Physician Assistant National Certifying Examination (PANCE) — Questions and Answers

Question 1: Which finding on chest X-ray is most characteristic of a tension pneumothorax?

Ipsilateral tracheal deviation with complete opacification
Unilateral pleural effusion without mediastinal shift
Contralateral tracheal deviation with ipsilateral lung collapse (Correct answer)
Bilateral diffuse infiltrates

Correct answer: Contralateral tracheal deviation with ipsilateral lung collapse

Tension pneumothorax causes mediastinal shift away from the affected side due to positive pressure buildup, displacing the trachea contralaterally.

Question 2: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

Copy what other organizations do without analysis
Use data-driven methods with measurable outcomes (Correct answer)
Make changes without measuring results
Wait for problems to occur before acting

Correct answer: Use data-driven methods with measurable outcomes

Data-driven quality improvement with measurable outcomes ensures that changes actually produce the intended improvements and can be verified.

Question 3: A 50-year-old presents with progressive bilateral conductive hearing loss. Audiometry shows a Carhart notch at 2000 Hz on bone conduction and an absent stapedial reflex. What is the most likely diagnosis?

Cholesteatoma
Ossicular chain disruption from trauma
Presbycusis
Otosclerosis (Correct answer)

Correct answer: Otosclerosis

Otosclerosis causes progressive conductive hearing loss from abnormal bony fixation of the stapes footplate; the Carhart notch at 2000 Hz and absent stapedial reflex are classic findings.

Question 4: A 47-year-old man has been pushing his lawn mower for the past three weeks while experiencing chest pain. He states he has never been treated for similar symptoms and has no problems presently. He smoked one pack each day for twenty years until giving it up seven years ago. Physical examination results are typical. Electrocardiograms don't reveal any anomalies. Which of the following first diagnostic tests is most appropriate?

Echocardiography
24-Hour ambulatory cardiac monitoring
Exercise stress test (Correct answer)
Coronary arteriography

Correct answer: Exercise stress test

The patient's exertional chest pain, occurring while pushing a lawn mower, is highly suggestive of stable angina, even with a normal resting EKG. An exercise stress test is the most appropriate initial diagnostic test to evaluate for exercise-induced myocardial ischemia. It helps determine if the heart receives enough blood flow during physical activity, which might not be evident at rest.

Question 5: What is an endoscopic retrograde cholangiopancreatography's (ERCP) most common complication?

Cholangitis
Aspiration
Perforation
Pancreatitis (Correct answer)

Correct answer: Pancreatitis

Post-ERCP pancreatitis is the most common and often the most serious complication of endoscopic retrograde cholangiopancreatography. It occurs due to irritation or injury to the pancreatic duct during the procedure, leading to inflammation of the pancreas. While other complications like cholangitis, aspiration, and perforation can occur, pancreatitis is statistically the most frequent.

Question 6: A 35-year-old presents with episodic positional vertigo triggered when lying down or rolling over in bed. Episodes last less than 1 minute. Dix-Hallpike test elicits upbeat-torsional nystagmus with a latency of 5 seconds. What is the first-line treatment?

MRI of the posterior fossa
Intratympanic gentamicin injection
Vestibular suppressant medications (meclizine)
Epley canalith repositioning maneuver (Correct answer)

Correct answer: Epley canalith repositioning maneuver

The Epley canalith repositioning maneuver moves displaced otoliths out of the posterior semicircular canal and is the first-line treatment for posterior canal BPPV.

Question 7: A child develops oliguria, microangiopathic hemolytic anemia, and thrombocytopenia after a bloody diarrheal illness. What is the diagnosis?

Hemolytic uremic syndrome (Correct answer)
Thrombotic thrombocytopenic purpura
ITP
DIC

Correct answer: Hemolytic uremic syndrome

HUS classically follows E. coli O157:H7 infection and presents with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI.

