PANCE common mistakes
PANCE · Understand the traps and how to avoid them.
In a hypertensive patient with tearing chest pain and ST elevation, activates the STEMI pathway and gives fibrinolysis without checking blood pressure in both arms, pulses, or ordering chest imaging.
ST elevation triggers a memorized ACS algorithm; aortic dissection is rare and time pressure discourages a broader differential.
What to do instead
Before reperfusion, assess for dissection with bilateral BP, pulse deficits, mediastinal widening, and pain character; obtain urgent CT angiography and surgical consult if suspected.
In an older smoker with acute dyspnea and wheezing, documents COPD exacerbation and discharges on prednisone without ABG, chest radiograph, ECG, or BNP.
Smoking history and wheeze anchor the diagnosis; heart failure, PE, and pneumonia can mimic COPD.
What to do instead
Obtain ABG, CXR, ECG, and BNP when indicated; treat COPD with bronchodilators plus systemic steroids and antibiotics as indicated, and reassess for alternative diagnoses.
In a febrile patient with a hot, swollen knee, starts colchicine for gout without arthrocentesis.
Gout is common and crystals may be assumed; procedure discomfort and time pressure discourage aspiration.
What to do instead
Aspirate the joint when septic arthritis is possible; send cell count, crystals, Gram stain, and culture; start empiric antibiotics if septic until cultures return.
In severe abdominal pain out of proportion to a benign exam, orders routine labs and gives opioids before CT angiography.
Early mesenteric ischemia can have a soft abdomen; opioids may mask findings and routine workup feels sufficient.
What to do instead
Recognize pain out of proportion, obtain urgent CT angiography, involve surgery early, and avoid delaying imaging for analgesia.
In a patient with a rising creatinine and suspected renal colic, orders IV contrast CT before assessing volume status and urine output.
CT protocol habit and focus on stones; contrast nephropathy risk is not routinely stratified.
What to do instead
Assess volume status, hold nephrotoxins, and use ultrasound first when AKI is present; hydrate and reserve contrast CT for when it changes management.
In a reproductive-age woman with abdominal pain and syncope, orders only a urine pregnancy test and discharges if negative without serum beta-hCG or pelvic ultrasound.
Urine hCG can be falsely negative early; ectopic pregnancy is time-sensitive and syncope suggests rupture.
What to do instead
Obtain serum beta-hCG and transvaginal ultrasound; treat ectopic pregnancy as possible until excluded and check blood type/Rh.
In diabetic ketoacidosis, stops the insulin infusion when glucose reaches 250 mg/dL and gives bicarbonate routinely.
Protocol memorization focuses on glucose normalization; fear of hypoglycemia drives early insulin cessation.
What to do instead
Continue insulin with added dextrose until the anion gap closes; reserve bicarbonate for pH <7.0 and monitor potassium closely.
In a young adult with acute focal weakness, attributes the deficit to migraine or stress without checking glucose or activating the stroke pathway.
Age bias and atypical presentation; stroke mimics are common but stroke is still possible.
What to do instead
Check glucose immediately, perform NIHSS, obtain urgent CT/CTA, and assess thrombolysis window regardless of age.
Admits a psychotic patient directly to psychiatry without checking vital signs, glucose, urine drug screen, or medication list for delirium.
A known psychiatric history or agitation label biases toward primary psychosis; medical causes are under-screened.
What to do instead
Screen for delirium and medical mimics with vitals, glucose, UDS, TSH, and medication review; treat reversible causes before psychiatric admission.
In a septic patient with pneumonia, orders blood cultures and antibiotics but delays the first antibiotic dose until after CT and lumbar puncture.
Diagnostic completeness and procedure sequencing take priority; sepsis time targets are underestimated.
What to do instead
Give broad-spectrum antibiotics within 1 hour after cultures when possible; do not delay antibiotics for imaging or LP in septic shock.