PANCE cheat sheet

STEMI: ST elevation ≥1 mm in two contiguous limb leads or ≥2 mm in two contiguous precordial leads (or new LBBB with ischemic symptoms); reperfusion goal of door-to-balloon time <90 minutes at a PCI-capable center.

HFrEF (EF ≤40%): four guideline pillars are ARNI (or ACE inhibitor/ARB), evidence-based beta blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor.

Atrial fibrillation: anticoagulate when CHA2DS2-VASc ≥2 in men or ≥3 in women; avoid nondihydropyridine calcium channel blockers in HFrEF.

Aortic stenosis is severe when valve area <1.0 cm², mean gradient ≥40 mmHg, or peak velocity ≥4 m/s; classic triad is angina, syncope, and exertional dyspnea.

Pericarditis: diffuse concave ST elevation with PR depression; treat with an NSAID plus colchicine.

Cardiac tamponade: Beck triad (hypotension, jugular venous distention, muffled heart sounds), pulsus paradoxus, electrical alternans; treat with IV fluids and pericardiocentesis.

Infective endocarditis: obtain three sets of blood cultures from separate sites before antibiotics; Staphylococcus aureus is the most common cause of acute endocarditis.

Nitroglycerin is contraindicated in right ventricular infarction and within 24-48 hours of PDE5 inhibitor use.

Obstructive lung disease is defined by a post-bronchodilator FEV1/FVC <0.70; severity is graded by FEV1 percent predicted, while restriction shows reduced FVC with a normal or high ratio.

Asthma: intermittent symptoms may be treated with a short-acting beta agonist alone; persistent symptoms require inhaled corticosteroid-containing therapy.

COPD: smoking cessation is the only intervention proven to slow the decline in FEV1; long-acting bronchodilators (LABA/LAMA) are first-line maintenance therapy.

Home oxygen improves survival in COPD when PaO2 ≤55 mmHg or ≤59 mmHg with cor pulmonale or polycythemia (SpO2 ≤88%).

Pulmonary embolism: low or intermediate pretest probability → D-dimer; high probability or positive D-dimer → CT pulmonary angiography.

Light criteria for exudative pleural fluid: pleural protein/serum protein >0.5, pleural LDH/serum LDH >0.6, or pleural LDH >2/3 the upper limit of normal serum LDH.

Anion gap = Na − (Cl + HCO3), normal 8-12; a high gap suggests MUDPILES causes, a normal gap suggests diarrhea, renal tubular acidosis, or acetazolamide.

CURB-65 (confusion, BUN >19 mg/dL, respiratory rate ≥30, low blood pressure, age ≥65) with ≥2 points supports consideration of inpatient admission for pneumonia.

Ottawa ankle rules: radiograph only if there is malleolar pain plus bone tenderness at the posterior edge of the distal 6 cm of the tibia or fibula, or inability to bear weight for four steps.

Septic arthritis: synovial WBC >50,000/mm³ with positive Gram stain and no crystals; obtain cultures then start empiric IV antibiotics.

Acute compartment syndrome: pain out of proportion and pain with passive stretch; fasciotomy when intracompartmental pressure >30 mmHg or within 30 mmHg of diastolic pressure.

Gout: needle-shaped, negatively birefringent monosodium urate crystals; pseudogout: rhomboid, positively birefringent calcium pyrophosphate crystals.

Osteoporosis is defined by a DXA T-score ≤ −2.5; a T-score between −1.0 and −2.5 defines osteopenia.

Anterior cruciate ligament tear: the Lachman test is the most sensitive maneuver; anterior drawer and pivot shift support the diagnosis.

Cauda equina syndrome (saddle anesthesia, urinary retention, bilateral leg weakness) requires emergent MRI and surgical decompression.

Upper GI bleeding: give IV proton pump inhibitor before endoscopy for suspected nonvariceal bleeding; suspected variceal bleeding → octreotide plus prophylactic ceftriaxone.

Acute pancreatitis: lipase >3× the upper limit of normal; early goal-directed IV fluids; severity is classified by the Atlanta criteria.

Serum-ascites albumin gradient ≥1.1 g/dL indicates portal hypertension; <1.1 g/dL suggests peritoneal tuberculosis, malignancy, or pancreatic ascites.

Spontaneous bacterial peritonitis: ascitic polymorphonuclear cells ≥250/mm³ → IV cefotaxime plus albumin (1.5 g/kg on day 1, 1 g/kg on day 3).

Celiac disease: anti-tissue transglutaminase IgA with a total IgA level, confirmed by duodenal biopsy showing villous atrophy while the patient is on gluten.

