The answer is C. 24 weeks

Prenatal care is extremely important. Screening for gestational diabetes is routinely done in pregnant patients at 24 weeks of gestation (typically until 28 weeks). Pregnancy is associated with insulin resistance, mostly because of the placenta’s secretion of human placental lactogen. There are bad consequences of gestational diabetes, so it is critical it is diagnosed and treated adequately.

The initial test is a one-hour 50-gram oral glucose tolerance test (GTT). A positive test >135 mg/dL. If a patient tests positive, they need to undergo the second test, which is a three-hour 100 mg oral GTT. The cut-offs are debated, but generally, the following are positive results: fasting > 95 mg/dL, 1 hour>180 mg/dL, 2 hours>155 mg/dL, 3 hours>140 mg/dL.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Complicated Pregnancy ⇒ Gestational diabetes

Also covered as part of the Women’s Health EOR topic list

The answer is A. Hyponatremia

The patient has hypervolemic hyponatremia secondary to cirrhosis. The causes of hypervolemic hyponatremia are cirrhosis, nephrotic syndrome, and CHF. Symptoms include nausea, headache, lethargy, and seizures. It’s important to have an approach to hyponatremia since it is the most common electrolyte abnormality in the hospital.

• First, it’s important to rule out pseudohyponatremia due to proteins, glucose, or mannitol. Also, make sure it’s not a diuretic causing hyponatremia.
• Next, consider the volume status – are they hypervolemic, hypovolemic, or euvolemic?
• Hypovolemic causes are more obvious (emesis, hemorrhage, etc.); however, urinary sodium can help differentiate between hypovolemia and euvolemia. If uNA < 20, then this means the renin-angiotensin-aldosterone system is on and trying to maintain pressure/volume; therefore, it is likely the patient is hypovolemic.

Treatment of hyponatremia depends on the cause. It usually involves fluid restriction and possibly (and carefully) a hypertonic solution. Remember – rapid correction of hyponatremia can lead to central pontine myelinolysis.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Renal System ⇒ Fluid and Electrolyte Disorders ⇒ Hyponatremia

Also covered as part of the Internal Medicine EOR topic list

The answer is B. Atrioventricular block

The patient most likely has Lyme disease, which is a tick-borne illness usually caused by Borrelia burgdorferi. It is more prevalent in the Northeast and upper Midwest. Erythema migrans, which is a circular, expanding rash that may look like a “bull’s eye” is seen about 20% of the time with Lyme disease. Clinical features in the early localized disease include fever, headaches, malaise, arthralgia, and lymphadenopathy. Treatment is doxycycline for non-pregnant adults and children. Amoxicillin is a second-line treatment. A well-known cardiac complication is an atrioventricular block.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Spirochetal Disease ⇒ Lyme disease

Also covered as part of the Internal Medicine EOR and Family Medicine EOR topic list

The answer is E. Fetal growth acceleration

Clinical features of a congenital rubella infection (CRI) include deafness, cataracts, and cardiac disease. Patients may also have CNS abnormalities, such as microcephaly. Typically, a congenital rubella infection will lead to fetal growth restriction, not fetal growth acceleration. A classic finding that you may see on exams is petechiae and purpura — some call these “blueberry muffin lesions.” In general, CRI should be considered in patients who have a suspected rubella infection during their pregnancy. Laboratory studies on the child (before the age of one) are done to help confirm the diagnosis. There is no treatment, and supportive care/surveillance is the main way to manage a congenital rubella infection.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Viral Infectious Disease ⇒ Rubella (German Measles)

Also covered as part of the Pediatric EOR topic list

The answer is C. Myocardial Infarction

Cardiogenic shock is a type of shock that occurs due to cardiac pump failure; essentially, it is the most severe expression of heart failure. It is defined by systemic tissue hypoperfusion secondary to poor cardiac output despite adequate intravascular volume. The most common cause of cardiogenic shock is a myocardial infarction. Other causes include atrial/ventricular tachyarrhythmias, aortic or mitral valve insufficiency, septal defects, free wall rupture, etc. Therapy options vary but may include inotropic support (e.g., dobutamine), intra-aortic balloon pump, and percutaneous ventricular assist devices.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Hypotension ⇒ Cardiogenic shock

Also covered as part of the Emergency Medicine EOR topic list

The answer is D. Nystatin

The patient has oropharyngeal candidiasis, which is a local infection in patients with certain risk factors (e.g., AIDs, dentures, radiation, inhaled glucocorticoids, etc.). This patient has asthma so the likely causative culprit is her inhaled glucocorticoids. The most common cause of oropharyngeal candidiasis is C. albicans. On a physical exam, you will see white plaques in the mouth (which can be scrapped). In smokers, the lesions may look more yellow/brown.

