Podcast Episode 75: Ten FREE PANCE and PANRE Audio Board Review Questions

Answer: B. Endoscopy 

Ingestion of caustic fluids (acid or alkali) such as drain cleaner may lead to esophageal damage and stricture. Any patient presenting after caustic ingestion should have an endoscopy performed between 12 and 24 hours of presentation. Injury due to ingestion of alkaline fluids such as drain/oven cleaner occurs rapidly in the first minutes to hours and is characterized by liquefactive necrosis of the esophageal tissue. Subsequently, esophageal strictures form due to scarring of the affected tissue. Patients should immediately be resuscitated following the ABC’s (airway, breathing, and circulation). Subsequent management involves endoscopy (typically within 12 to 24 hours of ingestion) to assess the extent of the damage and plan any further treatment that may be needed.

Incorrect Answers:

• Answer 1: Dilute hydrochloric acid or administration of any agent to titrate the ingestion is always contraindicated as this will lead to more tissue damage.
• Answer 3: Intubation would be indicated if the patient was failing to protect their airway or if they had impending airway loss. This well-appearing patient has no airway concerns.
• Answer 4: Observation is certainly a part of this patient’s care; however, she must also receive endoscopy to assess for any esophageal/GI tract injury.
• Answer 5: Polyethylene glycol or whole bowel irrigation has limited indications. It may be used to pass bags of drugs if ingested by a packer/stuffer but would not aid in the management of caustic ingestion.

Review NCCPA Blueprint Topic: Ingestion of toxic substances or foreign bodies

Answer: A. Cardiac contusion

This patient is presenting after blunt chest trauma (which is common in motor vehicle accidents) with chest pain, elevated troponins, and an elevated pulmonary capillary wedge pressure suggesting a diagnosis of a cardiac contusion. A cardiac contusion is a blunt injury to the heart which can disrupt the mechanical and electrical function of the heart. There will typically be visible signs of chest trauma such as bruising and the patient will often complain of chest pain and dyspnea. The ECG can be unremarkable, demonstrate sinus tachycardia, or even demonstrate more severe dysrhythmias such as supraventricular tachycardia, atrial fibrillation, and a right bundle branch block. Initial cardiac troponins can be elevated. In the setting of any ECG abnormality or elevated troponins, patients with a suspected diagnosis of a cardiac contusion should be admitted to the hospital and observed until clinically stable with normalization of their troponins.

Incorrect Answers:

• Answer 2: Hemorrhage would present with hypotension, tachycardia, and a decreased pulmonary capillary wedge pressure. Internal bleeding could be assessed with a FAST exam which assesses for pleural sliding, pericardial fluid and cardiac function, fluid in the hepatorenal and splenorenal recesses, and fluid surrounding the bladder.
• Answer 3: Myocardial infarction presents with chest pain, shortness of breath, ST elevation on ECG and elevated cardiac troponins. This patient’s elevated troponins are likely secondary to blunt trauma to the heart as he has no risk factors for ischemic heart disease and is young.
• Answer 4: Pulmonary contusion presents with chest pain, hypoxia, and patchy opacities on chest radiography which may not be initially apparent. Management for a pulmonary contusion is typically supportive in nature and to adequately control the patient’s pain.
• Answer 5: Takotsubo cardiomyopathy presents with chest pain and dyspnea as well as ST elevation on ECG without reciprocal changes. Global hypokinesis of the heart can be seen on echocardiography and minor elevations in troponins can be present. The typical precipitating event for Takotsubo cardiomyopathy is an emotionally stressful life event and the patient is typically a woman in contrast to this male patient who has a mechanism of injury that supports a diagnosis of a cardiac contusion.

Review NCCPA Blueprint Topic: Chest/Rib Fractures and Trauma

Answer: E. Primary hyperaldosteronism

This patient is presenting with hypertension refractory to a diuretic with a decreased potassium, a decreased renin level, and an increased aldosterone level suggesting a diagnosis of primary hyperaldosteronism.

Primary hyperaldosteronism occurs when the adrenal gland produces excess aldosterone. Aldosterone has the effect in the kidney of absorbing sodium (and thus water) and wasting potassium and hydrogen. Thus, hyperaldosteronism can lead to hypertension, hypokalemia, and a metabolic alkalosis. In primary hyperaldosteronism, the high blood pressure is detected by the kidney, and thus renin levels are decreased in the setting of an elevated aldosterone.