Crohn disease shows transmural inflammation, skip lesions, granulomas, and fistulas; ulcerative colitis shows continuous mucosal disease beginning at the rectum.

Helicobacter pylori: urea breath test or stool antigen confirms active infection; serology cannot be used to confirm eradication.

Acute cholecystitis: right upper quadrant ultrasound is first-line; a positive Murphy sign and pericholecystic fluid support the diagnosis, with HIDA scan for equivocal cases.

AKI by KDIGO: creatinine rise ≥0.3 mg/dL within 48 hours, ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 hours.

Prerenal azotemia: BUN/creatinine ratio >20, FENa <1%, bland sediment; acute tubular necrosis: FENa >2% with muddy brown casts.

Hyperkalemia with ECG changes: IV calcium gluconate first for membrane stabilization, then insulin with glucose and albuterol; dialysis if refractory.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipidemia; nephritic syndrome: hematuria, red cell casts, hypertension.

ACE inhibitors and ARBs precipitate acute kidney injury in bilateral renal artery stenosis and are contraindicated.

Struvite (triple phosphate) stones form with urease-producing bacteria and may become staghorn calculi; calcium oxalate is the most common stone overall.

Uncomplicated cystitis: nitrofurantoin or trimethoprim-sulfamethoxazole; nitrofurantoin is avoided when creatinine clearance is very low because it is ineffective.

Ectopic pregnancy: positive hCG without an intrauterine pregnancy on transvaginal ultrasound and a suboptimal hCG rise; treat with methotrexate or surgery.

Preeclampsia: blood pressure ≥140/90 after 20 weeks plus proteinuria or end-organ dysfunction; magnesium sulfate prevents seizures and delivery is definitive.

Screen for gestational diabetes with a 75-g oral glucose tolerance test at 24-28 weeks; treat with diet, adding insulin when glucose targets are not met.

RhoGAM is given to Rh-negative unsensitized mothers at 28 weeks, within 72 hours postpartum, and after abortion, amniocentesis, or vaginal bleeding.

Polycystic ovary syndrome (Rotterdam criteria): two of oligo-ovulation/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology.

Pelvic inflammatory disease: ceftriaxone plus doxycycline plus metronidazole; an IUD need not be removed unless symptoms fail to improve.

Combined oral contraceptives are contraindicated with migraine with aura, smoking at age ≥35, and prior venous thromboembolism.

Diabetes diagnosis: A1c ≥6.5%, fasting glucose ≥126 mg/dL, or 2-hour OGTT ≥200 mg/dL; metformin is first-line therapy unless contraindicated.

Diabetic ketoacidosis: anion-gap metabolic acidosis with ketonemia; check potassium before insulin - if K <3.3 mEq/L, hold insulin and replete potassium first.

Primary hypothyroidism: elevated TSH with low free T4, treated with levothyroxine; subclinical hypothyroidism is elevated TSH with normal free T4.

Graves disease: suppressed TSH, elevated free T4, positive TSH-receptor antibodies, and diffuse uptake on radioiodine scan.

Thyroid storm: beta blocker first, then propylthiouracil, then iodine at least one hour after the thionamide; treat the precipitating illness.

Primary adrenal insufficiency: hyponatremia, hyperkalemia, hypotension, and hyperpigmentation; confirm with a cosyntropin stimulation test.

Pheochromocytoma: screen with plasma free metanephrines; establish alpha blockade (phenoxybenzamine) before any beta blockade to avoid hypertensive crisis.

Hypercalcemia: elevated or inappropriately normal PTH suggests primary hyperparathyroidism (most common outpatient cause); suppressed PTH suggests malignancy.

Ischemic stroke: IV alteplase within 4.5 hours if blood pressure <185/110 mmHg and CT shows no hemorrhage; thrombectomy is an option up to 24 hours with large-vessel occlusion selected by imaging.

Subarachnoid hemorrhage: thunderclap headache → noncontrast head CT; if negative with persistent suspicion, lumbar puncture showing xanthochromia confirms the diagnosis.

Bacterial meningitis: vancomycin plus ceftriaxone (add ampicillin if age >50); give dexamethasone with or before the first antibiotic dose when pneumococcal disease is suspected.

Status epilepticus: a benzodiazepine (lorazepam or midazolam) first, then a second-line agent such as levetiracetam, fosphenytoin, or valproate.

Multiple sclerosis: periventricular and juxtacortical lesions with CSF oligoclonal bands; Uhthoff phenomenon refers to symptom worsening with heat.

Myasthenia gravis: fatigable ptosis and diplopia, anti-acetylcholine receptor antibodies, association with thymoma; treat with pyridostigmine and immunotherapy.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; levodopa-carbidopa is the most effective symptomatic therapy.