Diagnosis is usually clinical but can be confirmed by scraping the lesion. A KOH test can be performed on the scrapings — budding yeast with pseudohyphae are seen. The treatment of choice is nystatin swish and swallow or topical clotrimazole. If a patient has a severe disease or fails topical therapy, oral fluconazole can be given.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Fungal Infections ⇒ Candidiasis

Also covered as part of the Internal Medicine EOR and Pediatric Rotation EOR topic list

The answer is E. Huntington’s disease

Huntington’s disease is an autosomal-dominant disorder characterized by progressive neurodegeneration. It is due to the expansion of the cytosine-adenine-guanine (CAG) trinucleotide in the HTT gene. The main clinical features include choreiform movements, dementia, cognitive impairment, and psychiatric problems. Patients typically present during mid-life. Diagnosis is confirmed by genetic testing. A brain MRI may reveal caudate atrophy. Treatment is generally supportive and symptomatic. There is no cure for Huntington’s disease.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Huntington Disease

Also covered as part of the Internal Medicine EOR topic list

The answer is A. Initiate IV antibiotics and fluids

This patient has a severe case of cellulitis and sepsis. The best next step is to initiate intravenous antibiotics and fluids. A broad-spectrum antibiotic (like cefepime) plus coverage for MRSA (vancomycin) would be appropriate.

The most common cause of cellulitis is Group A beta-hemolytic Streptococcus pyogenes. What differentiates cellulitis from erysipelas is that erysipelas is more well-defined. Antibiotic options for more mild cellulitis cases include Bactrim, clindamycin, and Keflex.

It’s important to keep in mind that events don’t happen in a vacuum — the bug bite led to cellulitis, and the patient’s body responded to the cutaneous infection in a complex and dysregulated way (i.e. sepsis), eventually leading to hypotension and instability.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Dermatologic Infectious diseases ⇒ Bacterial Infections ⇒ Cellulitis

Also covered as part of the Family Medicine EOR, Emergency Medicine EOR, and General Surgery EOR topic list

The answer is B. Appetite suppression

The patient has attention-deficit hyperactivity disorder (ADHD). There are two main patterns: inattentive or hyperactive-impulse (some may have a combined presentation). The DSM V has criteria for diagnosing ADHD and the various subtypes, but in general, symptoms should be seen in multiple settings, last for 6 months or more, and negatively impact social/academic activities. The first-line pharmacological treatment for ADHD, in most cases, is a stimulant (e.g., methylphenidate, dextroamphetamine, etc.). The most adverse effects of stimulants include moodiness and irritability, and appetite suppression. It’s important to monitor children’s growth and weight when they are taking a stimulant for this very reason.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Neurodevelopmental disorders ⇒ Attention-Deficit/Hyperactivity Disorder

Also covered as part of the Pediatric Rotation and Psychiatry EOR topic list

The answer is B. 51-year-old with 31 pack-years who quit 10 years ago

The U.S. Preventive Services Task Force (USPSTF) recently changed the lung cancer screening guidelines in March 2021.

An annual low-dose chest CT scan (NOT chest x-ray) should be done for those who are 50 to 80 years old with at least a 20-pack-year history and who currently smoke or have quit within the past 15 years.

It is also important to note that these guidelines do not apply to those who have another illness that already severely limits their life expectancy.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Neoplasms ⇒ Lung cancer

Also covered as part of the Family Medicine EOR and Emergency Medicine EOR topic list

The correct answer is A) Colonoscopy

Colonoscopy is a procedure that involves inserting a flexible tube with a camera into the colon to visualize the mucosa and detect any abnormalities such as polyps, tumors, inflammation, or bleeding. It is indicated for patients with chronic constipation who are older than 50 years or have any red flag features for colorectal malignancy, such as weight loss, blood in stools, anemia, or a family history of colon cancer. This patient meets the age criterion and should undergo colonoscopy to rule out any serious causes of his constipation.

Answer explanations:

• Barium enema is an imaging test that involves injecting a contrast agent (barium sulfate) into the rectum and taking X-rays of the colon. It can show structural abnormalities such as diverticula, strictures, masses, or volvulus. However, it is less sensitive and specific than colonoscopy for detecting colorectal malignancy. Therefore, it is not the preferred test for this patient.
• Thyroid function tests are blood tests that measure the levels of thyroid hormones (T3, T4) and thyroid-stimulating hormone (TSH). They can help diagnose thyroid disorders such as hypothyroidism or hyperthyroidism. Hypothyroidism can cause constipation due to decreased gastrointestinal motility. However, this patient has no other signs or symptoms of hypothyroidism such as fatigue, cold intolerance, dry skin, hair loss, or bradycardia. Therefore, thyroid function tests are not necessary for this patient.
• Stool osmolarity is a test that measures the concentration of solutes in stool water. It can help differentiate between osmotic diarrhea (high stool osmolarity) and secretory diarrhea (low stool osmolarity). However, this test is not useful for evaluating constipation which is defined by infrequent or difficult defecation.
• Dietary modification is a nonpharmacological measure that involves increasing fiber and fluid intake to improve stool consistency and frequency. It may be effective for patients with primary constipation which has no identifiable organic cause. However, this patient has chronic constipation which requires further evaluation before initiating treatment.