Question 8: A 55-year-old man with small cell lung cancer develops ascending weakness and areflexia two weeks after chemotherapy. Anti-Hu antibodies are detected. This is an example of:

Chemotherapy-induced peripheral neuropathy
Direct tumor invasion of the spinal cord
Paraneoplastic encephalomyelitis/sensory neuronopathy (Correct answer)
Lambert-Eaton myasthenic syndrome

Correct answer: Paraneoplastic encephalomyelitis/sensory neuronopathy

Anti-Hu antibodies are associated with paraneoplastic sensory neuronopathy/encephalomyelitis, an immune-mediated syndrome triggered by SCLC.

Question 9: What is the fundamental principle behind cardiovascular system in the PANCE domain?

Using the newest technology exclusively
Balancing performance, reliability, and efficiency (Correct answer)
Following a single vendor solution
Cost minimization at all costs

Correct answer: Balancing performance, reliability, and efficiency

Effective technical design requires balancing performance requirements with reliability needs and operational efficiency.

Question 10: An 8-year-old boy presents with pubic hair and testicular enlargement. Bone age is advanced. LH and FSH are elevated. What is the most likely diagnosis?

Gonadotropin-independent (peripheral) precocious puberty
Congenital adrenal hyperplasia
Central (gonadotropin-dependent) precocious puberty (Correct answer)
Exogenous androgen exposure

Correct answer: Central (gonadotropin-dependent) precocious puberty

Elevated LH and FSH confirm central (GnRH-dependent) precocious puberty, which is driven by the hypothalamic-pituitary axis.

Question 11: What is the best practice for maintaining endocrine system performance over time?

Outsource all maintenance
Upgrade all equipment annually
Wait for failures before acting
Implement scheduled preventive maintenance (Correct answer)

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 12: A 9-year-old presents with a painless, firm, non-tender nodule on the upper eyelid that has been present for 3 weeks. There is no erythema or purulent discharge. What is the most likely diagnosis?

Hordeolum (stye)
Dacryocystitis
Chalazion (Correct answer)
Preseptal cellulitis

Correct answer: Chalazion

A chalazion is a chronic, painless granulomatous inflammation of a meibomian gland, presenting as a firm, non-tender eyelid nodule without acute inflammation.

Question 13: A 25-year-old woman has recurrent episodes of unilateral throbbing headache with photophobia, phonophobia, and nausea lasting 12–24 hours. What is the acute treatment of choice?

Topiramate
Beta-blockers
Triptans (e.g., sumatriptan) (Correct answer)
Opioids

Correct answer: Triptans (e.g., sumatriptan)

Triptans are serotonin 5-HT1B/1D receptor agonists and are first-line acute therapy for moderate-to-severe migraine.

Question 14: A 28-year-old female presents with amenorrhea, galactorrhea, and headaches. Labs show elevated prolactin. MRI reveals a pituitary mass. What is the first-line treatment?

Bromocriptine or cabergoline (Correct answer)
Radiation therapy
Surgical resection
Leuprolide

Correct answer: Bromocriptine or cabergoline

Dopamine agonists (bromocriptine or cabergoline) are first-line therapy for prolactinomas, as they effectively shrink the tumor and normalize prolactin.

Question 15: A 50-year-old returns from a trip to sub-Saharan Africa with fever, chills, and rigors occurring every 48 hours. Blood smear reveals ring-form trophozoites with appliqué (accolé) positioning and no Schüffner's dots. Which Plasmodium species is most likely responsible?

Plasmodium falciparum (Correct answer)
Plasmodium ovale
Plasmodium vivax
Plasmodium malariae

Correct answer: Plasmodium falciparum

Plasmodium falciparum shows ring-form trophozoites with appliqué positioning, multiple rings per RBC, and no Schüffner's dots — and is the most dangerous species causing severe malaria.

Question 16: A 25-year-old basketball player twists his knee and feels a pop. He develops a knee effusion within 2 hours and has a positive Lachman test. What structure is most likely injured?

