Welcome to episode 90 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.

Join me as I cover ten PANCE, PANRE and EOR review questions from the Smarty PANCE Instagram/Facebook page and the smartypance.com board review website.

Special from today’s episode:

Below you will find an interactive exam to complement today’s podcast.

I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of Smarty PANCE.

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1. A 32-year-old male presents with acute ascending symmetrical paralysis and diminished reflexes in his bilateral lower extremities. He has a history of bloody diarrhea a few days ago. What did he likely eat that led to his symptoms?

A. Uncooked rice

B. Mayonnaise

C. Uncooked chicken

D. Soft unpasteurized cheese

E. None of the above

C. Uncooked Chicken

This patient has Guillain-Barré Syndrome (GBS), an acute immune-mediated polyneuropathic disorder. Clinical features include ascending symmetrical paralysis, diminished tendon reflexes, and respiratory muscle weakness.

GBS is typically precipitated by an infection. Campylobacter jejuni infection is the most common precipitant of GBS. It is commonly found in uncooked poultry.

Cerebrospinal fluid analysis helps confirm the diagnosis. Treatment includes plasmapheresis and IV immune globulin.

View lesson: Guillain-Barré Syndrome

2. Which of the following disorders is characterized by a scaly, rough erythematous patch that appears on sun-exposed areas?

A. Seborrheic keratosis

B. Keratosis pilaris

C. Actinic keratosis

D. Lichen planus

E. Pityriasis rosea

Answer: C. Actinic keratosis

Actinic keratosis (AK) is a skin lesion that results from atypical keratinocyte proliferation. Risk factors include UV radiation, fair skin, and sunburns.

AK can present in various ways, but classically you will see an erythematous, scaly macule, papule, or plaque. A shave or punch biopsy can confirm the diagnosis. However, AK is often diagnosed clinically.

Treatment depends on the location and extent of the condition. Options include cryotherapy, fluorouracil, and imiquimod. It is important to remember that AK can develop into SCC.

View Lesson: Actinic keratosis (AK)

3. A 42-year-old male is admitted for typical pneumonia. He is given IV azithromycin and ceftriaxone. His QT interval becomes prolonged and he develops a polymorphic ventricular tachycardia. Which of the following is the most appropriate pharmacological management?

A. Intravenous calcium gluconate

B. Intravenous magnesium sulfate

C. Intramuscular epinephrine

D. Oral amiodarone

E. Oral procainamide

B. Intravenous magnesium sulfate

The patient developed torsades de pointes (Tdp), which is a specific type of polymorphic ventricular tachycardia in patients with a long QT interval. It is a ventricular dysrhythmia characterized by rapid (>100 bpm), irregular, wide QRS complexes that vary in size and shape. Diagnosis is made via EKG.

Examples of meds that prolong the QT interval include antiarrhythmics (amiodarone, sotalol), antimicrobials (fluoroquinolones, macrolides), antidepressants (fluoxetine, sertraline), and antipsychotics (haloperidol, quetiapine).

Treatment is usually IV magnesium sulfate.

View lesson: torsades de pointes (Tdp)

4. Which of the following is true about an indirect inguinal hernia?

A. It does not usually enter the scrotum

B. It is caused by a patent processus vaginalis

C. The strangulation risk is lower than a direct inguinal hernia

D. It is the least common type of inguinal hernia overall

E. It is medial to the inferior epigastric vessels

Answer: B. It is caused by a patent processus vaginalis

A hernia is a protrusion or projection of an organ through the body wall that typically contains it. An indirect inguinal hernia is specifically a protrusion of the abdominal organ into a patent processus vaginalis that extends into the inguinal canal.

Indirect inguinal hernias are the most common type of inguinal hernia. An indirect inguinal hernia is found lateral to the inferior epigastric vessels and it usually enters the scrotum. The strangulation risk is actually higher in indirect inguinal hernias. Definitive treatment is surgery.

View lesson: Indirect inguinal hernias

5. Which of the following is the most common cause of death in hemochromatosis?

A. Hepatocellular carcinoma

B. Diabetic-related complications

C. Acute respiratory failure

D. Left ventricular failure

E. Pancreatic cancer

Answer: A. Hepatocellular carcinoma

Hemochromatosis is an autosomal recessive disorder defined by excessive iron deposition in the liver, pancreas, and heart. It is often caused by a mutation in the HFE gene. Clinical features include skin hyperpigmentation, weakness, hepatomegaly, liver function abnormality, and diabetes mellitus.

Lab findings will show elevated serum iron, elevated ferritin, elevated transferrin saturation percentage, and decreased transferrin. Diagnostic tests include genetic testing and liver biopsy (gold standard, not always needed). Treatment consists of life-long phlebotomy. The most common cause of death in these patients is hepatocellular carcinoma.