(Review PANRE Blueprint Topic: Constipation)

The correct answer is A) Troponin

Acute myocardial infarction (AMI) is a serious medical emergency that requires prompt diagnosis and treatment. Cardiac biomarkers such as troponin, creatinine kinase-MB (CK-MB), and myoglobin are commonly used to diagnose AMI. Among these biomarkers, troponin is the most specific for the diagnosis of AMI. Troponin is a protein found in cardiac muscle cells, and its release into the bloodstream is a specific marker of myocardial injury. Elevated troponin levels are typically seen within 3-4 hours after the onset of symptoms and can remain elevated for up to 10-14 days after an AMI.

Incorrect answer explanations:

• Creatinine kinase (CK) is an enzyme found in various tissues, including skeletal and cardiac muscle. CK-MB is a specific isoform of CK found predominantly in cardiac muscle cells. Elevated levels of CK-MB can be seen in the early stages of AMI, but CK-MB is less specific for the diagnosis of AMI compared to troponin.
• Myoglobin is a protein found in skeletal and cardiac muscle cells. Elevated myoglobin levels can be seen within 1-3 hours after the onset of symptoms, but myoglobin is less specific for the diagnosis of AMI compared to troponin. Elevated myoglobin levels can also be seen in other conditions that cause muscle injury, such as rhabdomyolysis.
• C-reactive protein (CRP) is an acute-phase protein that is elevated in response to tissue injury, inflammation, and infection. While elevated CRP levels can be seen in patients with AMI, CRP is not specific for the diagnosis of AMI and cannot be used as a diagnostic tool on its own.
• Brain natriuretic peptide (BNP) is a hormone released by the heart in response to increased pressure and volume in the cardiac chambers. Elevated BNP levels can be seen in patients with heart failure and other cardiac conditions, but BNP is not specific for the diagnosis of AMI.

(Review PANRE Blueprint Topic: Acute myocardial infarction: ST-segment elevation myocardial infarction (STEMI))

The correct answer is B) Order duplex ultrasonography of the lower extremities

Duplex ultrasonography is a non-invasive test that uses sound waves to visualize the blood flow in the veins of the legs. It can detect thrombi by measuring the diameter, compressibility, and flow characteristics of the veins. It has high sensitivity and specificity for diagnosing DVT. It is considered the first-line diagnostic test for patients with suspected DVT. If negative, it can be repeated in one week or combined with D-dimer testing to rule out DVT.

Incorrect answer explanations:

• Heparin infusion and warfarin dose adjustment are indicated for patients with confirmed deep vein thrombosis (DVT) who have subtherapeutic INR levels. However, this patient has not yet been diagnosed with DVT and needs further diagnostic testing before initiating anticoagulation therapy.
• tPA is a thrombolytic agent that dissolves blood clots by activating plasminogen into plasmin. Plasmin degrades fibrin, which forms the meshwork of clots. tPA may be used for patients with massive or life-threatening DVT who have contraindications to anticoagulation or who have failed anticoagulation therapy. However, it carries a high risk of bleeding complications and should not be used without confirming DVT diagnosis first.
• Venography is an invasive procedure that involves injecting contrast dye into a vein and taking X-ray images to visualize any obstruction or narrowing in the venous system. It was once considered the gold standard for diagnosing DVT but has been largely replaced by duplex ultrasonography due to its higher cost, invasiveness, discomfort, and risk of allergic reactions or nephrotoxicity from contrast dye.
• Compression stockings are elastic garments that apply graduated pressure on the legs to improve venous return and prevent edema formation. They may be used as an adjunctive treatment for patients with confirmed DVT, along with anticoagulation therapy. Elevation of the leg can also reduce swelling and pain by decreasing hydrostatic pressure in the veins. However, these interventions do not address the underlying cause of DVT or prevent clot propagation or embolization. They should not be used as the sole therapy for suspected or confirmed DVT without diagnostic testing or anticoagulation therapy.

(Review PANRE Blueprint Topic: Deep venous thrombosis)

The correct answer is D) Topical mupirocin

The presentation of honey-colored crusting lesions on the face and extremities in a child is consistent with impetigo, a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. The most appropriate initial treatment for impetigo is topical antibiotics such as mupirocin. This is because impetigo is a localized skin infection, and topical antibiotics can effectively treat it without the need for systemic antibiotics. The topical antibiotic is applied to the affected area 2-3 times per day for 5-7 days.

Incorrect answer explanations:

• Topical corticosteroids are not appropriate for impetigo as they can exacerbate the infection by suppressing the immune response and promoting bacterial growth.
• Oral antihistamines are used to treat allergic reactions and are not effective in treating bacterial skin infections such as impetigo.
• Oral doxycycline can be used to treat impetigo, but it is not the initial treatment of choice. Oral antibiotics are reserved for cases of extensive or severe impetigo or for patients who cannot tolerate topical antibiotics.
• Oral acyclovir is an antiviral medication used to treat viral skin infections such as herpes simplex virus (HSV). It is not effective in treating bacterial skin infections such as impetigo.

