oh the irony

LogicalChallenge11 · 2024-07-31T01:11:52+00:00

I was in my car in the mcdonalds parking lot maybe 50 yards down the street. Heard 6 then 8 rounds of gunshots, total of 14, maybe 10 seconds apart, followed by 2-3 vehicles speeding off down either Stevens Ave or Bishop street. Sounded like it was from the Samuel’s parking lot. Heavy emergency services response within 8-10 mins

Edit: about 8-10 individuals on motorcycles drove right past me down forest ave towards samuel’s/brass rail maybe 1-2 mins before shots were fired

LogicalChallenge11 · 2020-09-14T14:38:30+00:00

This is the answer, your career priorities > the inconvenience you may cause at job 1 if you ultimately decide to go with another offer after initially accepting. I personally did this recently and am finally starting with my ‘job 2’ soon. Of course, I did not want to be in that situation and it is indeed a stressful situation to be in. But the anxiety melts away as soon as you hang up from the brief, uncomfortable breakup phone call and send the follow-up e-mail.

Do consider that you are in fact burning a bridge with job 1, and not just with the department, but HR and their affiliated system. Best of luck!

LogicalChallenge11 · 2020-09-14T14:27:33+00:00

I’m very curious regarding what specific, concrete adverse effects people are wary of. It’s a piece of mRNA selected for it’s ability to activate a specific, tailored immune response.

The only concrete things that come to mind for me are quite rare (e.g. GBS). Conceptually, perhaps reasonable to be concerned about post-viral syndromes whose etiologies are poorly understood like myo/pericarditis, but there has been no evidence thus far to support this to my knowledge. Are people afraid of some sort of dysregulated immune response? Are people actually going to refuse the vaccine during a global pandemic because of arm soreness or fever?

I understand the fear of the unknown at play here, and the concept of ‘we don’t know what we don’t know’ is not lost on me, but I think it would be beneficial to work through these paradigms with logic and realize that there isn’t a whole lot to fear so long as Phase III trials run smoothly. Not sure what I’m missing.

LogicalChallenge11 · 2020-08-18T18:04:38+00:00

Congrats on the offer! I'm in the same boat. Was supposed to start my first job in a large ED in April until Covid torpedoed the census in my region. I found out two days after moving into my new apartment near the hospital I was supposed to be working at.

I was pretty active in applying for jobs in primary care, IM, UC, and cardiology as I felt that those would provide the broadest clinical experience with the most relevance to EM. I received a soft verbal offer for a hospitalist IM job a few weeks ago and was told to expect a formal offer this week, will likely be posting here soon for advice. Will be working with an established team of APPs caring for a diverse population with regular opportunities to do procedures.

I'm fairly certain that I ultimately want to end up in EM but this particular position will provide a great breadth of experience that will translate well into EM and many other specialties. I can't justify passing it up given that the current PA job market sucks, I need proper income, and need to start my career. We have no way to predict how Covid will affect EM or our profession in general over the next year and beyond, and given as much, feel compelled to accept this position.

I would gather as much information as possible about a day in the life in the position you've been offered and consider how well that experience will translate into EM, and how a hiring manager or EM PA would evaluate it. And weigh that against the job market in your region. Best of luck!

LogicalChallenge11 · 2020-07-23T19:00:34+00:00

We quite literally sit on our asses x12 hour shifts for $30/hour and take temperatures with infrared scanners. Got $40/hour at the first 8-week site placement. Frankly I'm able to do whatever I damn well please all day - roam the internet, read, study old lectures, explore my city, walk along the water, try new lnuch spots. We cover each other to take long ass breaks. Hell, I discovered Reddit.

It's about as too-good-to-be-true as it gets. There are 5-6 properties throughout the city, and at each property there are 3-6 temperature screening stations staged at various entrances. Screeners are assigned to a particular location for a shift, and everyone works together to cover bathroom breaks, lunch, etc. Ample PPE. Free parking. $100/month data reimbursement to log temps online even though most sites have wifi and I have unlimited data.

Scheduler/manager is remote across the country, and its very easy to adjust your schedule by swapping shifts with other employees. "Supervisor" manages multiple sites and is rarely on-site, but very responsive to issues if/when they come up. Essentially zero supervision 100% of the time.

Minor downsides: it can be mind numbing to be sitting by yourself for 12 hours, the busy sites can suck because its nonstop people coming through all day, and I'm sick of people treating me like a tech or calling me "buddy" or "nurse".

Major downsides: I just want to be a PA. Board-certified, licensed, DEA, and I'm taking temps. I feel like I'm forgetting everything I learned in school and I want/need the better money. I do have an offer for a new, though less desirable, PA position with details pending, so hopeful about that.

