Podcast Episode 99: Ten PANCE, PANRE, and Rotation Review Questions

The answer is B. Nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus (DI) is a condition where the kidneys are resistant to the effects of ADH. Nephrogenic DI can occur secondary to lithium toxicity or chronic lithium use, pregnancy, inherited disorders, and electrolyte issues. Clinical features include polyuria, nocturia, and polydipsia. Serum sodium is either normal or high.

In this patient, lithium has entered the collecting duct, accumulated, and interfered with ADH’s capacity to increase water permeability. Treatment options for this patient include amiloride or thiazide diuretics. In general, whether or not lithium is discontinued depends on many factors.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Pituitary Disorders ⇒ Diabetes insipidus

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

The answer is B. Fluoxetine

This patient has dysthymia, or persistent depressive disorder. The DSM V criteria follow:

• Depressed mood ≥ 2 years on most days
• At least 2 of the following: appetite changes, sleep changes, low energy, low self-esteem, poor concentration, hopelessness
• Not without symptoms > 2 months at a time
• No mania or hypomania episodes, ever

Like other psychiatric disorders, symptoms can’t be attributable to drugs, and the symptoms must cause distress/impairment. 1st line treatment is selective serotonin reuptake inhibitors and psychotherapy.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Depressive disorders ⇒ Persistent depressive disorder (dysthymia)

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

The answer is E. Calcium gluconate

Hyperkalemia is caused by many things: iatrogenic (ACEI/ARBs), cellular destruction (hemolysis, tumor lysis syndrome, burns), renal failure, adrenal insufficiency, etc. Symptoms are nonspecific and include muscle weakness, N/V, decreased DTRs, etc. Classically on EKG, you may see peaked T waves (there are many other findings though…such as QRS widening, PR interval prolongation, sine-wave, etc). Management for severe hyperkalemia includes calcium gluconate (stabilizes the resting membrane potential of the myocardial membrane), shifting potassium intracellularly (via beta-agonists, sodium bicarbonate, insulin), and removing potassium (via diuretics, kayexalate, or hemodialysis).

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Renal System ⇒ Fluid and Electrolyte Disorders ⇒ Hyperkalemia/hypokalemia

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

The answer is B. Pain control, hydration, blood transfusions, oxygen, antibiotics, VTE prophylaxis

The patient has acute chest syndrome (ACS), which is defined as a new radiodensity on CXR with fever and/or pulmonary symptoms. It occurs due to vaso-occlusion in the pulmonary microvasculature, subsequently leading to deoxygenation of hemoglobin and sickling of RBCs. ACS is the main cause of death in patients with sickle cell disease (SCD). About 1 in 2 patients with SCD get ACS.

Patients may present with chest pain, extremity pain, and shortness of breath. Causes of ACS include fat emboli, infection, asthma, oversedation, and post-op issues. Treatment typically includes fluids, oxygen, pain control, blood transfusions, antibiotics, and VTE prophylaxis.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Hemoglobinopathies ⇒ Sickle cell anemia

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

The answer is B. Staphylococcus aureus

Bacterial sialadenitis is defined by inflammation of a salivary gland due to a bacterial infection. It is most commonly caused by Staphylococcus aureus. Usually, bacterial sialadenitis happens in the setting of a salivary gland stone (reduced salivary flow leads to bacteria building up in the mouth). Other risk factors include bad oral hygiene and old age. The most common gland affected is the parotid gland.

Clinical features include acute onset of fever, chills, and swelling/tenderness of the affected gland (possible to see purulent drainage). The treatment is broad-spectrum antibiotics: IV ampicillin-sulbactam. Surgical drainage is needed if an abscess develo

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Salivary disorders ⇒ Sialadenitis

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

The answer is C. Multiple myeloma

The patient has multiple myeloma, which is a clonal proliferation of abnormal plasma cells. It can present with “BREAK” symptoms: Bone pain, Recurrent infections, Elevated calcium, Anemia, and Kidney failure. A serum and urine protein electrophoresis will reveal a monoclonal spike. Other diagnostic studies include a CT or MRI (reveals lytic bone lesions), peripheral blood smear (normocytic anemia in rouleaux formation), and urinalysis (Bence Jones proteins aka free light chains).

The definitive diagnosis is a bone marrow biopsy. Treatment is high-dose chemotherapy with autologous hematopoietic cell transplantation.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Neoplasms, premalignancies, and malignancies ⇒ Multiple myeloma

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

The answer is E. Late menarche

The patient has endometrial cancer, the most commonly encountered gynecologic cancer. The cardinal symptom is abnormal uterine bleeding. Other clinical features include pelvic pain, pelvic masses, and weight loss.

Risk factors include conditions or medications that lead to chronically increased estrogen levels, such as nulliparity, tamoxifen, anovulation, and obesity. Early menarche and late menopause would be risk factors, not late menarche.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Reproductive System ⇒ Neoplasms of the breast and reproductive tract ⇒ Endometrial cancer

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

The answer is A. H. pylori and NSAIDs

Peptic ulcer disease (PUD) is a common GI disease defined by a defect in the mucosal lining of the stomach or duodenum. The two most common causes are H. pylori and NSAIDs. Other more rare culprits include Zollinger-Ellison Syndrome, cancer, stress, and radiation. Surprisingly, patients are asymptomatic about 70% of the time. Common symptoms are epigastric abdominal pain, dyspepsia, and bloating. Overall, an upper endoscopy is the best diagnostic test. A biopsy should be done for ulcers with malignant features on all gastric ulcers.

The preferred treatment is PPIs. If H. pylori is the cause, an antibiotic regimen is warranted (e.g., amoxicillin, clarithromycin, and a PPI).

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Gastric Disorders ⇒ Peptic ulcer disease

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

The answer is B. Order a duplex ultrasound

The patient has superficial thrombophlebitis, which is inflammation involving a superficial vein along with the presence of a superficial clot. Risk factors include varicose veins, estrogen, prior DVT, cancer, and hypercoagulable states. Clinical features include tenderness, induration, pain, and erythematous skin over a superficial vein.

In many cases, duplex ultrasound is needed to rule out a concurrent DVT (studies show that up to 25-50% of patients with superficial thrombophlebitis have a concurrent DVT). Treatment includes NSAIDs, warm/cold compresses, extremity elevation, and compression therapy. The decision to initiate anticoagulation for superficial thrombophlebitis depends on many factors.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Phlebitis/thrombophlebitis

The answer is C. Lichen planus

Lichen planus is a skin disorder characterized by a rash associated with the 5 Ps: polygonal, pruritic, papules, plaques, and purple. It commonly affects the wrists and ankles. Lichen planus can also cause the classic Wickham’s striae, which are white-lacelike lines (usually in the oral mucosa). A risk factor is hepatitis C.

A skin biopsy can help confirm the diagnosis. Treatment includes high potency topical corticosteroids. If a patient has an extensive form of lichen planus, then phototherapy, acitretin, or systemic steroids may help.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Dermatology ⇒ Papulosquamous Disorders ⇒ Lichen planus

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