Incorrect Answers:

• Answer 1: Benign essential hypertension typically occurs in overweight patients and has no clear underlying cause. It would not be associated with elevated aldosterone levels.
• Answer 2: Cushing syndrome would be associated with weight gain, limb muscle atrophy, and striae on dermatological exam in the setting of a decreased renin and aldosterone.
• Answer 3: Narrowing of the renal arteries (renal artery stenosis) would present with refractory hypertension in the setting of an elevated renin and aldosterone level.
• Answer 4: Pheochromocytoma would present with severe episodic hypertension and headaches secondary to an adrenal mass that releases catecholamines.

Summary: Primary hyperaldosteronism presents with hypertension, a decreased renin and potassium level, a metabolic alkalosis, and an increased aldosterone level.

Review NCCPA Blueprint Topic: Secondary hypertension

Answer: A. 100% oxygen

This patient is presenting after being rescued from a fire with confusion, headache, nausea, vomiting, and flushed skin suggesting a diagnosis of carbon monoxide poisoning which should be treated with 100% oxygen.

Carbon monoxide exposure is common in fires and in patients who heat their house with an old-fashioned wood stove. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen thus displacing it leading to symptoms. Carbon monoxide poisoning presents with confusion, headache, altered mental status, nausea, vomiting, and cherry-red skin. Pulse oximetry is often normal in these patients as the device detects hemoglobin bound to oxygen or carbon monoxide similarly. A carboxyhemoglobin level can be obtained to confirm the diagnosis in these patients; however, patients presenting with a clinical picture supportive of carbon monoxide poisoning should be treated with 100% (or hyperbaric) oxygen. Sequelae of carbon monoxide poisoning should be treated supportively, including dantrolene for increased muscle activity or benzodiazepines for seizure activity.

Incorrect Answers:

• Answer 2: CT scan of the head would be indicated if a patient presented with head trauma followed by altered mental status, nausea, and vomiting. This patient’s neurological abnormalities, as well as his nausea and vomiting, can be explained by his carbon monoxide poisoning.
• Answer 3: Hydroxocobalamin is the treatment of choice for cyanide poisoning which is also associated with exposure to fires. Patients will present with weakness, malaise, headache, dizziness, nausea, vomiting, and shortness of breath. Though this diagnosis is possible in this patient, a more likely diagnosis both epidemiologically and given his flushed skin is carbon monoxide poisoning. This patient will need empiric treatment for cyanide poisoning, however, a more dire intervention for the most likely diagnosis is putting the patient on oxygen to simultaneously and rapidly improve his respiratory status and treat his carbon monoxide poisoning.
• Answer 4: Normal saline may be necessary to stabilize this patient’s blood pressure; however, his tachycardia is likely secondary to his pain and a more important initial intervention is stabilizing the patient’s respiratory status including administering oxygen for this patient’s carbon monoxide poisoning.
• Answer 5: Ondansetron only treats this patient’s symptoms of nausea but does not address their respiratory status which should be treated promptly and prior to treating other concerns.

Summary: The treatment of carbon monoxide poisoning is 100% oxygen.

Review NCCPA Blueprint Topic: Burns (ReelDx)

Answer: E. Supportive therapy

This patient is presenting with asymptomatic gallstones discovered incidentally. Asymptomatic gallstones do not need to be managed with a cholecystectomy. 

Acute cholecystitis classically presents with right upper quadrant abdominal pain that presents in a fat, fertile, female in her forties. Once the diagnosis is confirmed with ultrasound, “cooling off” of the gallbladder is necessary (keeping the patient NPO and IV fluids) followed by a cholecystectomy that hospital visit. However, if asymptomatic gallstones are discovered incidentally, there is no indication for cholecystectomy. These patients should be managed conservatively.

Incorrect Answers:

• Answer 1: CT scan of the abdomen is unnecessary as there is no indication to perform a CT scan, in particular when the only finding in this assessment was asymptomatic gallstones on ultrasound. 
• Answer 2: NPO, IV fluids, and broad spectrum antibiotics is the best initial management of ascending cholangitis. Patients with ascending cholangitis are acutely ill and present with a fever, jaundice, and right upper quadrant tenderness. They require immediate treatment as well as decompression (from interventional radiology), followed by ERCP/cholecystectomy. 
• Answer 3: Performing a cholecystectomy this hospital visit is the appropriate management of acute cholecystitis. Acute cholecystitis would present with right upper quadrant abdominal pain in an overweight woman after eating a fatty meal. It is not indicated in the management of asymptomatic gallstones. 
• Answer 4: Scheduling an outpatient cholecystectomy is not necessary as this patient is asymptomatic. Outpatient cholecystectomies are not typically performed in the management of acute cholecystitis as most patients do not comply with outpatient recommendations (avoiding triggers like fatty foods and alcohol) and end up returning to the hospital for another flare before their procedure. In certain compliant patients, it may be a viable option.

