Podcast Episode 102: Ten PANCE, PANRE, and Rotation Review Questions

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