PANCE Review for Physician Assistant Certification Exam Prep + CME

Risk factors for vertebral osteomyelitis include IV drug abuse, diabetes, and chronic renal failure. Initial workup for vertebral osteomyelitis should always include complete blood count, blood cultures, and MRI if available.

Aortic dissection is a rare cause of back pain, but mortality rates exceed 90% if left untreated; initial workup should include advanced imaging studies based on availability (MRI, CT, or aortography). Cauda equina syndrome occurs in a very small percentage of patients with herniated discs; less than 1% will have this syndrome. Cancers of the breast, lung, thyroid, kidney, and prostate commonly metastasize to bone (remember the mnemonic: “BLT with a Kosher Pickle”). Eighty percent of patients with a history of cancer and back pain will have metastatic disease.

Reference:

Mahoney BD, et al. Back pain. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed, 2009.

Deep brain stimulation has been used for the treatment of intractable pain for at least 50 years. Approximately 20% of equipment failures are the result of lead erosion or migration. Although all the other complications listed have also been described in the literature, they are less likely candidates in this case.

References:
Bittar RG, Kar-Purkayastha I, Owen SL, et al. Deep brain stimulation for pain relief: a meta-analysis. J Clin Neurosci. 2005;12(5):515-519.
Kringelbach ML, Aziz TZ. Deep brain stimulation: avoiding the errors of psychosurgery. JAMA. 2009;301(16):1705-1707.
Vidailhet M, Vercueil L, Houeto JL, et al; French Stimulation du Pallidum Interne dans la Dystonie (SPIDY) Study Group. Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med. 2005;352(5):459-467.

Educational Objective:

Recognize that sudden hearing loss is considered an otologic emergency.

Key Point:

Sudden hearing loss, defined as hearing loss occurring ≤ 3 days, is an otologic emergency that requires rapid investigation.

Explanation:

Sudden hearing loss is an otologic emergency, even though the ultimate diagnosis is idiopathic in nearly 70% of patients (not 20%). In other words, most patients never have an identifiable cause and the remaining proportion are caused by otologic disease, trauma, vascular disease, hematologic disorders, or neoplasm.

Sudden hearing loss is a formal term that refers to sensorineural hearing loss that has occurred within 3 days. Most patients with sudden hearing loss do not present for the first 24 or 48 hours after onset secondary to the hope that the problem will resolve on its own. Even though most cases are ultimately labeled as idiopathic, a large number of vascular, metabolic, conductive, toxicologic, and neoplastic etiologies can, although rarely, cause sudden hearing loss in a small group of patients. In addition, approximately 13% of cases are thought to be due to infection.

Sudden isolated hearing loss or sudden hearing loss accompanied by minimal vertigo (ie, hearing loss is the dominant symptom and vertigo is absent or minimal) rarely involves a central pathology, or worse, a central catastrophe. Vertigo has been reported in 20% to 60% of patents with sudden hearing loss. Tinnitus is common in association with sudden hearing loss and is reported by up 90% of patients.

A thorough history that determines if the loss is unilateral, bilateral, acute, progressive, fluctuating, or is accompanied by fullness, neurologic deficits, or pain can help point the clinician toward the potential underlying etiology of this dramatic-appearing complaint. Sudden hearing loss is difficult to treat and is a medical emergency so that a search for possible medical treatment can be initiated.

References:

Pfaff JA. Otolaryngology (chapter 62). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:820-831.

Weber PC. Sudden sensorineural hearing loss. Updated May 2018. Accessed August 31, 2018.

Educational Objective:

Recognize the manifestations of acute hemolytic transfusion reaction.

Key Point:

Acute hemolytic transfusion reactions are serious reactions with symptoms that can include fever, hypotension, dyspnea, flank, abdominal, and chest pain. Laboratory values will show a positive DAT finding.

