Podcast Episode 106: Ten PANCE, PANRE, and Rotation Review Questions + Review of Adrenal Insufficiency

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.