Anterior cruciate ligament (Correct answer)
Medial collateral ligament
Lateral meniscus
Posterior cruciate ligament

Correct answer: Anterior cruciate ligament

ACL tears present with a pop, rapid hemarthrosis, and positive Lachman test; they are common in pivoting sports like basketball.

Question 17: A 40-year-old immunocompromised patient presents with painful vesicular lesions along a unilateral dermatomal distribution on the chest. Which antiviral, started within 72 hours of rash onset, is the treatment of choice?

Oseltamivir 75 mg BID × 5 days
Famciclovir 500 mg PO TID × 7 days
Valacyclovir 1000 mg PO TID × 7 days (Correct answer)
Acyclovir 800 mg PO 5 times daily × 7–10 days

Correct answer: Valacyclovir 1000 mg PO TID × 7 days

Valacyclovir 1000 mg TID for 7 days is preferred over acyclovir for herpes zoster (shingles) due to better bioavailability and simpler dosing schedule.

Question 18: Which approach best demonstrates mastery of musculoskeletal in PANCE practice?

Avoiding complex scenarios
Following procedures without understanding
Relying entirely on technology
Applying principles to novel situations with sound judgment (Correct answer)

Correct answer: Applying principles to novel situations with sound judgment

True mastery involves understanding underlying principles well enough to apply them to new and unfamiliar situations with professional judgment.

Question 19: A 68-year-old presents with productive cough, fever, and consolidation in the right lower lobe. Blood cultures are negative. She was hospitalized 3 weeks ago. Which organism is the most likely causative agent?

Haemophilus influenzae
Methicillin-resistant Staphylococcus aureus (MRSA) (Correct answer)
Klebsiella pneumoniae
Streptococcus pneumoniae

Correct answer: Methicillin-resistant Staphylococcus aureus (MRSA)

Healthcare-associated pneumonia occurring within 90 days of hospitalization has higher prevalence of MRSA and gram-negative rods, with MRSA being a key concern.

Question 20: A 25-year-old male presents with fever, headache, photophobia, and nuchal rigidity. CSF analysis shows WBC 1,200 cells/µL (predominantly neutrophils), glucose 30 mg/dL (serum glucose 90 mg/dL), and protein 180 mg/dL. What is the most likely causative organism in this age group?

Streptococcus pneumoniae
Listeria monocytogenes
Neisseria meningitidis (Correct answer)
Haemophilus influenzae

Correct answer: Neisseria meningitidis

Neisseria meningitidis is the most common cause of bacterial meningitis in adolescents and young adults (15–24 years), particularly in college dormitory settings.

Question 21: A patient presents with a painless, hard, left supraclavicular lymph node and significant weight loss. Upper endoscopy reveals a gastric mass. Which eponymous finding is described?

Blumer shelf
Sister Mary Joseph node
Virchow node (Correct answer)
Irish node

Correct answer: Virchow node

Virchow node (left supraclavicular lymphadenopathy) represents metastatic spread of intra-abdominal malignancy, most commonly gastric cancer, via the thoracic duct.

Question 22: A patient taking phenytoin for seizures presents with nystagmus, ataxia, and diplopia. Serum phenytoin level is 28 mcg/mL (therapeutic 10–20). What is the best management?

Increase phenytoin to achieve higher levels
Switch to levetiracetam immediately
Reduce phenytoin dose (Correct answer)
Add valproate for better seizure control

Correct answer: Reduce phenytoin dose

Phenytoin toxicity causes nystagmus, ataxia, and diplopia at supratherapeutic levels; dose reduction is the appropriate management.

Question 23: A 48-year-old woman presents with hot flashes, vaginal dryness, and irregular menses for 8 months. FSH is 62 mIU/mL. She has no uterus. Which hormone replacement is appropriate?

Progestin-only therapy
Combined estrogen-progestin therapy
Estrogen-only therapy (Correct answer)
Testosterone supplementation

Correct answer: Estrogen-only therapy

Women without a uterus require estrogen-only hormone therapy; adding progestin is unnecessary and provides no benefit since endometrial protection is not needed.

