Podcast Episode 95: Ten PANCE, PANRE, and Rotation Review Questions

The answer is D. Febrile non-hemolytic transfusion reaction

The most common transfusion reaction is a febrile non-hemolytic transfusion reaction (FNHTR).

Patients with FNHTR may present with a fever a few hours after receiving packed red blood cells (PRBCs), which is caused by the small number of white blood cells and cytokines that can be found in each unit of PRBCs. Treatment consists of giving acetaminophen and ruling out other causes of fever (e.g., central line infection, urinary tract infection, etc).

Incorrect Answers:

Transfusion-associated circulatory overload (Choice A) occurs when the volume of the transfused component causes hypervolemia.

Acute immune-mediated hemolytic reaction (Choice B) occurs when there are antibodies presented to blood donor antigens. Patients may present with hypotension, fever, or coagulopathic lab abnormalities.

Transfusion-related acute lung injury (Choice C) is due to antibodies reacting with antigens leading to the release of mediators that causes edema in the lungs. Symptoms include fever, hypoxia, and dyspnea.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Immunologic disorders ⇒ Transfusion reaction

The answer is E. All are side effects 

Lithium is the first-line treatment for bipolar disorder. It has many side effects that you should remember, such as hypothyroidism, hyperparathyroidism, nephrogenic diabetes insipidus, cognitive fog, and tremors. Lithium levels should be monitored to avoid toxicity.

Remember, bipolar disorder is characterized by the symptoms DIG FAST: Distractibility, Irritability, Grandiosity, Flight of ideas, Activity increased, Sleep deficits, and Talkativeness.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Bipolar and related disorder

• Also covered as part of the Emergency Medicine EOR, Psychiatry EOR, and Family Medicine PAEA EOR topic list

The answer is A. Increase in parasympathetic signals and withdrawal of sympathetic signals

Vasovagal syncope is the most common cause of syncope. Syncope is essentially transient loss of consciousness due to the lack of cerebral perfusion. Vasovagal syncope is usually triggered by something, such as emotion or stress.

A leading hypothesis of vasovagal syncope is that it is due to an increase in parasympathetic signals and withdrawal of sympathetic nervous signals.

Incorrect Answers:

A drop in blood pressure upon standing due to inadequate vasoconstriction describes neurogenic orthostatic hypotension (Choice C).

Occlusion of the pulmonary artery leading to RV dysfunction is describing a pulmonary embolism, which can lead to syncope (Choice D).

Blood accumulation in the brain leading to compression of brain structures is describing an intracranial hemorrhage (Choice E), which is a (rare) cause of syncope.

Narrowing of the aortic valve aka aortic stenosis (Choice B) can lead to syncope, but again, this is not vasovagal syncope.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Vascular Disorders ⇒ Syncope

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

The answer is B. Order a duplex ultrasound

This patient needs an ultrasound because he has a high pre-test probability for thrombosis. Ordering a d-dimer, in this case, would be inappropriate. Lots of things (e.g., cancer, trauma, etc) can elevate d-dimer.

Well’s Score helps us determine a patient’s risk for DVT based on these criteria: active cancer, surgery or bedridden, calf swelling, collateral veins presence, entire leg swollen, localized tenderness along deep venous system, pitting edema, previous DVT, recent immobilization, & alternative diagnosis more likely.

The main idea: d-dimer should be ordered in low-risk patients, and a venous duplex US should be ordered for high-risk patients.

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Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Venous thrombosis

Also covered as part of the General Surgery PAEA EOR topic list

The answer is A. 31-year-old who was in contact with a person who has active TB

Tuberculosis (TB) is a worldwide health concern and is deadly. A purified protein derivative (PPD) test can be used to screen for TB. A PPD test is considered positive depending on the patient’s risk factors. Remember, we measure induration, NOT erythema. See below for a high-yield list of positive PPD tests (not exhaustive):

>5 mm: HIV, immunosuppressive condition, or recent contact with active TB case

>10 mm: IVDU, came from a country with a high TB prevalence (<5 y prior), health care worker, resident/employee in a high-risk congregate setting

>15 mm: everyone else

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Infectious Pulmonary Disorders ⇒ Tuberculosis

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

The answer is E. Insulin growth factor 1

The patient has acromegaly, which is an endocrine disorder characterized by excess secretion of growth hormone after epiphyseal closure. The most common cause is a pituitary adenoma. Clinical manifestations include coarsening of facial features, enlarged hands/feet, macrognathia, bitemporal hemianopsia, sleep apnea, and headaches.

