Show notes
Listen to Podcast Episode 106: Ten PANCE, PANRE, and Rotation Review Questions + Review of Adrenal Insufficiency If you can’t see the audio player, click here to listen to the full episode. Welcome to episode 106 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast. Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams. Links from today’s episode: Sign up for our new PANCE and PANRE Test Taking Masterclass Sign up for the Entire Blueprint Email Series Follow Smarty PANCE and The Daily PANCE Blueprint on Instagram and Facebook Review adrenal insufficiency and adrenal disorders Join the Smarty PANCE Member’s Community, then sign up for a study group to get updates about upcoming webinars. I hope you enjoy this free audio component of the examination portion of this site. Smarty PANCE includes over 2,000 interactive board review questions, along with flashcards, ReelDx cases, integrated Picmonics, and lessons covering every blueprint topic available to all Smarty PANCE members. You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps You can listen to all the latest episodes, take interactive quizzes, and download more resources on each episode page. Interactive exam to complement today’s podcast 1. A 22-year-old female with an unknown past medical history presents to the ER with a prolonged seizure lasting more than 5 minutes per EMS. Her airway was supported, and IV access was obtained en route to the ER. Her blood glucose is 120. Her vitals are stable, and laboratory studies are relatively unremarkable. Which of the following would be an appropriate medication to give to this patient? A. Calcium gluconateB. Propofol infusionC. LorazepamD. ClonidineE. Narcan Answer and topic summary The answer is C. Lorazepam The patient has status epilepticus, which is defined as >5 minutes of continuous seizures or > 2 discrete seizures between which there is incomplete recovery of consciousness. Most episodes of status epilepticus in adults are due to a brain lesion or a toxic/metabolic disturbance (e.g., alcohol withdrawal, hypoglycemia, etc). Immediate management of status epilepticus includes stabilizing the airway, placing pulse oximetry and cardiorespiratory monitors, establishing IV access, and getting a glucose level. The first-line pharmacological agent given is a benzodiazepine (e.g., lorazepam or diazepam). Keppra, valproate, or other anti-seizure medication can be given as well. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Neurology ⇒ Seizure disorders ⇒ Status epilepticus Also covered as part of the Internal Medicine EOR and Emergency Medicine EOR topic list 2. A 41-year-old male presents to the ER after a construction accident that left him with severe right eye pain and decreased visual acuity. On a physical exam, you notice a teardrop-shaped pupil. Which of the following is the most likely diagnosis? A. Globe ruptureB. Acute angle-closure glaucomaC. Retinal detachmentD. Corneal lacerationE. Metallic foreign body Answer and topic summary The answer is A. Globe rupture Mechanical globe injuries occur when there is a laceration or full-thickness rupture through the cornea and/or sclera. Globe rupture (also called an open globe) follows blunt eye injury (e.g., motor vehicle crash, assault, thrown ball, etc). Globe lacerations occur after trauma from a sharp-penetrating object (e.g., knife or high-velocity projectile). PE signs include subconjunctival hemorrhage, irregularly-shaped pupil, hyphema (anterior chamber bleeding), decreased visual acuity, and limited EOM. This is an emergency and a patient should see an ophthalmologist immediately. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint EENT ⇒ Traumatic disorders ⇒ Globe rupture 3. A 45-year-old male veteran presents to your clinic complaining of the following for 4 months: problems with concentration, difficulty staying asleep, persistent negative state, inability to remember events that happened while he was in Iraq, feelings of detachment from others, avoidance of other veterans, and distress when seeing violence on the TV. He denies hallucinations. He has been a veteran for 5 years. Which of the following is the most likely diagnosis? A. Acute stress disorderB. Cyclothymic disorderC. Brief psychotic episodeD. Derealization/depersonalization disorderE. Post-traumatic stress disorder Answer and topic summary The answer is E. Post-traumatic stress disorder Post-traumatic stress disorder is a complex disorder defined by the behavioral, somatic, cognitive, and emotional effects of trauma. The most common causes are sexual relationship violence (33%), death or traumatic event of a loved one (30%), interpersonal violence like physical assault (12%), and participation in organized violence like combat (11%). The DSM-V criteria for PTSD is: Exposure to a traumatic event(s). And then for ≥1 month of each of these that started/worsened after a traumatic event and are associated with the traumatic event: 1) Intrusion symptoms 2) Avoidance of stimuli 3) Alterations in cognitions and mood 4) Alterations in arousal/reactivity Treatment is SSRIs + counseling/psychotherapy. About 50% of patients will recover in 3 months with treatment. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Trauma and stressor-related disorders ⇒ Post-traumatic stress disorder Also covered in Emergency Medicine EOR, and Family Medicine EOR Blueprint 4. Which of the following clinical findings would you likely expect in a patient with primary adrenal insufficiency? A. Hypernatremia, hypokalemia, tiredB. Moon facies, depression, bruisingC. Polyuria, polydipsia, intense thirstD. Fatigue, hyponatremia, hyperpigmentationE. Hypothermia, bradycardia, goiter Answer and topic summary The answer is d. Fatigue, hyponatremia, hyperpigmentation Adrenal insufficiency is defined as insufficient production of hormones by the adrenal glands. Remember, the MOST common cause of adrenal insufficiency overall is the sudden withdrawal of exogenous steroids. The most common primary cause of adrenal insufficiency is autoimmune adrenalitis (aka Addison disease, aka 21-hydroxylase antibodies against the adrenal gland). Patients will have symptoms and signs of glucocorticoid & mineralocorticoid deficiency, such as fatigue (MC), weight loss, nausea, vomiting, hyponatremia, hyperkalemia, skin hyperpigmentation (due to increased production of proopiomelanocortin prohormone), hypotension, and salt craving. Remember, secondary adrenal insufficiency does NOT lead to hyperpigmentation, only primary adrenal insufficiency (this is commonly asked in tests). Diagnosis of adrenal insufficiency is made by serum cortisol level and then a cosyntropin stimulation test. Treatment is glucocorticoids +/- mineralocorticoids. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Endocrinology ⇒ Adrenal Disorders ⇒ Primary adrenal insufficiency Also covered as part of the Family Medicine EOR, Internal Medicine EOR, and Emergency Medicine EOR topic list 5. A 42-year-old male presents with right upper extremity numbness, dysesthesia, weakness, and arm pain with exertion. The symptoms are aggravated by activity and reaching overhead. Which of the following is the most likely diagnosis? A. Thoracic outlet syndromeB. Median nerve compressionC. Biceps tendon ruptureD. Carpal tunnel syndromeE. Subclavian steal syndrome Answer and topic summary The answer is A. Thoracic outlet syndrome Thoracic outlet syndrome (TOS) refers to a constellation of signs & symptoms that occur due to compression of the neurovascular bundle in the space of the thoracic outlet. Causes include trauma, repetitive injuries, anatomical defects, and pregnancy. The clinical presentation depends on what is being compressed (i.e., nerve, vein, and/or artery), but may include the following: pain, numbness, weakness, muscle weakness, fatigue, swelling, or coldness. Often these symptoms are aggravated by activity or raising the arm overhead. Diagnostic tests include ultrasound, x-ray, CT scan, EMG, MRI, etc. Treatment options depend on what type of TOS the patient has (e.g., physical therapy for neurogenic TOS). Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Spinal Disorders ⇒ Thoracic outlet syndrome 6. A 34-year-old female is diagnosed with immune thrombocytopenic purpura. What is NOT a known cause or risk factor of ITP? A. Hepatitis CB. Systemic lupus erythematosusC. HIVD. COVID-19E. Warfarin Answer and topic summary The answer is E. Warfarin Immune thrombocytopenic purpura (ITP) is acquired thrombocytopenia caused by autoantibodies against platelet antigens. Primary ITP is specifically due to autoimmune mechanisms, whereas secondary ITP is associated with other conditions or drugs. Some examples of causes of secondary ITP include systemic lupus erythematosus (SLE), HIV infection, hepatitis C infection, COVID-19, and thyroid dysfunction. There are also many drugs that can lead to ITP, but warfarin is not known to be one of them. Clinical symptoms include petechiae, purpura, easy bleeding, bruising. Obviously, platelets will be low. Work-up for ITP should include HIV and HCV testing, TSH, ANA, coagulation studies, and peripheral blood smear. A bone marrow biopsy can be done to rule out something more pathological. Treatment includes steroids (high-dose) and IVIG. Definitive treatment is splenectomy. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Hematology ⇒ Coagulation Disorders ⇒ Thrombocytopenia ⇒ Idiopathic thrombocytopenic purpura Also covered as part of the Internal Medicine EOR topic list 7. A 72-year-old African American male presents to the clinic complaining of weight loss, fatigue, and back pain. During the physical exam, you palpate an enlarged, irregular, nodular prostate. Which of the following is the most important risk factor for the development of this most likely diagnosis? A. Genetic factorsB. EthnicityC. Increasing ageD. ObesityE. High meat diet Answer and topic summary The answer is C. Increasing age Prostate cancer is the most common cancer among men (excluding skin cancer) — as about 1 in 8 men will get it. The most important risk factor for the development of prostate cancer is increasing age. Other risk factors include ethnicity, genetic factors, obesity, tobacco, and a diet high in animal fat. Clinical manifestations may include non-specific urinary symptoms (frequency, urgency, etc), hematuria, bone pain, elevated PSA, and an indurated/asymmetrical prostate with nodules on digital rectal exam. Diagnosis is made by a transrectal biopsy of the prostate. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Genitourinary ⇒ Neoplasms of the Genitourinary System ⇒ Prostate cancer Also found in Internal Medicine EOR PAEA blueprint 8. A 52-year-old female with a history of previous abdominal surgeries presents to the ER with nausea, emesis, abdominal pain, and inability to pass gas. On physical exam, you notice abdominal distention and auscultate high-pitched tinkering sounds in the upper abdominal quadrants. Which of the following is the most likely diagnosis? A. Mesenteric ischemiaB. DiverticulitisC. Gastric ulcer perforationD. Small bowel obstructionE. Ischemic colitis Answer and topic summary The answer is D. Small bowel obstruction A bowel obstruction happens when the normal flow of the GI tract is interrupted. The most common cause of small bowel obstruction is intraperitoneal adhesions (s/t previous surgeries). Other causes include hernias or neoplasms. Clinical features include nausea, vomiting, crampy abdominal pain, and obstipation (inability to pass stool). On physical exam you may note abdominal distention, tinkling high-pitch sounds on auscultation, and hyperresonance to percussion. Initial diagnostic modalities include an abdominal x-ray and CT with contrast. These patients need to be admitted for further evaluation and management. Surgery should be consulted. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Diseases of the Small Intestine ⇒ Small bowel obstruction Also covered as part of the Family Medicine EOR, Emergency Medicine EOR, and General Surgery EOR topic list 9. Which of the following is the most common cause of acute cor pulmonale? A. Cardiac tamponadeB. Pulmonary embolismC. Mitral regurgitationD. Congestive heart failureE. Portopulmonary syndrome Answer and topic summary The answer is B. Pulmonary embolism The most common cause of acute cor pulmonale is a massive pulmonary embolism (PE). Cor pulmonale is defined by RV failure/enlargement due to a pulmonary issue. The reason a PE leads to acute right heart failure is because a PE is a mechanical obstruction that increases vascular resistance in lungs and increases RV afterload. The RV can’t unload sufficiently and this results in dilation of the RV. The dilated RV impedes on the LV, leading to decreased LV output and decreased supply to the coronary arteries. It also causes RV wall tension/pressure to build and thus coronary perfusion is impeded to the right heart, further leading to ischemia. Also, the dilation of the RV can lead to tricuspid regurgitation, which further reduces blood flow. As the RV becomes ischemic, it can’t contract as well and this further decreases RV output and LV output — leading to a dangerous cycle toward shock. You can risk stratify the degree of RV compromise by getting an echocardiogram, BNP, & troponin. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Blueprint Pulmonary ⇒ Pulmonary Circulation ⇒ Cor pulmonale 10. A 25-year-old female with no past medical history presents with nausea, emesis, and pelvic pain. She is normotensive, afebrile, and slightly tachycardic (HR 102 bpm). On physical exam, you palpate an ovarian/pelvic mass. Beta-hCG is negative. The pelvic US is pending. Which of the following is the most likely diagnosis? A. Ectopic pregnancyB. AppendicitisC. Pelvic inflammatory disorderD. Ovarian torsionE. Placenta abruption Answer and topic summary D. Ovarian torsion Ovarian torsion refers to the rotation of the ovary, often leading to complete or partial obstruction of blood supply. The most common predisposing factor is an ovarian mass. Presenting features include pelvic pain (90%), nausea, emesis, and fever. On physical exam they may have pelvic and/or abdominal tenderness. A pelvic ultrasound is the mainstay of evaluation when ovarian torsion is suspected. You can get a beta-hCG to rule out an ectopic pregnancy. The definitive diagnosis is made by directly visualizing a rotated ovary at the time of surgical evaluation. Surgery and OB-GYN should be consulted for further management. Smarty PANCE Content Blueprint Review: Covered under ⇒ PANCE Reproductive System Blueprint ⇒ Ovarian Torsion Also covered as part of the Women’s Health PAEA EOR topic lists This podcast is available on every device! You can download and listen to past FREE episodes here, on iTunes, Spotify, Google Podcasts, Stitcher, Amazon Music, and all podcasting apps. Download Interactive Content Blueprint Checklists for the PANCE, PANRE, EOR, and PANRE-LA Follow this link to download your FREE copy of the PANCE/PANRE/EOR Content Blueprint Checklists. Print it up and start crossing out the topics you understand, marking the ones you don’t, and making notes of key terms you should remember. The PDF version is interactive and linked directly to the individual lessons on Smarty PANCE. Smarty PANCE is not sponsored or endorsed by, or affiliated with, the National Commission on Certification of Physician Assistants.
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