The Daily PANCE and PANRE Extended Edition Final Exam (Questions 30-60)

This is Addison's disease, autoimmune destruction of the entire adrenal gland. No Cortisol, increased ACTH (pigmentation), high K & low Na (no aldosterone).

Incarcerated means "not reducible", strangulated means "ischemic", or no flow.

Traditionally, hypertensive crises have been divided into emergencies and urgencies. Hypertensive emergencies are severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction, and will require immediate BP reduction (not necessarily to normal ranges) to prevent or limit target organ damage. Examples include: hypertensive encephalopathy, intracranial hemorrhage, unstable angina pectoris, or acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, or eclampsia. While the level of BP at the time of presentation is usually very high (greater than 180/120 mm Hg), keep in mind that it is not the degree of BP elevation, but rather the clinical status of the patient that defines a hypertensive emergency. For example, a BP of 160/100 mm Hg in a 60-year-old patient who presents with acute pulmonary edema represents a true hypertensive emergency. Hypertensive urgencies are severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage. Most of these patients are, in fact, nonadherent to drug therapy or are inadequately treated hypertensive patients and often present to the ED for other reasons. Patients with severe elevations of BP can be managed in the ED with oral agents and appropriate follow-up within 24 hours to several days depending upon the individual characteristics of the patient. It is the correct differentiation of these two forms of hypertensive crises, however, that presents the greatest challenge to the physician.

Olecranon bursitis from leaning on a hard surface.

Prolactin-secreting adenoma is the most common cause of galactorrhea/amenorrhea (after exclusion of pregnancy). I would choose Sheehan's syndrome if the question stated that the patient had a postpartum hemorrhage. The others do not cause this.

Target lesions are erythema multiforme - commonly caused by drugs (many drugs) and some illnesses, like mycoplasma Another common problem with OCP's is erythema nodosum which causes PAINFUL purple nodules on the anterior shins.

Strep commonly co-exists with mono.

The combination of high sodium intake and high animal protein intake will raise urinary calcium more than high calcium intake will. The reason is that only a net of 100 to 300 mg of calcium is absorbed from the intestine/day. In contrast, 10,000 mg of calcium is filtered and 9,700 to 9,900 mg is reabsorbed by the kidney. Since sodium and animal protein inhibit calcium reabsorption by the kidney, it is not surprising that they affect urinary calcium substantially.

This is a typical "borderline personality disorder" presentation.

Dysphagia is the most common presenting symptom in a patient with scleroderma.

Hepatitis C is the most common blood borne infection in the US, causes chronic hepatitis in almost all persons infected, is the most common reason for liver failure in the US, and the most common reason for liver transplant.

Peak flows should be done in ALL asthma patients with an acute exacerbation. It gives you a baseline, and allows you to decide how effective nebulizer treatments are. CXR is not necessary unless you suspect the patient has pneumonia. ABG's may be indicated in a severe asthma attack, but not typically.

This is impetigo (staph skin infection). For the Boards, use dicloxacillin for staph. Mupirocin cream would be indicated if there was only a small area infected, although there now is an indication for Mupirocin (Bactroban) for staph in the nose. Erythromycin is not a bad choice but choose dicloxacillin for staph aureus.

This Q suggests bipolar disorder - thyroid function should be checked in all patients with a psych diagnosis.

S4 is almost always present in an acute MI.

This is the classic presentation of TE fistula - when the patient drinks he aspirates because there is a connection between the trachea and the esophagus.

This is Hutchinson's sign and suggests an involvement of the cornea with herpes. An ophthalmologic referral is indicated. (Fluorescein staining would show a dendritic lesion on the cornea).

This is temporal arteritis (or giant cell arteritis). It is a vasculitis and can cause blindness if not treated aggressively with steroids.

This is superior vena cava syndrome suggestive of bronchogenic carcinoma causing lymphadenopathy in the mediastinum which can impinge on the SVC.

Kussmaul's is the pulmonary compensation for the metabolic acidosis of DKA. The lungs blow off C02(an acid) to normalize the pH. Remember "K" for Ketoacidosis

This patient has chronic pancreatitis which predisposes this patient to cancer. The head of the pancreas is sometimes palpable.

Pericardial effusion would cause diastolic pressures. AV fistula would cause increased systolic pressures with decreased diastolic pressures as well. Thyrotoxicosis would cause high systolic, but low diastolic pressures (increased HR reduces filling time, so less EDV). PDA would cause increased systolic pressures with reduced diastolic pressures.

This is the ulnar collateral ligament - must be referred. Look at the anatomy of the thumb!

Fibrocystic breast disease is most likely in this patient

Options for prophylaxis of traveler’s diarrhea include norfloxacin, ciprofloxacin, ofloxacin, or trimethoprim/sulfamethoxazole.

Neuroleptic malignant syndrome is characterized by extrapyramidal signs, blood pressure changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, cardiovascular instability, fever, pulmonary congestion and diaphoresis. Controlling fever and fluid support are the best initial management. With a normal pulse oximetry mechanical ventilation is not indicated.

Gross or microscopic hematuria, flank pain, or mass is common in renal cell carcinoma.

Aspirin inhibits platelet aggregation by blocking cyclooxygenase-1 activity.

This patient most likely has a spontaneous pneumothorax which is supported by the presenting symptoms of sudden onset of dyspnea and pleuritic chest pain as well as the physical exam findings of absent breath sounds and hyperresonance to percussion.

This patient presents with a ruptured abdominal aortic aneurysm (AAA). Emergency operative repair is required and endovascular aneurysm repair is preferred and has a better survival rate than open repair. Abdominal aortic aneurysm is a local enlargement of the abdominal aorta larger than 3 cm that is commonly observed in elderly patients. Risk factors include smoking, high blood pressure, and other heart or blood vessel diseases. AAA rupture is a true emergency with mortality exceeding 90%. The majority of patients (~70%) do not make it to the hospital alive. Symptoms include vague back, abdominal, or chest pain and are often accompanied by hypotension and hypovolemic shock. If the AAA ruptures in the intraabdominal cavity, death usually results. Retroperitoneal rupture can result in temporary tamponade which can increase survival and allow enough time for surgical intervention to be performed. Treatment is emergency operative repair. The two primary operative approaches are endovascular and open repair. Endovascular aneurysm repair is preferred and has a better survival rate than open repair, which has a mortality rate exceeding 50%.