Review NCCPA Blueprint Topic: Cholelithiasis (ReelDx + Lecture)

Answer: A. Canalithiasis

This patient is presenting with intermittent, severe vertigo which is provoked by position changes which is most consistent with benign paroxysmal positional vertigo (BPPV). BPPV is commonly caused by canalithiasis.

Benign paroxysmal positional vertigo (BPPV) is a common form of peripheral vertigo that results from a dislodged piece of otolith (called otoconia when dislodged) causing disturbances in the semicircular canals. The presentation of BPPV involves sudden and episodic vertigo with head movements that lasts for seconds to minutes accompanied by nausea and vomiting. Physical exam will demonstrate a horizontal nystagmus with specific head postures (such as the Dix-Hallpike maneuver). Treatment involves repositioning exercises (such as the Epley maneuver) as well as meclizine or diphenhydramine for symptomatic control.

Incorrect Answers:

• Answer 2: Increased endolymph production describes Meniere disease which presents with chronic symptoms including hearing loss and ear fullness and intermittent episodes of vertigo. Treatment involves diuretics and salt restriction.
• Answers 3-4: Inflammation of the vestibular apparatus and the vestibulocochlear apparatus describes vestibular neuritis (sustained/persistent vertigo after a cold) and labyrinthitis (sustained/persistent vertigo and hearing loss after a cold), respectively. This condition will resolve on its own; however, symptoms can be treated with meclizine or diphenhydramine.
• Answer 5: Vertebrobasilar insufficiency can present with syncope or if there is a hemorrhage/ischemia, may present in an elderly patient with multiple risk factors with sustained and severe vertigo that is sudden onset and associated with dysarthria and dystonia.

Summary: Benign paroxysmal positional vertigo is commonly caused by canalithiasis.

Review NCCPA Blueprint Topic: Vertigo (ReelDx + Lecture)

Answer: E. Meiotic nondisjunction

This patient presents with tall stature, gynecomastia, and small testes with elevated FSH and LH, which suggests a diagnosis of Klinefelter syndrome. Klinefelter syndrome is usually caused by meiotic nondisjunction that results in a 47,XXY genotype.

Klinefelter syndrome is the most common cause of primary hypogonadism. Patients with Klinefelter syndrome present with tall stature, neurocognitive difficulties (ADHD) and features of hypogonadism including gynecomastia, small testes, small phallus, hypospadias, underdeveloped secondary sex characteristics, and cryptorchidism. Patients without hypospadias or cryptorchidism are often not diagnosed until after puberty, when the symptoms of gynecomastia and small testes become more prominent. Because the hypogonadism in Klinefelter syndrome is caused by testicular fibrosis, laboratory results demonstrate a low testosterone and elevated FSH and LH.

Incorrect Answers:

• Answer 1: Anabolic steroid use causes decreased levels of FSH and LH due to the suppression of GnRH release by the hypothalamus, which in turn suppresses FSH and LH release by the pituitary gland. Anabolic steroid use would not present with signs of hypogonadism.
• Answer 2: The CGG trinucleotide repeat disorder characterizes Fragile X syndrome. Fragile X presents with macroorchidism rather than hypogonadism, and patients typically have dysmorphic features of a long, narrow face with large ears, prominent forehead, and prominent chin. Fragile X is the most common cause of inherited intellectual disability.
• Answer 3: The CTG trinucleotide repeat disorder characterizes myotonic dystrophy. Although myotonic dystrophy presents with hypogonadism, patients would also present with symptoms of progressive weakness, such as facial weakness, dysphagia, or hand grip weakness.
• Answer 4: Failure of neuronal migration characterizes Kallmann syndrome. Kallmann syndrome presents with the classic symptoms of loss of smell and hypogonadism, but patients with Kallmann syndrome have a low FSH and LH.

Summary: Klinefelter syndrome results in primary hypogonadism and presents with tall stature, gynecomastia, small testes, a small phallus, hypospadias, and cryptorchidism.