Cluster headache: high-flow oxygen and subcutaneous sumatriptan are first-line abortive treatments.

Major depressive disorder: ≥5 of 9 symptoms for ≥2 weeks including depressed mood or anhedonia; SSRIs plus psychotherapy are first-line.

Bipolar mania: elevated or irritable mood with ≥3 of grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased activity, and risky behavior.

Serotonin syndrome: clonus, hyperreflexia, agitation, autonomic instability, and hyperthermia; stop serotonergic agents, give cyproheptadine, and provide supportive care.

Neuroleptic malignant syndrome: rigidity, hyperthermia, autonomic instability, and elevated creatine kinase after dopamine antagonists; stop the drug and use dantrolene or bromocriptine.

Alcohol withdrawal: benzodiazepines titrated to CIWA score; give thiamine before or with glucose to prevent Wernicke encephalopathy.

Delirium: acute onset with fluctuating course and inattention; identify and treat the underlying cause rather than sedating the patient.

Anorexia nervosa: monitor for refeeding syndrome (hypophosphatemia, hypokalemia, hypomagnesemia) when nutritional rehabilitation is started.

Microcytic anemia: iron deficiency shows low ferritin, low serum iron, high TIBC, and low saturation; anemia of chronic disease shows low TIBC with normal or high ferritin.

Macrocytic anemia: vitamin B12 deficiency causes neurologic symptoms with elevated methylmalonic acid; folate deficiency has a normal methylmalonic acid level.

Hemolysis: elevated LDH and indirect bilirubin, low haptoglobin, reticulocytosis; a positive direct antiglobulin test indicates autoimmune hemolysis.

Heparin-induced thrombocytopenia: platelet count falls >50% at 5-10 days with thrombosis risk; stop heparin and start argatroban, bivalirudin, or fondaparinux.

Thrombotic thrombocytopenic purpura: schistocytes, thrombocytopenia, neurologic and renal dysfunction, and fever; treat with urgent plasma exchange, not platelet transfusion.

Disseminated intravascular coagulation: prolonged PT and aPTT, low fibrinogen, elevated D-dimer, and thrombocytopenia; treat the underlying cause.

Neutropenic fever (absolute neutrophil count <500/µL with temperature ≥38.3°C): obtain cultures and start an empiric antipseudomonal beta-lactam immediately.

Melanoma: ABCDE criteria (asymmetry, border irregularity, color variation, diameter >6 mm, evolution); Breslow thickness is the strongest prognostic factor.

Basal cell carcinoma: pearly papule with telangiectasia and rolled borders; squamous cell carcinoma: keratotic or ulcerated lesion with higher metastatic potential.

Stevens-Johnson syndrome involves <10% body surface area epidermal detachment, overlap 10-30%, and toxic epidermal necrolysis >30%; stop the culprit drug and give burn-type supportive care.

Psoriasis: well-demarcated plaques with silvery scale on extensor surfaces, positive Auspitz sign, Koebner phenomenon; screen for psoriatic arthritis.

Acute otitis media: bulging, erythematous tympanic membrane; amoxicillin is first-line unless there has been recent antibiotic exposure.

Acute angle-closure glaucoma: painful red eye, halos, mid-dilated fixed pupil, elevated intraocular pressure; treat with timolol, pilocarpine, and acetazolamide or mannitol, then laser iridotomy.

Sudden sensorineural hearing loss: unilateral loss developing over <72 hours requires urgent corticosteroids and MRI to exclude acoustic neuroma.

Sepsis is infection with organ dysfunction; septic shock is vasopressor requirement to maintain MAP ≥65 mmHg with lactate >2 mmol/L despite fluids - obtain cultures and give antibiotics within one hour.

Tuberculin skin test induration thresholds: ≥5 mm for HIV, immunosuppression, or recent contact; ≥10 mm for high-risk groups; ≥15 mm for low-risk patients; IGRA is unaffected by BCG vaccination.

HIV: screen with a fourth-generation antigen/antibody test; start antiretroviral therapy regardless of CD4 count; trimethoprim-sulfamethoxazole prophylaxis when CD4 <200/µL.

Clostridioides difficile: oral vancomycin or fidaxomicin is preferred over metronidazole for initial and severe episodes.

Lyme disease: erythema migrans is a clinical diagnosis; doxycycline is first-line for early localized disease.

Syphilis: screen with a nontreponemal test (RPR or VDRL) and confirm with a treponemal test; early syphilis is treated with benzathine penicillin G.

Infectious mononucleosis: Epstein-Barr virus with a positive heterophile antibody test; avoid amoxicillin (rash) and contact sports for about four weeks because of splenic rupture risk.