Question 24: A 68-year-old woman presents with progressive proximal muscle weakness, difficulty rising from a chair, and a heliotrope rash. CK is markedly elevated. What is the diagnosis?

Multiple sclerosis
Dermatomyositis (Correct answer)
Myasthenia gravis
Polymyalgia rheumatica

Correct answer: Dermatomyositis

Dermatomyositis presents with proximal muscle weakness, elevated CK, and characteristic skin findings including the heliotrope rash.

Question 25: Graves disease is caused by which mechanism?

Thyroid peroxidase antibodies causing hypothyroidism
Destruction of follicular cells by cytotoxic T cells
TSH receptor-blocking antibodies
Stimulating antibodies against the TSH receptor (Correct answer)

Correct answer: Stimulating antibodies against the TSH receptor

Thyroid-stimulating immunoglobulins (TSI) bind and activate the TSH receptor, causing hyperthyroidism in Graves disease.

Question 26: Which documentation is essential when working with reproductive system in PANCE?

Detailed technical specifications and as-built diagrams (Correct answer)
Only verbal notes
General descriptions without specifics
Marketing materials

Correct answer: Detailed technical specifications and as-built diagrams

Detailed technical specifications and as-built diagrams provide the accurate reference information needed for maintenance and troubleshooting.

Question 27: A 35-year-old woman presents with an 8 mm pigmented lesion on her foot showing amelanotic areas and nail involvement (melanonychia). What is the most important next diagnostic step?

Paring to look for black dots
Repeat examination in 6 months
Dermoscopy and punch biopsy (Correct answer)
Topical antifungal and follow-up

Correct answer: Dermoscopy and punch biopsy

Acral lentiginous melanoma, the most common melanoma in darker-skinned individuals, can mimic benign lesions on the foot; biopsy is mandatory for any concerning pigmented acral lesion.

Question 28: A 70-year-old male presents with bilateral leg cramping when walking that is relieved by leaning forward or sitting. MRI shows narrowing of the lumbar spinal canal. What is the diagnosis?

L4 disc herniation
Lumbar spinal stenosis (Correct answer)
Peripheral arterial disease
Deep vein thrombosis

Correct answer: Lumbar spinal stenosis

Lumbar spinal stenosis causes neurogenic claudication with pain relieved by flexion (leaning forward), distinguishing it from vascular claudication which improves with rest alone.

Question 29: A 68-year-old nursing home resident develops sudden onset high fever, myalgias, headache, and dry cough during influenza season. Rapid influenza test is positive. Which antiviral is most appropriate if started within 48 hours?

Baloxavir 40 mg PO single dose
Amantadine 100 mg PO BID × 5 days
Zanamivir 10 mg inhaled BID × 5 days
Oseltamivir 75 mg PO BID × 5 days (Correct answer)

Correct answer: Oseltamivir 75 mg PO BID × 5 days

Oseltamivir (Tamiflu) 75 mg PO BID for 5 days is the preferred neuraminidase inhibitor for influenza treatment in most clinical settings due to oral administration and proven efficacy.

Question 30: A patient with CKD has normocytic anemia and a reticulocyte count of 0.5%. What is the most likely pathophysiologic cause?

Vitamin B12 deficiency
Iron deficiency
Decreased erythropoietin production (Correct answer)
Hemolysis

Correct answer: Decreased erythropoietin production

CKD causes anemia primarily through decreased renal erythropoietin production, leading to inadequate red cell stimulation.

Question 31: A 22-year-old college student presents with fever, severe headache, nuchal rigidity, and a petechial rash. Which organism is the most likely cause?

Streptococcus pneumoniae
Listeria monocytogenes
Haemophilus influenzae
Neisseria meningitidis (Correct answer)

Correct answer: Neisseria meningitidis

Neisseria meningitidis causes bacterial meningitis with a classic petechial/purpuric rash due to septicemia, particularly in young adults.

Question 32: A 25-year-old woman presents with recurrent episodes of severe unilateral headache with photophobia, phonophobia, and nausea lasting 8-12 hours. She has no neurological deficits. What is the best abortive therapy?