Review NCCPA Blueprint Topic: Hypogonadism

Answer: E. Lacunar stroke

This patient is presenting with risk factors and symptoms suggestive of a diagnosis of a lacunar stroke. 

Lacunar strokes typically occur in patients with risk factors such as hypertension, diabetes, old age, and smoking. The basal ganglia, pons, and subcortical white matter are commonly affected. The pathophysiology occurs secondary to a small penetrating artery occlusion from hypertensive arteriolar sclerosis, lipohyalinosis, or microatheroma formation. Patients present with neurological deficits that can include pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, or dysarthria-clumsy hand syndrome.

Incorrect Answers:

• Answer 1: Berry aneurysm rupture describes a subarachnoid hemorrhage that would present with a sudden onset, severe headache.
• Answer 2: Bridging vein tear describes a subdural hematoma which could present with gradual neurological deficits and altered cognition in the setting of recent trauma in an elderly patient/alcoholic.
• Answer 3: Cerebellar bleeding would present with ataxic gait and an abnormal finger-nose and heel-shin exam.
• Answer 4: Hypertensive encephalopathy presents with general CNS dysfunction which can include headache, irritability, nausea/vomiting, disturbances of consciousness, and seizures.

Review NCCPA Blueprint Topic: Stroke (ReelDx + Lecture)

Answer: B. Laparoscopy

This patient is presenting with sudden onset abdominal pain, nausea, vomiting, and free fluid around the ovary with normal blood flow which is still concerning for ovarian torsion that should be managed with laparoscopy. Ovarian torsion occurs when the ovary twists around its blood supply causing ischemia and necrosis. Patients are typically young women who experience sudden/severe abdominal or vaginal pain, blood per vagina, a left adnexal mass with adnexal tenderness, and a negative urine pregnancy test. The best initial test is a transvaginal ultrasound with Doppler which can show blood flow to the ovary as well as ovarian enlargement and edema (signs of ischemia). Even in the setting of normal blood flow, torsion is possible as the ovary may twist and untwist. Patients presenting with symptoms concerning for ovarian torsion should be managed with laparoscopy to definitively treat and salvage the ovary.

Incorrect Answers:

• Answer 1: CT scan of the abdomen would not be necessary as this patient has no abdominal tenderness and has physical exam and ultrasound findings concerning for ovarian torsion which should be managed surgically. 
• Answer 3: Laparotomy is an open procedure that would be indicated if the patient suddenly decompensated and needed more aggressive management to stop acute bleeding. 
• Answer 4: MRI of the pelvis would be a very accurate test for diagnosing pelvic pathology; however, it is not necessary in this patient who has a history and findings concerning for ovarian torsion. Performing an MRI would only delay treatment.
• Answer 5: Observation and serial abdominal exams would be the appropriate management of a patient with abdominal pain with a clear etiology after a CT scan had ruled out any serious pathology. This patient’s likely ovarian torsion should not be observed.

Summary: Ovarian torsion should be treated with laparoscopy. 

Review NCCPA Blueprint Topic: Ovarian torsion

Answer: C. Vitamin C deficiency

An elderly, malnourished, cigarette-smoking male with swollen gums, bruising, and corkscrew hair is most likely suffering from vitamin C deficiency.

Though vitamin C deficiency, or scurvy, is uncommon in the developed world, cases in developing countries still exist. Typically, these cases occur in those who are very old or very young due to the inability to feed themselves properly. Since vitamin C, or ascorbic acid, is found in citrus fruits and green vegetables, deficiency in these foods or consumption of these foods with denatured vitamins (due to over-boiling) can result in deficiency. Those who smoke cigarettes have also been found to be more deficient in vitamin C.

Incorrect Answers:

• Answer 1: Iron deficiency anemia would most commonly be asymptomatic, and if serious, would present with symptoms of fatigue and shortness of breath. It would not present with glossitis or corkscrew hair.
• Answer 2: Vitamin B3, or niacin, can present with glossitis, but would typically also have the “3 D’s”: diarrhea, dermatitis, and dementia.
• Answer 4: Vitamin B12 deficiency can also present with glossitis, but it would also have physical exam signs such as numbness and parasthesias of the extremities along with ataxia.
• Answer 5: Vitamin K deficiency can present with bleeding and bruising, but it would not present with the other symptoms typically associated with scurvy.

Review NCCPA Blueprint Topic: Hypervitaminosis/hypovitaminosis