Podcast Episode 89: Ten PANCE, PANRE, and Rotation Review Questions

Answer: E. Subnormal visual acuity in one or both eyes despite correction of refractive error

Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to process inputs from one eye and over time favors the other eye. It results in decreased vision in an eye that otherwise typically appears normal

• Amblyopia is not correctable by refractive means
• Amblyopia occurs in early childhood when nerve pathways between the brain and an eye aren’t properly stimulated
• It may be caused by strabismus (crossed eye); uremia; or toxins, such as alcohol, tobacco, lead, and other toxic substances
• Symptoms include a wandering eye, eyes that may not appear to work together, poor depth perception, blurred vision, or double vision. Both eyes may be affected

DX: Screening to detect amblyopia in all children younger than five years of age

• Screening includes vision risk assessment at all health maintenance visits and vision screening at age three, four, and five years of age

TX: Treatment includes correction of refraction error as well as forced use of the amblyopic eye by patching the better eye

• Some children cannot tolerate the patch, in which case the good eye is blurred with glasses or drops (penalization therapy) to stimulate proper visual development of the more severely affected eye
• It is more resistant to treatment at an older age; thus, children should be treated early

View lesson: Amblyopia

Answer: C. Toxic megacolon

The hallmarks of toxic megacolon (toxic colitis) are nonobstructive colonic dilatation (>6 cm) and signs of systemic toxicity. It occurs following complications from causes of colitis e.g. ulcerative colitis as is the case in the index patient.

Incorrect Answers:

• Hirschsprung’s disease (choice A) presents with chronic constipation. Patients are not usually toxic except when intestinal perforation occurs.
• Cytomegalovirus colitis and Kaposi’s sarcoma (choice B and D) Occurs in immunocompromised persons.

View lesson: Toxic megacolon

Answer: A. Hepatitis A

Hepatitis A is transmitted via the fecal-oral route

Incorrect Answers:

• Hepatitis B can be transmitted via blood and blood products through close living quarters/playground play as a toddler, vertical transmission, infected unscreened blood, needle stick injury, etc.
• Hepatitis D is transmitted via blood.
• Hepatitis C is transmitted via blood and blood products through Intravenous drug misuse, unscreened blood products, needle stick injury, vertical transmission etc

View lesson: Acute and Chronic Hepatitis

Answer: B. 24 to 48 h after birth

In the US and many developed countries, all neonates are screened for PKU 24 to 48 h after birth. Tandem mass spectrometry is the method of choice. It has a low false-positive rate, and excellent accuracy and precision.

View lesson: Phenylketonuria

Answer: C. Anti-tissue transglutaminase antibody

The patient has Celiac disease, which is an immune disorder characterized by sensitivity to gluten. It is more common in patients with Type 1 diabetes, autoimmune thyroiditis, Trisomy 21, and Turner syndrome.

Clinical features include diarrhea with bulky, foul-smelling floating stool, flatulence, and weight loss. Patients may have dermatitis herpetiformis, which is a rash located on the elbows, forearms, and knees.

Laboratory studies to order include anti-tissue transglutaminase antibodies and IgA anti-endomysial antibodies. The best diagnostic test is an upper endoscopy with a small bowel biopsy. Patients must avoid food with gluten, which includes barley, rye, oats, and wheat.

Incorrect Answers:

• Anti–cyclic citrullinated peptide antibodies (choice A) are highly specific to rheumatoid arthritis.
• Anti-dsDNA antibodies (choice B) are a specific marker for systemic lupus erythematosus.
• Anti-topoisomerase antibodies (choice D) are specific to diffuse scleroderma.
• anti-beta 2 glycoprotein 1 antibodies (choice E) are specific to antiphospholipid syndrome.

View lesson: Celiac disease

Answer: B. Uterine atony

Postpartum hemorrhage is an obstetric emergency. It is defined as an estimated blood loss ≥ 500 mL during vaginal delivery or ≥ 1000 in a cesarean section. The most common cause is uterine atony.

Uterine atony presents as a soft, boggy uterus after delivery and should initially be managed with fundal massage and IV oxytocin.

In general, the main focus of managing postpartum hemorrhage should be (1) resuscitation and management of hypovolemic shock and (2) identifying and treating the underlying cause.

View lesson: Postpartum hemorrhage

Answer: C. Pericardiocentesis

The patient is experiencing cardiac tamponade, which is defined as fluid accumulation in the pericardial sac. The most common cause of cardiac tamponade is trauma. Other causes include malignancy, uremia, infection, and iatrogenic.

Patients may have Beck’s Triad – hypotension, muffled heart sounds, and jugular vein distention. They may also have pulsus paradoxus (large decrease in systolic blood pressure on inspiration).

The best diagnostic test is an echocardiogram. The treatment of cardiac tamponade is pericardiocentesis. An open surgical approach (i.e., thoracotomy) is typically needed for traumatic cases though.

Incorrect Answers:

• Emergent needle decompression (choice A) is the treatment of choice for a tension pneumothorax, which is when air rapidly accumulates in the pleural space. It typically presents as shortness of breath.
• IV beta-blockers (choice B) would be the management of an aortic dissection, not cardiac tamponade. An aortic dissection presents with sharp chest pain, pulse deficits, and hypotension.
• Thrombolytics (choice D) would be the preferred treatment for an unstable patient with a massive pulmonary embolism.

View lesson: Cardiac Tamponade

Answer: E. Both A and B

Acute kidney injury (AKI) is defined by an acute decline in renal function. You will see an increase in serum creatinine with possible oliguria or anuria.

AKI can be broken up into 3 main etiologies: pre-renal, intrinsic, and post-renal. The most common cause of acute kidney injury overall is reduced perfusion. Prolonged pre-renal AKI can lead to ischemic acute tubular necrosis.

Nephrotoxic agents, such as NSAIDs, vancomycin, aminoglycosides, and ACEI/ARBs, should be avoided. Treatment is managing the underlying cause, plus correcting acid-base & electrolyte issues.

View lesson: Acute Renal Failure

Answer: B. Selective serotonin reuptake inhibitors

The patient most likely has panic disorder. The DSM V criteria for panic disorder include the following:

• 1 or more panic attack that reoccurs without warning and at least 4 or more symptoms
• Must be worried about having another attack or change behaviors

Symptoms of a panic attack include diaphoresis, chest pain, lightheadedness, shortness of breath, palpitations, sense of doom, or fear of dying. The treatment of panic disorder is selective serotonin reuptake inhibitors. Patients may benefit from taking hydroxyzine or benzodiazepines on a short-term, as-needed basis.

View lesson: Panic Disorder

Answer: D. Low serum sodium, low serum osmolality, high urine osmolality

SIADH or syndrome of inappropriate antidiuretic hormone secretion is characterized by the excessive release of ADH. ADH increases the permeability of the distal convoluted tubule and collecting ducts, increasing the reabsorption of water. This decreases plasma osmolality, increases urine osmolality, and leads to hyponatremia.

Causes include intrathoracic diseases (pneumonia, TB, acute respiratory failure, lung cancer), neurological issues (stroke, hemorrhage, tumors), and drugs (NSAIDs, opioids, ecstasy, and SSRIs). The goal is to determine and manage the underlying cause. Fluid restriction is often used as well.

View lesson: Syndrome of inappropriate antidiuretic hormone secretion