Sumatriptan 50 mg orally (Correct answer)
Ergotamine 2 mg
Acetaminophen 1000 mg
Prednisone 60 mg

Correct answer: Sumatriptan 50 mg orally

Triptans (5-HT1B/1D agonists) are first-line abortive therapy for moderate-to-severe migraines, providing targeted relief by causing vasoconstriction and blocking pain pathways.

Question 33: A 25-year-old male has recurrent hemarthroses, a prolonged aPTT, and normal PT. Factor VIII activity is 2%. What is the diagnosis?

Hemophilia A (Correct answer)
Factor X deficiency
Hemophilia B
Von Willebrand disease type 3

Correct answer: Hemophilia A

Hemophilia A is caused by factor VIII deficiency, presenting with hemarthroses and a prolonged aPTT with normal PT.

Question 34: A 52-year-old man has a serum calcium of 11.8 mg/dL, PTH of 95 pg/mL, and is asymptomatic. What is the most likely diagnosis?

Humoral hypercalcemia of malignancy
Primary hyperparathyroidism (Correct answer)
Vitamin D toxicity
Hypoparathyroidism

Correct answer: Primary hyperparathyroidism

Elevated calcium with elevated (or inappropriately normal) PTH is the hallmark of primary hyperparathyroidism.

Question 35: A 23-year-old woman presents with 3 months of secondary amenorrhea, galactorrhea, and headache. MRI shows a 12 mm pituitary mass. What is first-line treatment?

Bromocriptine or cabergoline (Correct answer)
Radiation therapy
Combined oral contraceptives
Transsphenoidal surgery

Correct answer: Bromocriptine or cabergoline

Dopamine agonists (cabergoline preferred over bromocriptine) are first-line treatment for prolactinomas regardless of size, effectively normalizing prolactin and reducing tumor size.

Question 36: A 55-year-old presents with progressive bilateral sensorineural hearing loss, tinnitus, and episodic vertigo lasting 20 minutes to several hours. Audiometry shows low-frequency hearing loss. What is the most likely diagnosis?

Ménière's disease (Correct answer)
Vestibular neuritis
Acoustic neuroma
Benign paroxysmal positional vertigo

Correct answer: Ménière's disease

Ménière's disease is characterized by the triad of episodic vertigo, fluctuating sensorineural hearing loss (initially low-frequency), and tinnitus due to endolymphatic hydrops.

Question 37: A 30-year-old woman presents with bilateral proptosis, lid retraction, and a stare. Thyroid-stimulating hormone is suppressed and free T4 is elevated. What finding on extraocular muscle testing is most characteristic of her orbital condition?

Limitation of abduction (medial rectus palsy)
Limitation of elevation (inferior rectus restriction) (Correct answer)
Limitation of adduction (lateral rectus restriction)
Complete ophthalmoplegia

Correct answer: Limitation of elevation (inferior rectus restriction)

Thyroid eye disease (Graves' orbitopathy) most commonly affects the inferior rectus muscle, causing restriction of elevation and hypotropia.

Question 38: A 28-year-old presents with bloody diarrhea, tenesmus, and proctitis. Colonoscopy shows continuous mucosal inflammation starting from the rectum. Which diagnosis is most consistent?

Infectious colitis
Crohn disease
Ulcerative colitis (Correct answer)
Ischemic colitis

Correct answer: Ulcerative colitis

Ulcerative colitis characteristically starts in the rectum with continuous mucosal involvement, causing bloody diarrhea and tenesmus.

Question 39: A 40-year-old male with gout has his second attack in 6 months. Serum uric acid is 9.2 mg/dL. He tolerates NSAIDs well. What is the most appropriate long-term management?

Dietary restriction alone
Colchicine indefinitely
Allopurinol therapy (Correct answer)
High-dose aspirin

Correct answer: Allopurinol therapy

Allopurinol, a xanthine oxidase inhibitor, is indicated for urate-lowering therapy in patients with recurrent gout attacks to prevent future episodes.

