Podcast Episode 104: Ten PANCE, PANRE, and Rotation Review Questions

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