View lesson: Hemochromatosis

6. A 15-year-old female with no medical history presents to the ER with altered mental status. She is tachycardic. Labs reveal a glucose level of 900 mg/dL and elevated beta-hydroxybutyric acid. Which of the following acid-base issues would you expect to see?

A. Normal anion gap metabolic acidosis

B. High anion gap metabolic acidosis

C. Metabolic alkalosis

D. Respiratory alkalosis

E. Respiratory acidosis

Answer: B. High anion gap metabolic acidosis

The patient most likely has diabetic ketoacidosis (DKA), a life-threatening emergency defined by insulin insufficiency, along with an elevation in counter-regulatory hormones. Patients in DKA will usually have a high-anion gap metabolic acidosis (HAGMA).

An anion gap is calculated by subtracting anions (HCO3- and Cl-) from a cation (Na+). It is normally 8 to 12. The gap is elevated in DKA because unmeasured anions (ketones) are giving off H+, which interacts with bicarbonate. Bicarbonate becomes depleted, thus increasing the gap.

Other causes of HAGMA include acute kidney injury, lactic acidosis, and toxins.

View lesson: Acid-Base Disorders

7. Which of the following is the first-line treatment for nasal polyps in patients with chronic rhinosinusitis?

A. Anti-histamines

B. Intranasal steroids

C. Leukotriene inhibitors

D. Beta-agonists

E. None of the above

Answer: B. Intranasal steroids

Nasal polyps are grayish masses filled with inflammatory mediators in the nasal cavity or sinuses. They are associated with aspirin sensitivity, chronic rhinosinusitis, asthma, allergies, and cystic fibrosis. Symptoms include increased nasal drainage, congestion, anosmia.

Nasal examination via nasal endoscopy can help confirm the diagnosis. The first-line treatment for nasal polyps is typically nasal corticosteroid spray. Surgery may be needed if the nasal polyp obstructs the cavity/airway.

View lesson: Nasal polyps

8. A 52-year-old female with a history of mitral valve regurgitation presents with exertional dyspnea. On physical exam, you notice abdominal swelling and lower extremity edema. You suspect pulmonary hypertension (PH). Which of the following is the gold standard for diagnosing PH?

A. Right heart catheterization

B. Chest radiograph

C. Computed tomography angiography

D. Echocardiogram

E. Polysomnography

Answer: A. Right heart catheterization

Pulmonary hypertension (PH) is defined by a mean pulmonary arterial pressure > 25 mmHg. The World Health Organization lists 5 broad etiologies of PH: pulmonary arterial hypertension (Group 1), left heart disease (Group 2), lung disease (Group 3), chronic thromboembolism (Group 4), and unknown causes (Group 5).

Symptoms are usually related to right ventricle failure and include “body congestion” signs: pitting edema, abdominal swelling, hepatomegaly, etc. A transthoracic echocardiogram is the best initial diagnostic test. A right heart catheterization is the gold standard for diagnosing PH.

View lesson: Pulmonary hypertension (PH)

9. A 72-year-old female smoker with a history of atrial fibrillation presents to the ER with severe abdominal pain for a few hours. Vitals are unremarkable. Physical exam reveals nothing significant. Which of the following is the gold standard diagnostic modality for the most likely diagnosis?

A. Computer tomography scan

B. Right upper quadrant ultrasound

C. Abdominal radiographs

D. Mesenteric angiography

E. None of the above

Answer: D. Mesenteric angiography

The patient most likely has acute mesenteric ischemia, which is the sudden onset of small intestinal hypoperfusion. The most common cause is emboli from the heart (usually from atrial fibrillation). Other causes include thrombosis and atherosclerotic disease. The most common artery occluded is the superior mesenteric artery.

Clinical features include acute onset of abdominal pain out of proportion of exam findings, abdominal distention, and elevated lactate. A good initial diagnostic test for a stable patient is an abdominal CT scan. The gold standard test is mesenteric angiography. Treatment is surgical revascularization and antibiotics.

View lesson: acute mesenteric ischemia

10. Orbital cellulitis most commonly occurs when an infection spreads into the orbit from which sinus?

A. Maxillary sinus

B. Frontal sinus

C. Sphenoid sinus

D. Ethmoid sinus

E. Temporal sinus

Answer: D. Ethmoid sinus

Orbital cellulitis is an ophthalmic emergency, as it can lead to vision loss. Clinical features include diplopia, decreased vision, pain during eye movement, proptosis, fever, and an erythematous, edematous eyelid. The most common bacterial culprits are Staphylococcus aureus and Streptococcus species. The ethmoid sinus is the most common origin of infection (90%).

The best diagnostic test is a high-resolution CT scan. Treatment is intravenous antibiotics, like IV vancomycin and ceftriaxone.

View lesson: Orbital cellulitis

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