(Review PANRE Blueprint Topic: Impetigo)

The correct answer is A. Administer intravenous alteplase

The patient has a clinical diagnosis of acute ischemic stroke, which is caused by occlusion of a cerebral artery by a thrombus or embolus. The most important factor in determining the treatment of acute ischemic stroke is the time from symptom onset to presentation. If the patient presents within 4.5 hours of symptom onset and has no contraindications, intravenous alteplase (a tissue plasminogen activator or tPA) should be administered as soon as possible to dissolve the clot and restore blood flow to the ischemic brain tissue. Intravenous alteplase has been shown to improve functional outcomes and reduce disability after acute ischemic stroke. The patient meets the criteria for intravenous alteplase because she presented within 4.5 hours of symptom onset, has no evidence of hemorrhage on head CT scan, and has no other contraindications such as recent surgery, active bleeding, severe hypertension (>185/110 mmHg), or use of anticoagulants. The other answer choices are incorrect because they are not indicated or effective in this scenario.

Incorrect answer explanations:

• Intravenous heparin administration is not recommended for acute ischemic stroke because it does not improve outcomes and may increase the risk of bleeding complications.
• Carotid endarterectomy is a surgical procedure that removes plaque from the carotid artery to prevent recurrent strokes in patients with significant carotid stenosis (>70%) who are asymptomatic or have had a transient ischemic attack (TIA) or minor stroke within the past 6 months. It is not indicated for patients with acute ischemic stroke who have not been stabilized medically.
• Mechanical thrombectomy is an endovascular procedure that uses a catheter-based device to remove large vessel occlusions in patients with acute ischemic stroke who have a large penumbra (area of potentially salvageable brain tissue). It can be performed within 24 hours of symptom onset if intravenous alteplase is contraindicated or ineffective. However, it should not delay or replace intravenous alteplase if eligible.
• Oral aspirin is recommended for secondary prevention of ischemic stroke after initial treatment with intravenous alteplase or mechanical thrombectomy. It can also be used as initial treatment for patients who present more than 24 hours after symptom onset or who have contraindications to intravenous alteplase. However, it should not be given within 24 hours of receiving intravenous alteplase because it may increase the risk of bleeding complications.

(Review PANRE Blueprint Topic: Stroke)

[dt_sc_button type=”type2″ link=”https://smartypance.com/lessons/vascular-disorders/stroke-reeldx266/” size=”small” target=”_blank” timeline_button=”no”]View blueprint lesson[/dt_sc_button]

The answer is C. Gastrointestinal bleeding

The patient has a microcytic anemia, which is characterized by a low MCV (<80 fL). The most common cause of microcytic anemia is iron deficiency. Iron deficiency can result from inadequate dietary intake, malabsorption, increased demand, or chronic blood loss. In this patient, the most likely source of chronic blood loss is gastrointestinal bleeding due to his history of peptic ulcer disease and the use of omeprazole. Omeprazole can mask the symptoms of gastrointestinal bleeding by reducing acid secretion and healing ulcers but does not prevent recurrence or complications. The patient may also have occult blood loss that is not visible in the stool. The RDW is elevated (>15%), indicating increased variation in red blood cell size due to iron deficiency. To confirm iron deficiency, iron studies such as serum ferritin, serum iron, total iron-binding capacity (TIBC), and transferrin saturation should be ordered. The patient should also undergo endoscopy to evaluate for the source and severity of gastrointestinal bleeding and rule out malignancy. The other answer choices are incorrect because they are not causes of microcytic anemia but rather causes of normocytic or macrocytic anemia.

Incorrect answer explanations:

• Chronic kidney disease can cause normocytic anemia due to reduced production of erythropoietin by the kidneys. The MCV would be normal (80-100 fL).
• Folate deficiency can cause macrocytic anemia due to impaired DNA synthesis in red blood cell precursors. The MCV would be high (>100 fL).
• Thalassemia trait can cause microcytic anemia due to reduced synthesis of alpha or beta globin chains that form hemoglobin. However, thalassemia trait usually has a normal or low RDW (<15%) because red blood cells are uniformly small. Thalassemia trait also has a genetic basis and is more common in people of Mediterranean, African, or Southeast Asian descent.
• Vitamin B12 deficiency can also cause macrocytic anemia due to impaired DNA synthesis in red blood cell precursors as well as neurological symptoms such as peripheral neuropathy, ataxia, dementia, or psychosis. The MCV would be high (>100 fL).

(Review PANRE Blueprint Topic: Iron Deficiency Anemia)

The correct answer is D) Taper omeprazole to every other day for 4 weeks

Explanation:

The patient has a history of GERD that has responded well to PPI therapy and lifestyle modifications. The goal of treatment is to achieve symptom relief and prevent complications such as esophagitis, stricture, Barrett’s esophagus, or adenocarcinoma. PPIs are more effective than H2 blockers or antacids for healing erosive esophagitis and maintaining remission. However, long-term use of PPIs may be associated with adverse effects such as increased risk of fractures, infections, hypomagnesemia, vitamin B12 deficiency, and chronic kidney disease. Therefore, it is reasonable to attempt a step-down approach after achieving symptom control with PPIs for at least 8 weeks. This involves tapering the dose of PPI gradually over 2-4 weeks to avoid rebound acid hypersecretion. If symptoms recur after discontinuation of PPIs, then switching to an H2 blocker or restarting PPI maintenance therapy with the lowest effective dose may be indicated.