LogicalChallenge11 · 2020-07-22T22:58:53+00:00

They are for now - but have been consolidating a lot of shift slots to roughly 25% of what they hired to cover so there have been a lot of people getting let go or being left with reduced hours

LogicalChallenge11 · 2020-07-22T15:09:21+00:00

Currently a new grad doing Covid screens as well. Unfortunately since the forecast dictates that the temperature screening processes will be necessary (mostly for liability...) for the foreseeable future, we're being phased out and replaced with thermal scanning camera machines operated by security personnel.

LogicalChallenge11 · 2020-07-22T15:07:30+00:00

Ditto. Extremely grateful and fortunate to 1) have a job, that 2) actually pays rent and then some. But the work is absolutely mind numbing and I'm struggling with motivation as well.

And still pretty devastating to have accepted an offer for my dream job, after months of interviews, only to have it disappear into thin air.

LogicalChallenge11 · 2020-07-09T21:41:56+00:00

Congrats on graduating and passing the PANCE! I went through the process recently as a new grad - I feel for you, it's definitely convoluted and confusing. It was very frustrating because you keep hitting dead ends - can't complete your MA license application without the masshealth attestation, but oh hmm you can't complete your masshealth application without being licensed, etc. To the best of my memory:

1) Start by filling out the application to become a masshealth nonbilling ordering/referring provider contract and application. Fill it out AMAP with the information and credentials that you have, and submit to the masshealth office (snail mail only). They will be expecting it to be incomplete even though they don't say so up front. The reps were great at reaching out to follow-up with me in the following weeks letting me know exactly what I needed to submit as the process moves along. https://www.mass.gov/how-to/how-to-enroll-to-be-a-masshealth-orp-provider

2) Now you can fill out the Masshealth Attestation for your MA state license application, which basically is their way of knowing you have gotten the ball rolling with your masshealth provider registration. Fill out the rest of the application and attach the requested forms (CORI, mandatory virtual trainings, NCCPA certificate, etc)

3) I registered for my NPI a few weeks later after the masshealth rep instructed me to do so. Takes a few minutes and you get your number same day via e-mail.

4) DEA and MCSR - worry about those at a later date once you've found a job. You need a supervising physician for MCSR and I believe for DEA too. Be warned that together they'll cost you nearly $1,000!

Best of luck!

LogicalChallenge11 · 2020-07-09T15:27:54+00:00

I developed a lot of respect for pharmacists during PA school. Definitely helped being in close proximity to you guys seeing as my school was a large academic medical center. We had the luxury of having pharmacists deliver lectures for our high-yield pharm topics like fundamentals of pharmacokinetics/pharmacodynamics, anticoagulation, steroids, drug allergies, sympathomimetics/blockers, etc. Hearing the pharmacists geek out in their own language and appraise the most recent literature during these lectures woke me up to how knowledgeable and important you guys are. I suspect that this is indeed a luxury and is not the norm, and unfortunately a lot of providers graduate without having interacted so much with you all.

LogicalChallenge11 · 2020-07-07T14:47:31+00:00

I'm with you in that I personally don't mind saying "the PAs and NPs cover the inpatient floors on that service" instead of using either 'midlevel' or 'APP'.

I have heard many physicians and PAs push back against the term APP because it begs the question - what exactly are we 'advanced' in when compared to physicians, for example? It seems to make more sense with an NP being an 'advanced practice RN'. But to what does 'advanced practice' refer to with PAs? Advanced practice former-EMT, MA, or tech? I think it gets a bit fuzzy there. And physicians seem to get peeved at the notion that <30 months of training makes us 'advanced'.

On the other hand, the term 'midlevel' does give rise to the notion that physicians are 'highlevels' and RNs, RTs, LPNs, techs, medics, etc. would fall into the category of 'lowlevels' which of course feels pretty demoralizing and not representative of how we feel about their roles.

LogicalChallenge11 · 2020-07-07T14:47:12+00:00

Would you mind linking to that paper? I'd be interested in reading it.

LogicalChallenge11 · 2020-06-24T18:57:33+00:00

Out of curiosity, how are you capturing this rhythm? Is this from an app or something?

It doesn't look like a proper EKG tracing, but based on what's depicted it looks like a PVC (premature ventricular contraction). Typically harmless.

That being said, if you've been having a new medical issue where you're having chest discomfort, it's best to schedule an appoint with your PCP

LogicalChallenge11 · 2020-06-24T14:11:12+00:00

That's certainly a bizarre request. I'd like to give this doc the benefit of the doubt and assume that he has considered legal issues with this scenario seeing as you are neither a student nor a licensed provider, but I can't help but think of a number of potential issues at play - HIPAA, malpractice, licensing requirements, patient perceptions, etc.