Question 40: A patient with known primary pulmonary hypertension develops worsening dyspnea. Echocardiogram shows RV systolic pressure of 80 mmHg. Which medication class acts by increasing cyclic GMP to cause pulmonary vasodilation?

Endothelin receptor antagonists (bosentan)
Phosphodiesterase-5 inhibitors (sildenafil) (Correct answer)
Prostacyclin analogs (epoprostenol)
Calcium channel blockers (nifedipine)

Correct answer: Phosphodiesterase-5 inhibitors (sildenafil)

PDE-5 inhibitors prevent breakdown of cGMP, sustaining NO-mediated pulmonary vasodilation and reducing pulmonary vascular resistance.

Question 41: In PANCE practice, what is the best approach to quality improvement in eent?

Wait for problems to occur before acting
Make changes without measuring results
Use data-driven methods with measurable outcomes (Correct answer)
Copy what other organizations do without analysis

Correct answer: Use data-driven methods with measurable outcomes

Data-driven quality improvement with measurable outcomes ensures that changes actually produce the intended improvements and can be verified.

Question 42: What is the value of continuing education in musculoskeletal for PANCE professionals?

It is primarily a social activity
It replaces workplace experience
It keeps professionals current with evolving standards and practices (Correct answer)
It is only needed for recertification

Correct answer: It keeps professionals current with evolving standards and practices

Continuing education ensures professionals stay current with the latest developments, standards, and best practices in their field.

Question 43: A patient exposed to a bat in their bedroom is brought to the ED. The bat was not captured for testing. The patient has no visible bite marks but was asleep. What is the appropriate management?

Administer rabies vaccine series only (4 doses)
Culture wound site and start prophylactic amoxicillin-clavulanate
Reassure and discharge — no treatment needed without confirmed bite
Administer rabies immune globulin at wound site plus initiate rabies PEP vaccine series (Correct answer)

Correct answer: Administer rabies immune globulin at wound site plus initiate rabies PEP vaccine series

Bat exposure in a sleeping person (potential unrecognized bite) is considered a high-risk rabies exposure; post-exposure prophylaxis (RIG + 4-dose vaccine) is indicated.

Question 44: For the past four weeks, a 35-year-old African American lady has been experiencing increased malaise, dyspnea, and low-grade fever. Her iritis was just treated. Physical examination reveals modest hepatomegaly and red nodules over the anterior lower legs. An x-ray of the chest reveals bilateral hilar adenopathy. Which of the subsequent diagnoses is most likely?

Mesothelioma
Tuberculosis
Sarcoidosis (Correct answer)
Lymphoma

Correct answer: Sarcoidosis

The constellation of symptoms—erythema nodosum (red nodules on lower legs), bilateral hilar adenopathy on chest X-ray, iritis, and systemic symptoms like malaise, dyspnea, and low-grade fever—is highly characteristic of sarcoidosis. Sarcoidosis is a multisystem granulomatous disease that commonly affects the lungs, skin, and eyes.

Question 45: Which acid-base disorder is most commonly seen in end-stage renal disease?

Normal anion gap metabolic acidosis
Metabolic alkalosis
High anion gap metabolic acidosis (Correct answer)
Respiratory acidosis

Correct answer: High anion gap metabolic acidosis

Inability to excrete acid and regenerate bicarbonate in ESRD leads to high anion gap metabolic acidosis from accumulation of organic acids.

Question 46: A 55-year-old male presents with dysphagia to solids that has progressed to liquids over 3 months, with a 15-lb weight loss. Which diagnosis is most likely?

Esophageal spasm
Achalasia
Esophageal adenocarcinoma (Correct answer)
Zenker diverticulum

Correct answer: Esophageal adenocarcinoma

Progressive dysphagia from solids to liquids combined with significant weight loss in an older adult is the classic presentation of esophageal carcinoma.