Incorrect answer choices:

• Continuing omeprazole 20 mg daily may expose the patient to unnecessary risks of long-term PPI use without attempting a trial of dose reduction or discontinuation.
• Discontinuing omeprazole and monitoring symptoms may cause rebound acid hypersecretion and recurrence of GERD symptoms due to abrupt withdrawal of PPI therapy.
• Immediately switching to an H2 blocker (such as famotidine) may not provide adequate symptom control for GERD, as H2 blockers are less potent than PPIs in suppressing gastric acid secretion. Slowly taper off the PPI first over 2-4 weeks (the higher the dose, the longer the taper). If symptoms return, it would be appropriate to start again with an H2 blocker.  If long-term treatment is needed, H2 blockers allow better absorption of nutrients than PPIs and so potentially have fewer long-term adverse effects. If symptoms are still difficult to control, consider adding the PPI back at the lowest effective dose.
• Perform an upper endoscopy: This option is not indicated for patients with uncomplicated GERD who have responded well to medical therapy. Endoscopy is reserved for patients who have alarm features such as dysphagia, odynophagia, weight loss, anemia,

(Review PANRE Blueprint Topic: GERD)

The answer is E. Switch to low-dose ICS/formoterol as needed

This patient has well-controlled asthma on medium-dose ICS and LABA, which corresponds to step 4 of the asthma treatment algorithm. Step-down therapy can be considered for patients with at least 3 months of continuous good control of asthma. The goal of step-down therapy is to reduce medication use to the lowest effective dose while maintaining asthma control. According to the Global Initiative for Asthma (GINA), one option for stepping down from step 4 is to switch to low-dose ICS/formoterol as needed. This regimen involves using a combination inhaler containing low-dose ICS (budesonide) and formoterol (a fast-acting LABA) both as maintenance therapy and as reliever therapy instead of a short-acting beta agonist (SABA). This strategy has been shown to reduce exacerbations, improve symptom control, and decrease steroid exposure compared with conventional maintenance therapy with higher doses of ICS/LABA plus SABA as needed.

(Review PANRE Blueprint Topic: Asthma)

The correct answer is D) Generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by persistent, excessive, and unrealistic worry about everyday things that lasts for at least 6 months. The worry causes significant distress or impairment in social, occupational, or other areas of functioning. The anxiety is not attributable to any specific triggers or stressors. The diagnosis of GAD requires at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

• Panic disorder is characterized by recurrent unexpected panic attacks that cause fear of having another attack or avoidance of situations that might trigger an attack. Panic attacks are sudden episodes of intense fear or discomfort that peak within minutes and are accompanied by at least 4 physical or cognitive symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control or dying. The patient does not report having panic attacks.
• Obsessive-compulsive disorder (OCD) is characterized by recurrent obsessions (intrusive thoughts or images that cause anxiety) and/or compulsions (repetitive behaviors or mental acts that aim to reduce anxiety). The patient does not report having obsessions or compulsions.
• Post-traumatic stress disorder (PTSD) is characterized by exposure to a traumatic event that involved actual or threatened death, serious injury, or sexual violence, and subsequent re-experiencing, avoidance, negative alterations in cognition and mood, and increased arousal related to the event. The patient denies any history of trauma.
• Adjustment disorder is characterized by emotional or behavioral symptoms that develop within 3 months of an identifiable psychosocial stressor and cause significant impairment in social, occupational, or other areas of functioning. The symptoms usually resolve within 6 months after the termination of the stressor unless it has chronic consequences. The patient’s anxiety is not related to any specific stressors and has lasted longer than 6 months.

(Review PANRE Blueprint Topic: Generalized Anxiety Disorder)

The correct answer is B) Intravenous normal saline infusion

This patient has hyperosmolar hyperglycemic syndrome (HHS), which is a complication of diabetes mellitus characterized by severe hyperglycemia (>600 mg/dL), hyperosmolality (>320 mOsm/kg), and dehydration in the absence of ketoacidosis. HHS is often triggered by an acute stressor such as infection, medication noncompliance, or excessive carbohydrate intake. The mainstay of treatment for HHS is fluid replacement with isotonic saline to correct dehydration, lower serum glucose and osmolality, and improve renal function. Insulin therapy can be initiated after adequate fluid resuscitation, usually at a low dose (0.05-0.1 units/kg/hour). Electrolyte abnormalities such as hypokalemia or acidosis should be corrected as needed.

Incorrect answer explanations:

• Insulin infusion is not the first-line treatment for HHS, as it can worsen dehydration, hypokalemia, and cerebral edema if given before adequate fluid replacement. Insulin should be started after fluid resuscitation at a low dose to avoid rapid drops in serum glucose and osmolality.
• Sodium bicarbonate infusion is not indicated for HHS unless there is severe acidosis (pH <7.0). The patient’s serum bicarbonate level is mildly low (18 mEq/L), but not enough to warrant bicarbonate therapy. Moreover, sodium bicarbonate can increase serum osmolality and worsen cerebral edema.
• Intravenous potassium chloride infusion is unnecessary for HHS unless there is hypokalemia (<3.5 mEq/L). The patient’s serum potassium level is normal (4.0 mEq/L), so potassium supplementation is not required. However, potassium levels should be monitored closely during fluid and insulin therapy, as they may drop rapidly due to intracellular shifts.
• Insulin glargine injection is a long-acting insulin that provides basal coverage for up to 24 hours. It is not suitable for treating acute hyperglycemia in HHS, as it has a slow onset of action and cannot be titrated easily according to blood glucose levels. Moreover, subcutaneous insulin administration may be unreliable in patients with poor perfusion due to dehydration.

