Rapid Rounds 01: 15 Mixed PANCE Practice Questions

Carbon monoxide poisoning

• Pulse oximetry can’t tell carboxyhemoglobin from oxyhemoglobin. It reads normal while the patient is being poisoned.
• Get a carboxyhemoglobin level by co-oximetry. Treat with 100% oxygen by non-rebreather; hyperbaric oxygen for severe cases.

Radial head subluxation (nursemaid’s elbow)

• The mechanism gives it away: a pull on an extended, pronated arm.
• Classic story and exam, no X-ray needed. Reduce with hyperpronation, or supination and flexion. Most kids are using the arm again within minutes.

Acute pericarditis

• ST elevation in one territory is an MI. Diffuse ST elevation with PR depression is pericarditis.
• Better leaning forward, worse lying flat. Treatment: NSAIDs plus colchicine.

Primary hyperaldosteronism (Conn syndrome)

• Hypertension plus low potassium plus metabolic alkalosis: think aldosterone.
• Aldosterone high, renin suppressed. Medical treatment is spironolactone.

Emergent MRI of the lumbar spine

• Saddle anesthesia and urinary retention are the red flags. Back pain plus either one changes everything.
• This is cauda equina syndrome. Emergent MRI, then surgical decompression. Hours matter.

Heparin-induced thrombocytopenia (HIT)

• Platelets fall by more than half, 5 to 10 days after heparin starts. That timing is the tell.
• HIT clots, it doesn’t bleed. Stop all heparin, including flushes, and start a non-heparin anticoagulant like argatroban. Don’t transfuse platelets.

Pemphigus vulgaris

• Skin shearing off with lateral pressure is a positive Nikolsky sign.
• Flaccid blisters plus the mouth: pemphigus vulgaris. Tense blisters in an older patient, mouth usually spared: bullous pemphigoid.

Lumbar puncture

• Thunderclap headache: CT first. A negative CT doesn’t end the workup.
• The LP is looking for xanthochromia. Positive confirms subarachnoid hemorrhage, then CT angiography to find the aneurysm.

Akathisia

• Inner restlessness, can’t sit still, days after starting an antipsychotic.
• The trap is calling it anxiety and raising the dose. Lower the dose or switch; propranolol is first-line treatment.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

• Low sodium, low serum osmolality, urine more concentrated than it should be, and the patient is euvolemic.
• Causes: SSRIs, carbamazepine, small cell lung cancer, CNS disease. Treat with fluid restriction.
• Correct slowly, no more than about 8 in 24 hours, or you risk osmotic demyelination.

Acute mesenteric ischemia

• Pain out of proportion to the exam plus AFib: an embolus to the SMA until proven otherwise.
• The belly can feel soft early, which is why it gets missed. Heparin and emergent revascularization.

Prolactinoma

• Before you call it a tumor, rule out pregnancy, hypothyroidism, and medications like antipsychotics.
• Then MRI of the pituitary. First-line treatment is cabergoline.

Tetanus immunoglobulin (TIG) and Tdap vaccine

• Dirty wound with unknown or fewer than three doses: give both.
• Fully vaccinated: no TIG. Vaccine only if the last dose was more than 5 years ago for a dirty wound, 10 years for a clean one.

Central retinal vein occlusion

• Hemorrhages in all four quadrants with dilated, tortuous veins: the “blood and thunder” fundus.
• Compare central retinal artery occlusion: a pale retina with a cherry-red spot. Vein is blood everywhere. Artery is pale.

Papillary muscle rupture

• A new murmur at the apex radiating to the axilla is acute mitral regurgitation. Days after an MI, that’s papillary muscle rupture.
• Inferior MI is the setup. The posteromedial papillary muscle has a single blood supply.
• The distractor is ventricular septal rupture: also a new holosystolic murmur, but at the left lower sternal border. Both go to emergency surgery.

I talk a lot about active versus passive studying and I was working with some students this week and I thought, geez, I need to actually push this even more. And for PA week, I thought it’d be really fun to introduce a new sort of show into the feed and see how this goes and do some active questions right here in the regular podcast feed. So today we’re going to have 15, we’ll see how long it takes, maybe we’ll cut it short, maybe we’ll add a couple, but we’re looking at 15 mixed practice questions and let’s jump in and just get started. A firefighter is pulled from a burning building with a headache, confusion, and nausea. Pulse ox reads 99%. What diagnosis must be suspected despite a normal SpO2?

Think it through for a second. Firefighter pulled from a burning building, headache, confusion, nausea, pulse ox 99. What do you have to consider even though he’s got a normal SpO2? Carbon monoxide poisoning. The pulse ox can’t necessarily tell you how much carbon monoxide is on the hemoglobin, right? It doesn’t know the difference. So here’s another question, follow up question. How do you treat it?

How do you treat carbon monoxide poisoning? It’s another good question. It’s actually not in my list, but it’s 100% oxygen. 100% oxygen, it would be on a non-rebreather, it may be hyperbaric, but the idea is just we want to give them as much oxygen as possible to help replace it.