Question 47: A 40-year-old woman with butterfly-shaped erythema across her cheeks and nose presents after sun exposure. Her ANA is positive with anti-dsDNA antibodies. Which skin finding would be considered discoid lupus?

Scarring plaques with follicular plugging and dyspigmentation (Correct answer)
Livedo reticularis on the extremities
Malar rash sparing nasolabial folds
Non-scarring diffuse alopecia

Correct answer: Scarring plaques with follicular plugging and dyspigmentation

Discoid lupus erythematosus features scarring plaques with follicular plugging, central atrophy, and dyspigmentation, potentially causing permanent hair loss.

Question 48: A 62-year-old man presents with progressive dysphagia to solids more than liquids and a 20-lb weight loss over 3 months. He has a 40-pack-year smoking history. What is the most likely diagnosis?

Achalasia
Zenker diverticulum
Esophageal carcinoma (Correct answer)
Diffuse esophageal spasm

Correct answer: Esophageal carcinoma

Progressive dysphagia to solids worse than liquids with significant weight loss in an older smoker is classic for esophageal carcinoma.

Question 49: An 8-year-old child presents with honey-crusted erosions around the nares and mouth. Gram stain shows gram-positive cocci in clusters. What is the most appropriate treatment?

Oral acyclovir
Oral fluconazole
Topical mupirocin or oral cephalexin (Correct answer)
Topical hydrocortisone

Correct answer: Topical mupirocin or oral cephalexin

Impetigo caused by Staphylococcus aureus is treated with topical mupirocin for localized disease or oral cephalexin for widespread infection.

Question 50: A 70-year-old presents with sudden onset severe abdominal pain out of proportion to exam, with a history of atrial fibrillation. Lactate is elevated. What is the most likely diagnosis?

Ischemic colitis
Acute pancreatitis
Perforated peptic ulcer
Acute mesenteric ischemia (Correct answer)

Correct answer: Acute mesenteric ischemia

Acute mesenteric ischemia from embolism (commonly from atrial fibrillation) causes severe pain disproportionate to exam findings with elevated lactate from bowel ischemia.

Question 51: A 35-year-old with Crohn disease develops a new fistula between the bowel and the bladder. What is the most specific symptom of this complication?

Feculent vaginal discharge
Pneumaturia (air in the urine) (Correct answer)
Persistent hematuria
Recurrent UTIs only

Correct answer: Pneumaturia (air in the urine)

Pneumaturia (passage of gas in urine) is the pathognomonic symptom of an enterovesical fistula, caused by a bowel-bladder connection.

Question 52: Which professional attribute is most valued in dermatology within the PANCE field?

Working in isolation
Avoiding challenging situations
Prioritizing personal convenience
Accountability and commitment to standards (Correct answer)

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 53: A 70-year-old male presents with insidious onset dyspnea and a dry cough over 18 months. HRCT shows honeycombing with basal predominance. Pulmonary function tests reveal a restrictive pattern. Which diagnosis is most likely?

Hypersensitivity pneumonitis
Idiopathic pulmonary fibrosis (IPF) (Correct answer)
Nonspecific interstitial pneumonia (NSIP)
Cryptogenic organizing pneumonia (COP)

Correct answer: Idiopathic pulmonary fibrosis (IPF)

IPF classically presents in older males with progressive dyspnea, basal honeycombing on HRCT, and a restrictive PFT pattern with no identifiable cause.

Question 54: A 70-year-old man on warfarin for atrial fibrillation presents with an INR of 8.5 and active GI bleeding. What is the most appropriate reversal strategy?

Fresh frozen plasma alone
Protamine sulfate IV
4-factor prothrombin complex concentrate plus vitamin K IV (Correct answer)
Vitamin K 10 mg IV alone

Correct answer: 4-factor prothrombin complex concentrate plus vitamin K IV

For life-threatening bleeding on warfarin, 4-factor PCC provides rapid reversal combined with IV vitamin K for sustained effect.

