Welcome to episode 95 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.

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The Audio PANCE/PANRE and EOR PA Board Review Podcast

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Podcast Episode 95: Ten PANCE/PANRE and EOR Topic Blueprint Questions

1. A 52-year-old patient is admitted with a lower gastrointestinal bleed. He is given 2 units of packed red blood cells. A few hours later the patient develops a fever but has no other symptoms or changes in vital signs. Lab studies reveal no significant changes. Which of the following is the most likely diagnosis?

A. Transfusion-associated circulatory overload
B. Acute immune-mediated hemolytic reaction
C. Transfusion-related acute lung injury
D. Febrile non-hemolytic transfusion reaction
E. None of the above

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.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

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

2. Which of the following is not a side effect of lithium?

A. Hyperparathyroidism
B. Hypothyroidism
C. Cognitive fog
D. Tremors
E. All are side effects

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.

VIEW BLUEPRINT LESSON

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Bipolar and related disorder

3. Which of the following best explains the pathophysiology of vasovagal syncope?

A. Increase in parasympathetic signals and withdrawal of sympathetic signals
B. Severe narrowing of the aortic valve
C. Drop in blood pressure upon standing due to inadequate peripheral vasoconstriction
D. Occlusion of the pulmonary artery leading to right ventricle dysfunction
E. Blood accumulation in the brain leading to compression of adjacent brain structures

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.

VIEW BLUEPRINT LESSON

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

4. A 71-year-old male smoker with prostate cancer presents to your clinic complaining of unilateral leg swelling and pain. Vital signs are unremarkable. On a physical exam, the entire leg is swollen with localized tenderness along the venous system. Which of the following is the next best step?

A. Order a d-dimer
B. Order a duplex ultrasound
C. Admit to the hospital immediately
D. Reassurance and follow-up in 6 months
E. Order a CT angiogram

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.

VIEW BLUEPRINT LESSON

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

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

5. Which of the following individuals would be considered to have a positive purified protein derivative test at 6 millimeters of induration?

A. 31-year-old who was in contact with a person who has active TB
B. 65-year-old intravenous drug user
C. 53-year-old who lives in a prison
D. 90-year-old with hypertension
E. None of the above

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

VIEW BLUEPRINT LESSON

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

6. A 48-year-old male presents with headaches, vision loss, enlarged jaw, and enlarged hands. Which of the following laboratory studies is the preferred initial diagnostic test?

A. Beta glycoprotein 2a
B. Growth hormone
C. Prolactin
D. Calcitonin
E. Insulin growth factor 1

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.

VIEW BLUEPRINT LESSON

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

7. A 14-year-old obese male presents to the ER complaining of dull pain in the right hip and thigh for the past few weeks. No history of trauma. On physical exam, the affected leg is held in an externally rotated position and is shorter than the left leg. What is the most likely diagnosis?

A. Legg Calve Perthes
B. Septic arthritis
C. Slipped capital femoral epiphysis
D. Transient synovitis
E. Pelvic stress fracture

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.

VIEW BLUEPRINT LESSON

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

8. A 32-year-old male with sarcoidosis presents to the clinic complaining of shortness of breath, fatigue, and palpitations for a few months. His in-office EKG reveals QRS prolongation and some premature ventricular beats. A chest radiograph shows cephalization of the pulmonary vessels and cardiomegaly. Which of the following is the most likely diagnosis?

A. Cryptogenic organizing pneumonia
B. Hypertensive encephalopathy
C. Cardiac sarcoidosis
D. Acute coronary syndrome
E. Pneumoconiosis

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.

VIEW BLUEPRINT LESSON

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

9. A 64-year-old male presents with tremors in both of his hands. He says the tremors worsen with movement and caffeine. The tremors improve with alcohol use. Which of the following is the best initial treatment option for his likely diagnosis?

A. Dopamine agonist
B. Beta-blocker
C. Alpha antagonist
D. NMDA antagonist
E. None of the above

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).

VIEW BLUEPRINT LESSON

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

10. Which of the following is the most common cause of infective lactational mastitis?

A. Escherichia coli
B. Staphylococcus aureus
C. Bacteroides species
D. Staphylococcus epidermidis

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.

VIEW BLUEPRINT LESSON

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

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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.