Insulin growth factor-1 is the best initial diagnostic test to screen for acromegaly. A CT or MRI can help confirm the presence of a pituitary adenoma. A glucose suppression can also be ordered. Definitive treatment is transsphenoidal resection of the pituitary adenoma.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Pituitary Disorders ⇒ Acromegaly/gigantism

Also covered as part of the Internal Medicine PAEA EOR topic list

The answer is C. Slipped capital femoral epiphysis

The patient most likely has slipped capital femoral epiphysis (SCPE), which is defined as displacement of the capital femoral epiphysis from the femoral neck (through the physeal plate). The classic clinical presentation is hip pain in an obese, adolescent male. Remember, it can be bilateral (~20-40%)!

On physical exam, the affected leg may be externally rotated and shorter than the other leg. Cases are diagnosed via plain radiographs (AP view and lateral views of both hips). Once diagnosed with SCPE, most patients should be made non-weight-bearing and referred to an orthopedic surgeon.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Lower extremity disorders ⇒ Disorders of the hip ⇒ Slipped capital femoral epiphysis

Also covered as part of the Pediatric Rotation PAEA EOR topic list

The answer is C. Cardiac sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder; it impacts the lungs, eyes, lymph nodes, heart, skin, and nervous system. Cardiac sarcoidosis (CS) is often under-recognized and can occur as a clinical feature of sarcoidosis. Presenting symptoms may include palpitations, syncope, fatigue, & dyspnea.

CS happens because granulomas infiltrate the heart, leading to conduction issues, tachyarrhythmias, cardiomyopathies, & heart failure. Holter monitoring and echocardiography are two helpful tests. The gold standard would be a heart biopsy (not routinely done because it is so invasive; cardiac MRI is preferred). Treatment is steroid therapy and anti-arrhythmic drugs.

Incorrect Answers:

Cryptogenic organizing pneumonia (Choice A) is a type of diffuse interstitial lung disease that typically presents with cough, fever, dyspnea, and malaise.

Hypertensive encephalopathy (Choice B) manifests as headaches, vomiting, confusion, and neurological symptoms. The patient has none of these.

Acute coronary syndrome (Choice D) is more likely to present with diaphoresis and crushing chest pain.

Pneumoconiosis (Choice E) is a fancy word that means the accumulation of dust (e.g., coal, asbestos, etc) within the lungs. This patient has absolutely nothing in his history that suggests this.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Restrictive Pulmonary Disease ⇒ Sarcoidosis

Also covered as part of the Internal Medicine PAEA EOR topic list

The answer is B. Beta-blocker

The patient likely has an essential tremor (ET) which is the most common cause of action tremor in adults. It occurs bilaterally in both hands, commonly worsens with anxiety, and improves with alcohol use. The tremor becomes more noticeable when the hands are outstretched or during goal-directed movement (e.g., writing with a pencil).

ET is a clinical diagnosis. Treatment includes beta blockers (propranolol), anticonvulsants (primidone, gabapentin, topiramate) and benzodiazepines. Propranolol and primidone are the most effective treatment options. Remember there is often a strong genetic component (family history is present 30-70% of the time).

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Essential tremor

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

The answer is B. Staphylococcus aureus 

Lactational mastitis presents as a red, painful, swollen breast usually during the first three months of breastfeeding. It commonly results from poor drainage. The most common cause is Staphylococcus aureus. If it develops over 24 hours, patients may also have flu-like symptoms and a fever — this is considered “infective” lactational mastitis.

Treatment includes cold compresses and complete emptying of the breasts. For infective lactational mastitis, antibiotics (e.g., clindamycin, cephalexin, dicloxacillin) should be given. Remember, patients should NOT stop breastfeeding.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Breast Disorders ⇒ Mastitis 

Also covered as part of the Women’s Health EOR and Emergency Medicine PAEA EOR topic list