Podcast Episode 98: Ten PANCE, PANRE, and Rotation Review Questions

The answer is B. MRI of the lumbosacral spine

Cauda equina syndrome is a surgical emergency caused by severe stenosis in the lumbar spine (often due to acute disc herniation).

Clinical manifestations include bowel/bladder dysfunction, decreased lower extremity reflexes, sciatica, saddle anesthesia (loss of sensation over the perineum, buttock, medial aspect of thighs), and decreased anal sphincter tone. Symptoms can develop acutely or chronically.

An emergent MRI of the lumbosacral spine is the preferred diagnostic test. Surgery is the preferred treatment.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Spinal Disorders ⇒ Cauda equina syndrome

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

The answer is A. Iatrogenic

Cushing syndrome is a condition defined by too much cortisol. The most common cause of Cushing syndrome is exogenous steroid therapy (i.e., medical providers prescribing steroids). Other causes include a pituitary ACTH-secreting adenoma, adrenal tumors, and ectopic ACTH production from neoplasms. Classic clinical features include buffalo hump, moon-facies, purple striae, easy bruising, weight gain, depression, and weakness.

Laboratory tests will be remarkable for elevated cortisol. Late night-salivary cortisol or 24-hour urinary free cortisol is typically the initial screening test. A low-dose dexamethasone test can be done. Referral to an endocrinologist is usually done at this point (or even prior).

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Adrenal Disorders ⇒ Cushing’s syndrome

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

The answer is A. 5-HIAA in urine

Carcinoid tumors are uncommon tumors that originate from neuroendocrine cells and secrete serotonin. The most common site is the appendix, but they can also be found in the lungs, kidney, etc.

Carcinoid syndromes develop 10% of the time; clinical features include flushing, sweating, wheezing, and watery diarrhea. These symptoms are due to the release of serotonin and can be precipitated by foods high in tyramine or ethanol.

The best initial diagnostic study is a 24-hour measurement of urinary excretion of 5-HIAA (Note: 5-HIAA is a degradation product from 5HT). Surgical resection is the definitive treatment of choice.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Neoplasms ⇒ Carcinoid tumors

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

The answer is B. Vomiting

Mallory-Weiss Syndrome (MWS) is defined by a mucosal tear at or below the gastroesophageal junction. MWS is one of the most common causes of an upper GI bleed. It is most commonly due to forceful vomiting. It is classically associated with alcoholism (binge drinking), but really anything that can cause vomiting can lead to a tear. Other causes include iatrogenic, trauma, hiatal hernia, and corrosive ingestion. Diagnosis is made via upper endoscopy. Intervention is rarely necessary, but if needed, the patient can undergo surgery or embolization. Do not confuse this with Boerhaave syndrome, which is an actual perforation of the esophagus!

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Esophageal Disorders ⇒ Mallory Weiss tear

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

The answer is D. Tension headache

A tension-type headache (TTH) is the most common headache. It usually presents with steady, aching, “band-like” pain that circles the entire head. There may also be tightness in the posterior neck muscles. Precipitants include anxiety, depression, and stress.

You should treat any underlying depression and/or anxiety. NSAIDs and acetaminophen are the first-line abortive treatment options for mild-moderate TTHs. For long-term prophylactic treatment, amitriptyline is preferred.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Headaches ⇒ Tension headache

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

The answer is A. Holosystolic blowing murmur best heard at the apex with radiation to the axilla

Mitral regurgitation (MR) is characterized by a blowing, holosystolic murmur at the apex with radiation to the axilla. It can be acute or chronic. Acute causes include endocarditis and papillary muscle rupture; chronic causes include mitral valve prolapse (MVP), rheumatic fever, cardiomyopathy. The most common cause of MR is MVP.

Remember, regurgitation murmurs will often have blowing sounds, while stenotic murmurs are harsh and rumbling. Diagnosis should be made with an echocardiogram. Treatment (repair vs. replace vs. medical therapy) depends on many factors.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Valvular Disorders ⇒ Mitral regurgitation

Also covered as part of the Emergency Medicine EOR topic list

The answer is D. Pulmonary fibrosis

Polyarteritis nodosa is a systemic vasculitis of medium-sized vessels (specifically involving the nervous system and GI tract) that leads to thrombi and microaneurysms. It is associated with hepatitis B, HIV, and drug reactions. Clinical features include fever, hypertension, livedo reticularis, abdominal pain, and arthralgias. Remember patients may be positive for pANCA, but are ANCA negative.

A definitive diagnosis is made via biopsy of involved tissue (or mesenteric angiography). What sets polyarteritis nodosa apart from other vasculitides is that it spares the lungs. Treatment includes high-dose steroids. The prognosis is not really good.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Rheumatologic Disorders ⇒ Polymyalgia rheumatica

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

The answer is E. Ciprofloxacin/dexamethasone drops

The patient has otitis externa (aka swimmer’s ear), which is inflammation of the external auditory canal. The most common bacterial cause is Pseudomonas aeruginosa (~40%). Risk factors include water exposure, trauma, ear devices, and dermatologic conditions. Clinical features include ear pain, pruritus, auricular discharge, pain/tenderness when pressure is applied to the tragus, and hearing loss.

Treatment is topical ear antibiotic/steroid drops. Medication options include neomycin/polymyxin B /hydrocortisone and ciprofloxacin/dexamethasone. **Remember that aminoglycosides are ototoxic and should be avoided when the tympanic membrane can’t be visualized!**

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Ear Disorders ⇒ External ear ⇒ Otitis externa

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

The answer is A. Pill-rolling tremor, bradykinesia, rigidity, masked facies

Parkinson’s disease is a neurodegenerative disease. Its 3 cardinal features are tremor (“pill-rolling” at rest), bradykinesia, and rigidity. Tremor is the presenting feature in most patients. Other clinical features include hypomimia (masked facies), speech impairment, mood disorders (depression or anxiety), dysphagia, shuffling gait, stooped posture, sleep issues, cognitive dysfunction, and autonomic dysfunction.

It is mainly a clinical diagnosis. When patients respond to dopaminergic drugs, this supports the diagnosis. The mainstay of treatment is levodopa or dopamine agonists (pramipexole, ropinirole). For mild disease, monoamine oxidase type B inhibitors or amantadine can be given.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Movement Disorders ⇒ Parkinson’s disease

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

The answer is B. CEA

The patient has colorectal cancer (CRC), which is the third most common cause of cancer death in the U.S. The USPSTF suggests screening at age 45 for individuals with an average risk. Patients may present with alarming “red flag” symptoms, a bowel obstruction, or CRC may just be found via routine screening. The most common symptom is a change in bowel habits (~70%). Other symptoms include rectal bleeding, iron deficiency anemia, and pain.

Initial diagnostic tests include colonoscopy, CBC, fecal occult blood testing, and tumor markers like carcinoembryonic antigen (CEA). CEA is more often used for surveillance and not screening though (since its sensitivity for CRC is only 46%).

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastrointestinal System Neoplasms ⇒ Colon cancer

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