The answer is E. You will always see ST depressions

A non-ST elevation myocardial infarction (NSTEMI) is defined by the absence of persistent ST-elevation with elevated cardiac biomarkers (e.g., troponin I or T, CKMB, etc). It happens due to a partially occluded epicardial coronary artery (leading to subendocardial ischemia). NSTEMI typically presents as pressure-type chest pain.

Patients with a suspected NSTEMI should receive a 12-lead EKG within 10 minutes of arrival. ST depression, transient ST-elevation, and/or T-wave inversions may be seen on EKG, but they are NOT required for the diagnosis of NSTEMI. The most important medication to give is non-enteric-coated chewable aspirin 325 mg. Other meds include sublingual nitroglycerin, oxygen as needed, beta-blockers (assuming no C/I), high-intensity statin, ACE inhibitors (if CKD, DM, or EF < 40%), P2Y12 inhibitor (e.g., clopidogrel), anticoagulation, and possibly PCI with stenting or CABG.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Coronary Heart Disease ⇒ Acute myocardial infarction ⇒ Non-ST-Segment Elevation MI (NSTEMI)

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, Emergency Medicine EOR topic list

The answer is C. Admit to hospital for antibiotics, fluids, & insulin

The patient most likely has pyelonephritis, which is an infection of the upper urinary tract and kidneys. It is one of the most common causes of sepsis in pregnancy. The pyelonephritis is also precipitating diabetic ketoacidosis in this diabetic patient.

Clinical features of pyelonephritis include fever, flank pain, N/V, and possible CVA tenderness. Pregnant patients are at high risk for obstetric and medical complications from the infection. It is recommended that pregnant women with acute pyelonephritis should be admitted for IV antibiotics (typically at least until the woman is febrile for 1-2 days and symptomatically improved). Antibiotic options include cefepime, piperacillin-tazobactam, and meropenem. This patient will also need insulin and fluids.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Genitourinary ⇒ Infectious Disorders ⇒ Pyelonephritis

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Emergency Medicine EOR topic list

The answer is B. Hepatic hemangioma

Hepatic hemangiomas are the most common benign liver lesions. The typical patient is a 30 to a 50-year-old woman. Exposure to estrogen may increase the size of hepatic hemangiomas. Patients are typically asymptomatic; however, if they do have symptoms they may have RUQ abdominal pain. An ultrasound will show a homogeneous, hyperechoic mass. If lesions are < 5 cm, you usually don’t need to do anything. If > 5 cm, monitoring is needed Q6-12 months via MRI.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastrointestinal System Neoplasms ⇒ Liver neoplasms

The answer is C. Peritonsillar abscess

A peritonsillar abscess is a collection of pus near the tonsils. The most common causes are Streptococcus pyogenes (group A), Streptococcus anginosus, & Staphylococcus aureus. Clinical features include muffled voice, sore throat, fever, drooling, neck pain, fatigue, and decreased PO intake. On physical exam, the uvula may be deviated. Diagnostic tests that can be done include ultrasound or CT with contrast (depends). Treatment is antibiotics, drainage, and supportive care.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Oropharyngeal disorders ⇒ Infectious and inflammatory disorders ⇒ Peritonsillar abscess

Also covered as part of the Pediatric EOR, Family Medicine EOR, and Emergency Medicine EOR topic list

The answer is B. Haemophilus influenzae

Acute epiglottitis is an inflammatory condition of the epiglottis (usually due to a bacterial infection). In severe situations, it is life-threatening. The most common cause overall is said to be Haemophilus influenzae; however, in adults, Streptococcal species now tend to be more common. The management of this disease should focus on giving antibiotics and steroids. Airway management and securing an airway is the most important part of treatment.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Acute epiglottitis

Also covered as part of the Pediatric EOR and Emergency Medicine EOR topic list

The answer is A. Topical antibiotics and warm water soaks

The patient has acute paronychia, which is a very common condition and essentially is just inflammation of the nail folds. The most common bacterial causes are Staph aureus and Strep pyogenes. Risk factors include manicures, nail biting, and picking at nails. Clinical features include sudden onset of painful erythema and swelling. Sometimes an abscess will be present. In this patient’s case, there was no fluctuance and so topical antibiotics and warm water soaks would be appropriate.

If the patient had an abscess, oral antibiotics and incision/drainage (with number 11 surgical blade) would be reasonable.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Bacterial Disease ⇒ Methicillin-resistant Staphylococcus aureus infection

The answer is A. Acute myeloid leukemia

The patient has acute myeloid leukemia (AML), which is a group of cancers that involve the myeloid precursor cells. It is characterized by clonal proliferation (excessive growth) of abnormal myeloid precursor cells. Risk factors include smoking and chemotherapy/radiation.