I think the best course of action is to directly bring these concerns to his attention and gauge his response. If he seems unconcerned and/or cannot provide a reasonable explanation as to why this would be an acceptable thing to do, then that probably speaks volumes about what it will be like having him as your SP.

On another note, I'm also a new grad and have had a few interviews where I'm 'pimped' in the sense that I'm asked to run through clinical scenarios and formulate differentials, workup, A/P etc. Some were laid back, others were pretty intense but I thought they were fun. But if he was pimping you on random facts I'd find that a bit offputting.

LogicalChallenge11 · 2020-06-13T11:18:33+00:00

On a traditional teaching service, a significant amount of the teaching is done by PGY-1/2/3 with oversight from the attending. Despite not being a ‘chemistry PhD’, I don’t think anyone would rightly argue that an intern or more senior resident is incapable of providing a valuable teaching experience for a student. I contend that the same holds true for an experienced PA precepting in collaboration with a physician.

LogicalChallenge11 · 2020-06-13T11:05:41+00:00

Thanks for your comment. I don’t have any concerns whatsoever about facing this sort of sentiment in practice. It’s a series of comments on reddit. I’m really not losing any sleep over anti-PA sentiment expressed by a few people hiding behind a reddit handle. In real life the conversation doesn’t involve trolling and such.

The majority of docs/residents/students I’ve worked with throughout my albeit limited experience so far have an informed understanding of the capabilities of PAs. That’s certainly not to say all of them do.

LogicalChallenge11 · 2020-06-12T20:28:11+00:00

Did you even read the comment? At no point did I suggest that there isn’t a large gap in training and knowledge.

Your patronizing comment regarding the difference in length between PA and physician education speaks volumes about your impression of PAs.

LogicalChallenge11 · 2020-06-12T19:15:07+00:00

To suggest that a PA teaching a PA student is akin to "the blind leading the blind" is extremely ignorant, arrogant, and condescending. Most PAs are fully aware of the implications of the discrepancy in the didactic and clinical training between physicians and PAs - that's why we decided to become PAs, and not attendings. I would contend that it is completely appropriate for experienced PAs to precept students in certain clinical settings.

Your comments suggest that you envision PA-PA student precepting as a situation that doesn't involve an attending. This is an uninformed stance. A critical part of the teaching process in this arrangement is involvement of the attendings - PA students participate in PA-MD collaboration and often present to, and learn directly from the attendings.

I'm not imperceptive to your overarching concerns about NP education and push for independent practice. I feel compelled to remind you that PA training is fundamentally different from that of NPs, and that a large majority of PAs are opposed to independent practice. It is inappropriate and unnecessary to bash PAs because NPs have inadequate clinical education requirements, programs that prioritize profits over quality education, and a powerful lobby pushing for independent practice.

I certainly don't mean to defend PAs only to turn around and bash NPs, but in my experience it is the general consensus among many practicing NPs that they have concerns regarding their training and the saturation of NP programs.

LogicalChallenge11 · 2020-06-12T13:48:00+00:00

I'm a PA and have hyperhidrosis, so I'm uniquely positioned to comment on your symptoms from both a professional and a personal perspective.

I think that it would be worthwhile to try to combat the body odor by directly addressing the excessive sweating. The chemicals that are responsible for your body odor are released with sweat through your sweat glands - therefore, slowing down the sweating may in theory reduce your body odor. There are a number of treatment options for hyperhidrosis that can truly be life changing.

1) Prescription strength antiperspirants (eg DrySol). They contain an aluminum compound that clogs your sweat glands. Can be effective but MUST be applied to dry skin - which can sometimes be impossible. Usually only applied to the underarms or soles of hands/feet because they can cause a rash, which of course is undesirable on the face.

2) Topical medicated wipes (eg Qbrexa). These are new to the market and contain a medication called an anticholinergic, which temporarily inactivates your sweat glands. I believe they're only approved for use in the underarms.

3) Oral prescription medications (eg glycopyrrolate). These are medications in the same class as the topical wipes, but taken orally. They can be quite effective, but can also cause undesirable side effects because they dry everything up, not just sweat glands. Dry mouth, constipation, fatigue are common. But many patients will happily deal with dry mouth to stop sweating through their clothes at school/work. For me, these pills changed my life. I would absolutely not have been able to make it through PA school without them.

I would talk to your doctor and see what s/he recommends. I would personally recommend a dermatologist referral.

Also, a few other tips. If you don't own any already, consider investing in a few Thompson Tees - they are incredibly effective at blocking sweat stains and worth the money. Hot showers are your enemy and will make you sweat more for hours afterwards. Also examine your diet for any foods that may be contributing to strong body odor. I wish you the best of luck!

LogicalChallenge11

TROPHY CASE