A toddler holds the arm flexed and pronated after being pulled by the wrist. What diagnosis should this make you think of?

I did this to my oldest son three different times. This is a radial head subluxation, nursemaid’s elbow. And it’s going to be based on how it happens, right? If a toddler’s being pulled by the wrist, it’s a very, I’m not going to say super common, but it does happen.

While we’re on it, what’s the management here? This does not require an x-ray, this is a clinical diagnosis. Pretty obvious when you’ve seen it. You’re going to reduce with supination and flexion. I was able to put all three of them back in on my own. A 30-year-old has a sharp, pleuritic chest pain that improves leaning forward with diffuse ST elevation and PR depression, what’s the diagnosis?

Acute pericarditis.

ST elevation in one area is an MI, right? Diffuse ST elevation with PR depression is pericarditis. The leaning forward part’s helpful too. A 45-year-old woman has resistant hypertension, a potassium of 2.9 and a metabolic alkalosis. Her plasma aldosterone to renin ratio is elevated, what’s the diagnosis?

A 45-year-old woman has resistant hypertension, a potassium of 2.9 and a metabolic alkalosis. Her plasma aldosterone to renin ratio is elevated, what’s the diagnosis? Primary hyperaldosteronism.

You should think when you see hypertension plus low potassium plus metabolic alkalosis, maybe that’s a lot, but you should be thinking aldosterone.

A 50-year-old with chronic back pain develops sudden bilateral leg weakness, saddle anesthesia and urinary retention. What imaging is needed immediately? So I’m only thinking one thing when I see saddle anesthesia, right? I don’t know that there’s anything else that causes that. I don’t know, maybe write in and let me know if you find something else. Only one thing I know causes saddle anesthesia, like in the middle of like the night, like emergently, not like a trauma, not like a traumatic event. But you get a phone call with bilateral leg weakness, saddle anesthesia. I’m thinking cauda equina, right? That’s what I’m thinking. So what we need, how do we find that? Well, we need an MRI immediately. And what’s the obvious treatment here? Surgery, we’re going to go in and decompress the area.

Number six, a patient on unfractionated heparin for DVT develops a platelet count, drop from 250,000 to 80,000 on day five of the heparin therapy. What’s the most likely diagnosis? I mean, that’s sort of straightforward, right? Heparin induced thrombocytopenia. That’s just platelets fall in more than half in five to 10 days after starting heparin. That’s the story. A middle aged patient has painful oral erosions and flaccid blisters on the trunk. Painful oral erosions and flaccid blisters on the trunk. Gentle lateral pressure on uninvolved skin causes the epidermis to shear off. What’s the diagnosis?

We’re going to give a second question out of this too, because this one’s a good one. Middle aged patient has painful oral erosions and flaccid blisters on the trunk. Gentle lateral pressure on uninvolved skin causes the epidermis to shear off. What’s the diagnosis? Pemphigus vulgaris. This is flaccid blisters and in the mouth is probably what you’re looking for. What’s the sign? What’s the name for the sign that’s positive here? The skin shearing off with lateral pressure.

The Nikolsky sign. Excellent. Question eight. A 48 year old woman describes the worst headache of her life with sudden onset at peak intensity while exercising. Head CT is negative. What do you do next?

Here we’re getting a lumbar puncture.

Because we’re looking for a subarachnoid hemorrhage. We’re concerned because our story is so classic and that the CT is first, but we don’t end there, we move on to the lumbar puncture.

A patient started on risperidone three days ago, reports an intense inner restlessness and cannot stop pacing or shifting from foot to foot. What complication is this? This is a vocabulary term you need.

Akathisia.

So what do we do? We lower the dose or we switch it out.

A patient, number 10. A patient on SSRI has a sodium of 125 with concentrated urine and low serum osmolality. What’s the most likely cause?

SIADH, syndrome of inappropriate antidiuretic hormone secretion. So this patient is euvolemic with low sodium, low serum osmolality, and urine more concentrated than it should be. SSRIs are on the list of causes here.

What are some other things on the list of causes?