Explanation:

Acute hemolytic transfusion reactions are dangerous, severe reactions that may result from the administration of as little as 10 mL of incompatible blood. The reaction may be either acute or delayed (> 24 hours), with acute reactions most commonly resulting from the transfusion of ABO-incompatible RBCs. Pertinent physical signs, which are present in this case,  include fever, hypotension, dyspnea, flank, abdominal, and chest pain. Laboratory findings supporting the diagnosis of acute hemolytic transfusion reaction include a positive finding on DAT, pink serum, coagulation abnormalities, hemoglobinuria, hyperbilirubinemia, and the presence of schistocytes, spherocytes, or both.

Treatment consists of discontinuing the transfusion immediately in combination with a saline infusion started in the line. Issues with hypotension and renal blood flow should also be promptly addressed, with the urine flow rate maintained at above 1 mL/kg/hour; furosemide should be added if necessary. If disseminated intravascular coagulation is present, then the patient may need cryoprecipitate, plasma, and platelet transfusions. Severe reactions may require a red cell exchange transfusion, depending on the amount of incompatible blood transfused.

TACO is a common complication of transfusion. Patients susceptible to TACO include those older than 70 years of age (especially those with congestive heart failure) and infants. The presentation involves acute pulmonary edema through volume overload. Additional characteristics include jugular venous distension, dyspnea, orthopnea, ST-segment and T-wave changes, elevated B-type natriuretic peptide (BNP), increased serum troponin, widened cardiothoracic ratio on chest x-ray, and hypertension. Hypertension and elevated BNP are several features one may use to differentiate TACO from TRALI.

TRALI presents with bilateral pulmonary edema, fever, chills, hypotension, dyspnea, and is comparable to the presentation of acute respiratory distress syndrome (ARDS). The ARDS-like picture distinguishes TRALI from TACO.

Febrile nonhemolytic transfusion reaction presents as an increase in body temperature of at least 1 °C--which is at least 38 °C--and is not attributable to other causes. Although the reaction is most commonly observed during the transfusion, it may occur up to 4 hours following transfusion.

References:

Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-2035.

Vassallo R, Bachowski G, Benjamin RJ, et al; American Red Cross. A Compendium of Transfusion Practice Guidelines. 2nd ed., 2013.

Educational Objective:

Discuss the presentation and early management of presumed Boerhaave’s syndrome in an unstable patient.

Key Point:

A patient with severe vomiting accompanied by sudden severe chest pain, unstable vital signs without hematemesis, and with a widened mediastinum on chest x-ray and no previous history or preceding trauma has a ruptured esophagus (Boerhaave’s syndrome) until proven otherwise. In unstable patients, Boerhaave’s syndrome requires emergent definitive care.

Explanation:

This patient’s symptoms are most likely due to Boerhaave’s syndrome.  Symptoms include neck, chest, or epigastric pain after forceful episodes of vomiting.  CXR should be obtained on an emergent basis and may show pleural effusion, widened mediastinum, pneumomediastinum, or pneumothorax. 

If the patient is unstable with a widened mediastinum (as the above patient) and a likely diagnosis of Boerhaave’s based on history, the patient can decompensate very rapidly if definitive care is delayed. Boerhaave’s syndrome carries a 50% mortality, which rises rapidly as time passes.

In the above patient, the existing information is sufficient to initiate an emergent surgical consult.  An in-house surgeon may still elect to do a quick CT-scan on the way to the operating room, or a commuting surgeon may ask the emergency department to complete a CT scan while the surgeon is en route to the hospital; either way, notification of the surgeon should not be delayed in an unstable patient.

In a stable patient with suspected Boerhaave’s syndrome, it may be reasonable to obtain advanced imaging prior to mobilizing definitive care.

Reference:  

Guttman J. Nausea and Vomiting. (Chapter 26) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 230-241e1.

Mueller DK. Esophageal Rupture. Updated: Feb 24, 2017; accessed August 22, 2018.