Clinical features include fatigue, pallor, weakness, bone pain, gingival bleeding, and organomegaly. Lab findings are variable but may include pancytopenia (decrease in RBCs, WBCs, and platelets), electrolyte derangements, and/or hypoxemia. Workup should include a peripheral blood smear and bone marrow biopsy. The bone marrow biopsy will classically show Auer rods and >20% blasts.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Acute and chronic myelogenous leukemia

Also covered as part of the Family Medicine EOR topic list

The answer is D. Atrial septal defect

Atrial septal defect is the most common congenital heart lesion in adults. People often don’t have symptoms until adulthood. The most common type is ostium secundum. Symptoms include fatigue and dyspnea. A classic physical exam finding on a test would be a systolic ejection crescendo-decrescendo flow murmur @ LUSB with FIXED S2, loud S1. Echocardiography is the initial imaging modality of choice. Keep in mind that a complication of ASD is that the left to right shunt can cause volume and pressure overload of the right heart and pulmonary circulation, leading to pulmonary hypertension.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Congenital Heart Disease ⇒ Atrial septal defect

Also covered as part of the Pediatric EOR topic list

The answer is A. Murphy sign

Appendicitis is one of the most common indications for emergent abdominal surgery. The most common physical exam finding is RLQ tenderness. There are some tests that may help with the diagnosis — keep in mind though that these tests/signs are NOT sensitive.

• Rovsing sign: pain in the RLQ with palpation of the LLQ (indicative of peritoneal irritation)
• McBurney sign: tenderness about 2 inches from the ASIS (on a straight line from ASIS to the umbilicus)
• Psoas sign: RLQ pain with passive right hip extension
• Obturator sign: flexion of the right hip and knee, followed by internal rotation of the right hip elicits RLQ pain

Murphy’s sign is positive in acute cholecystitis, not appendicitis. A positive test is RUQ pain on inspiration.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Diseases of the Small Intestine ⇒ Appendicitis

Also covered as part of the Emergency Medicine EOR, Family Medicine EOR, Pediatric EOR, and General Surgery EOR topic list

The answer is D. Fasciotomy

The patient has acute compartment syndrome, which is when the tissue pressure within a closed muscle compartment exceeds the perfusion pressure. It can result in ischemia. The most common location is the calf. Many cases of acute compartment syndrome in the lower extremity are associated with fractures, burn injuries, crush injuries, or soft tissue infections. The “5 P’s” can help you remember the symptoms – pain, pallor, paresthesia, pulselessness, paralysis. Extremity fasciotomy is the treatment for acute compartment syndrome.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal  ⇒ Compartment Syndrome

The answer is B. Transient ischemic attack

The patient had a transient ischemic attack (TIA), which is characterized by transient neurological symptoms without objective evidence of acute infarction. Symptoms vary, but patients may have hemiparesis, hemiplegia, aphasia, or vision loss. Risk factors include alcohol, hypertension, smoking, diabetes, illicit drug use, and atrial fibrillation.

Urgent evaluation is needed in patients with symptoms of TIA (e.g., coagulation studies, TTE, EKG, CT or MRI head, imaging of the cervicocephalic vasculature via carotid US, CTA, or MRA). Treatment for high-risk patients includes dual antiplatelet therapy (ASA + clopidogrel) for 21 days and risk factor management (statin, exercise, etc). Remember the risk of an actual stroke is high after a TIA.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Vascular Disorder ⇒ Transient ischemic attack

Also covered as part of the Internal Medicine EOR, Family Medicine EOR, and Emergency Medicine EOR topic list

The answer is D. Warfarin

Antiphospholipid syndrome (APS) is an autoimmune disease defined by venous thromboembolism, arterial thrombosis, and obstetric morbidity in the presence of circulating antiphospholipid antibodies (aPLs). It is the most common form of acquired thrombophilia.

aPLs include lupus anticoagulant, anticardiolipin, anti-b2-glycoprotein I antibodies. Clinical features include DVTs (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), PEs (9%), and fetal loss (8%). The mainstay of treatment is warfarin. Other anticoagulants have been found to be less effective than warfarin so far.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Coagulation Disorders ⇒ Hypercoagulable states

Also covered as part of the Internal Medicine EOR and Emergency Medicine EOR topic list

The answer is A. Virus

Acute bronchitis is characterized by a cough due to inflammation of the large airways and trachea with no evidence of pneumonia. Acute bronchitis often follows an upper respiratory infection. The most common cause of acute bronchitis is viral. Symptoms include cough (10-20 days), headache, shortness of breath, and wheezing. The presence of fever should make you consider pneumonia or influenza.

Diagnosis is clinical. A chest radiograph should be given if it is hard to clinically distinguish between pneumonia and bronchitis. Treatment is mainly supportive care (rest, hydration) and symptomatic management (antitussives for cough, bronchodilators for wheezing, etc). Antibiotics should NOT be given for acute bronchitis.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Acute bronchitis

Also covered as part of the Emergency Medicine EOR topic list

The answer is C. Beta-blockers

The patient has hypertrophic cardiomyopathy (HCM), which is a genetic disease of the heart muscle due to mutations in the sarcomere genes. It often presents with fatigue, dyspnea, chest pain, or syncope. The murmur on the physical exam is due to LV obstruction; it will be a harsh crescendo-decrescendo systolic murmur heard at the apex and LLSB. It’s important to keep in mind that the murmur intensity will decrease with more venous return (squatting) and increase with less venous return (Valsalva).

