Podcast Episode 101: Ten PANCE, PANRE, and Rotation Review Questions

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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