Small cell lung cancer, carbamazepine. Number 11. A 62 year old with sudden, severe, periumbilical pain out of proportion to exam findings has a history of atrial fib. Do you know this one yet? Because I know where I’m in. CT angiography shows a filling defect in the superior mesenteric artery. What’s the diagnosis? So this is a situation and let me just stop for a second to point this out. I have a lot of students who would read this, as you move through this question. Because maybe there are parts you don’t know, but there are parts you do know. So then you start to question and say, hey, am I good here? Do I know this? Am I all right? Maybe I don’t know it. Maybe I don’t know what I thought I knew. And you talk myself in and out of answers. When I said I knew it, right? That first sentence really gives this away to me. 60-year-old with sudden severe periumbilical pain out of proportion to exam findings. That is word for word acute mesenteric ischemia. Right? Periumbilical pain out of proportion to exam findings. I saw this in a, she was like eight or nine once. They thought it was appendicitis, but the way that she was reacting, I really just thought it was acute mesenteric ischemia. Didn’t want it to be. We went in to do her appendectomy and found a whole six, eight inches of dead bowel that had to be removed. Really terrible situation, but it really sticks with me. And this is a set of key terms that should stand out to you. Especially to add in the atrial fib, right? Because now we have an embolic source. Now the next clue, I don’t know. So CT angiography shows a filling defect in the superior mesenteric artery. I’m not sure what it’s supposed to show. I have a gap. I’m not clear on this. What do I do? I think it’s ischemia. Hopefully, if you have multiple choice, you can find the right answer. But a lot of times people start to talk themselves out of things because they don’t know this piece or they don’t know the first piece, but they know the second piece. My philosophy is go with what you know and assume what you don’t know isn’t sending you in another direction. It might be, it absolutely could be. But I think more often than not, it’s confirming evidence, not evidence sending you in the wrong direction. So in this case, I’m thinking acute mesenteric ischemia and then it says CT angiography shows a filling defect in the superior mesenteric artery. What’s the diagnosis? I’m going to stick with acute mesenteric ischemia because I’m not sure what it’s supposed to show. I don’t remember. But it’s including a defect in the superior mesenteric artery. So I’m going to stick with my answer. But I hope you understand that the point there is don’t talk yourself out of something because you have a knowledge gap. You can and it wouldn’t necessarily be wrong every time. You certainly wouldn’t be wrong every time. But I think more often than not, and that’s what I’m trying to do on my exams. Question 12, a 28-year-old non-pregnant, non-breastfeeding woman has bilateral milky nipple discharge and oligomenorrhea. I’m just joking, laughing to myself silently that I got that one right. And with all the things I get wrong, that’s one I can get right, oligomenorrhea. Serum prolactin is 95. What’s the most likely diagnosis? 28-year-old non-pregnant, non-breastfeeding woman has bilateral milky nipple discharge. This should be pretty straightforward. Prolactinoma.

An unvaccinated 34-year-old sustains a deep puncture wound from a rusty nail. What’s the two treatments should be given for tetanus prophylaxis? What are we going to do?

You can do tetanus immunoglobulin and Tdap vaccine. A lot of times, because you just don’t know when the last vaccination was.

So it makes sense to do both. A 68-year-old with hypertension has sudden painless vision loss in one eye. So when we say sudden painless vision loss, that should narrow your thought process. Fundoscopy shows dilated tortuous veins with hemorrhages. I got oligomenorrhea, but I got hemorrhages wrong. In all four quadrants. Fundoscopy shows dilated tortuous veins with hemorrhages in all four quadrants. What’s the diagnosis?

Central retinal vein occlusion. This is our blood and thunder fundus, right? Hemorrhages in all four quadrants.

What would it be? Let’s go break off for a second here. What would it be if it was central artery occlusion? Instead of central vein occlusion? Here we’d have a pale retina with cherry red spot.

And these are things that really, I struggled with in PA school a lot, a lot, a lot, because I was trying to memorize them, right? But look at this one. If I have a blocked artery, I got a pale retina with a cherry red spot. When you cut off the blood supply, it goes pale, right? That makes sense. So I’m thinking, so that should be something you can store away. Clotting off the vein causes the blood to go everywhere because it can’t drain out, right? Does that make sense? So to me, I’m setting those together. I’m combining them and I’m telling myself that story so that it sticks.

Just before we cover the last question, question 15, I just want to mention that we’re in PA week. So still today, I’m running a giveaway for PA week that’s including The Final Step version 3.0, a brand new version of The Final Step, which is a lot of, it’s basically over 2,000 questions just like these, rapid fire, really quick. Either you know it or you don’t know it to help you lock in the information. Go to physicianassistantexamreview.com/giveaway to find out more about that. If you are interested, there’s over $1,200 worth of prizes so that we’re given away for PA week. It’s going to be, it is a ton of fun. I’ve got, you’ll see, head over to the webpage, you’ll figure it out. All right, number 15, a new holosystolic murmur at the apex radiating to the axilla with acute pulmonary edema a few days after an inferior MI should make you think of what complication? A new holosystolic murmur at the apex radiating to the axilla with acute pulmonary edema a few days after an inferior MI should make you think of what complication? So again, this should sort of pop off the page at you.

This is a papillary muscle rupture.

The inferior MI is really the setup here, right? That’s the part that makes this jump off the page to me. And the rest of it is just filling in the details. So a new murmur at the apex radiating to the axilla. What is that? That’s mitral regurg. Days after an MI, that’s papillary muscle rupture.

All right, this was a ton of fun. I really think this is something we may do moving forward. Let me know what you think. Love to have you here. And I think this actively engaged piece of the show is going to be really helpful for you guys moving forward. Let me know what you think in the…

Let me know what you think. We’re going to keep doing these for a while and see how they settle in. All right, until next week, take care.