Diagnostic tests include an EKG, echocardiogram, and exercise stress testing. Treatment is indicated for symptomatic patients and includes a negative inotropic agent (i.e., nondihydropyridine CCBs or beta-blockers) and diuretics as needed for volume overload. If patients are refractory to medications, septal myectomy and percutaneous septal ablation can be performed.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Cardiomyopathy ⇒ Hypertrophic Cardiomyopathy

Also covered as part of the Pediatric Rotation EOR topic list

The answer is E. Inevitable abortion

The patient most likely has a spontaneous abortion, which is a nonviable intrauterine pregnancy up to 20 weeks gestation. The most common cause of miscarriages in the first trimester is chromosomal abnormalities. There are many different types of spontaneous abortions.

The patient specifically has an inevitable abortion, which typically presents with vaginal bleeding, crampy abdominal pain, and an open external cervical os without expulsion of products of conception. The fetus is not viable.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Complicated Pregnancy ⇒ Abortion

Also covered as part of the Women’s Health EOR topic list

The answer is E. All of the above are risk factors 

Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a certain type of S. aureus that is resistant to several antibiotics. Risk factors include previous antibiotic use, injection drug use, indwelling hemodialysis catheter, living in a long-term care facility, HIV infection, and recent hospitalization.

The most common site for MRSA infections to occur is the skin/soft tissue. Oral antibiotics that cover MRSA include Bactrim, doxycycline, and clindamycin. For severe MRSA infections, IV vancomycin is preferred.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Bacterial Disease ⇒ Methicillin-resistant Staphylococcus aureus infection

The answer is A. Acute myeloid leukemia

The patient has acute myeloid leukemia (AML), which is a group of cancers that involve the myeloid precursor cells. It is characterized by clonal proliferation (excessive growth) of abnormal myeloid precursor cells. Risk factors include smoking and chemotherapy/radiation.

Clinical features include fatigue, pallor, weakness, bone pain, gingival bleeding, and organomegaly. Lab findings are variable but may include pancytopenia (decrease in RBCs, WBCs, and platelets), electrolyte derangements, and/or hypoxemia. The workup should include a peripheral blood smear and bone marrow biopsy. The bone marrow biopsy will classically show Auer rods and >20% blasts.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Acute and chronic myelogenous leukemia

Also covered as part of the Internal Medicine EOR, Emergency Medicine EOR, Family Medicine EOR, and Pediatric EOR topic list

The answer is B. Temporal artery biopsy

The patient has temporal arteritis, which is a vasculitis of large and medium vessels. Clinical features often include fever, fatigue, weight loss, headache, jaw claudication, and transient vision loss. The typical clinical vignette is an older female presenting with a headache and jaw claudication. On physical exam, you may appreciate a temporal artery that is thickened, tender, or erythematous.

ESR and CRP are sensitive, but not specific for the diagnosis. The definitive diagnosis of temporal arteritis is a temporal artery biopsy. Treatment is high-dose steroids. It’s important that temporal arteritis is treated because it can lead to blindness, thrombotic events, and other complications.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Giant cell arteritis

Also covered as part of the Internal Medicine EOR topic list

The answer is E. Optic neuritis

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. There are many types of MS patterns. Clinical features suggestive of MS include sensory loss in limbs or one side of the face, gait/balance issues, heat sensitivity (Uhthoff), fatigue, and Lhermitte sign. The most common presenting symptom is optic neuritis.

MRI of the brain (+/- spinal cord) is the diagnostic test of choice. The McDonald diagnostic criteria can be used to help make the diagnosis of MS. Treatment of MS includes disease-modifying pharmacotherapy, such as glatiramer acetate (Copaxone), dimethyl fumarate, natalizumab (Tysabri), interferons, and many more. Acute exacerbations of MS are managed with short-term, high-dose glucocorticoids.

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Neuromuscular disorders ⇒ Multiple sclerosis

Also covered as part of the Internal Medicine EOR topic list

The answer is A. Esomeprazole

The patient has gastrointestinal reflux disease (GERD), which is a common condition characterized by stomach acid flowing up into the esophagus. Classic symptoms include heartburn (burning sensation around the sternum) after eating, water brash, regurgitation, and dysphagia.

The diagnosis is usually clinical; however, if the patient has alarming symptoms (e.g., weight loss, anemia, etc), it is appropriate to get an upper endoscopy. The gold standard is an ambulatory 24-hour pH monitoring system. Initial management includes weight loss, elevating the head of the bed, and eliminating triggers (spicy foods, chocolate, etc). Most recommend starting with histamine 2 receptor antagonist therapy first (e.g., ranitidine) and then transitioning to proton pump inhibitors (e.g., esomeprazole).

View blueprint lesson

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Esophageal Disorders ⇒ Gastroesophageal reflux disease

Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Pediatric EOR topic list