Question 55: A patient presents with sudden painless monocular vision loss lasting 10 minutes, described as a 'curtain coming down.' Fundoscopy during the episode shows a pale retina. What is the most likely diagnosis?

Optic neuritis
Amaurosis fugax due to carotid artery stenosis (Correct answer)
Acute angle-closure glaucoma
Central retinal vein occlusion

Correct answer: Amaurosis fugax due to carotid artery stenosis

Amaurosis fugax (transient monocular blindness) caused by cholesterol emboli from ipsilateral carotid artery stenosis produces the classic 'curtain' vision loss.

Question 56: A 35-year-old HIV-positive patient with a CD4 count of 50 cells/µL presents with headache, altered mental status, and a positive India ink stain of the CSF. Which medication is first-line induction therapy?

Fluconazole
Voriconazole
Caspofungin
Amphotericin B plus flucytosine (Correct answer)

Correct answer: Amphotericin B plus flucytosine

Amphotericin B plus flucytosine is the standard induction therapy for cryptococcal meningitis in HIV-positive patients, providing fungicidal activity.

Question 57: A 29-year-old pregnant woman at 28 weeks is found to have Rh-negative blood type. Her partner is Rh-positive. What is the correct management?

Administer Rh immunoglobulin at 28 weeks and within 72 hours postpartum if infant is Rh-positive (Correct answer)
Check maternal antibody titers monthly and treat if positive
No treatment needed until delivery
Administer Rh immunoglobulin only postpartum

Correct answer: Administer Rh immunoglobulin at 28 weeks and within 72 hours postpartum if infant is Rh-positive

Standard protocol is Rh immunoglobulin at 28 weeks gestation and again within 72 hours of delivery if the neonate is Rh-positive to prevent isoimmunization.

Question 58: A patient with sickle cell disease presents with acute bone pain, fever, and dactylitis. What is the most appropriate initial management?

Emergent exchange transfusion
IV fluids, oxygen, and analgesics (Correct answer)
Bone marrow transplant referral
Hydroxyurea initiation

Correct answer: IV fluids, oxygen, and analgesics

Acute vaso-occlusive crisis is managed with IV hydration, supplemental oxygen, and adequate analgesia.

Question 59: What is the most important professional competency for PANCE certification in gastrointestinal?

Ability to work alone exclusively
Memorization of all reference materials
Deep knowledge combined with practical application skills (Correct answer)
Speed of task completion

Correct answer: Deep knowledge combined with practical application skills

Professional competency requires both deep knowledge of the subject matter and the ability to apply that knowledge in practical situations.

Question 60: A patient with COPD exacerbation has a PaCO2 of 65 mmHg and pH of 7.28 despite controlled oxygen therapy. Which intervention has the strongest evidence for avoiding intubation?

Heliox therapy
IV methylxanthines
High-flow nasal cannula
Non-invasive positive pressure ventilation (NIPPV) (Correct answer)

Correct answer: Non-invasive positive pressure ventilation (NIPPV)

NIPPV (BiPAP) is first-line for hypercapnic respiratory failure in COPD exacerbation, reducing intubation rates and mortality.

Question 61: A 34-year-old G1P0 at 41 weeks gestation has a Bishop score of 3. Induction of labor is planned. Which agent is most appropriate for cervical ripening?

Oxytocin IV infusion
Amniotomy alone
Castor oil orally
Misoprostol intravaginally (Correct answer)

Correct answer: Misoprostol intravaginally

Misoprostol (PGE1 analogue) applied intravaginally is effective for cervical ripening in an unfavorable cervix (Bishop score <6) prior to labor induction.

Question 62: What is the value of continuing education in gastrointestinal for PANCE professionals?

It replaces workplace experience
It keeps professionals current with evolving standards and practices (Correct answer)
It is only needed for recertification
It is primarily a social activity

Correct answer: It keeps professionals current with evolving standards and practices

Continuing education ensures professionals stay current with the latest developments, standards, and best practices in their field.

Question 63: A 22-year-old college student presents with fever, pharyngitis, cervical lymphadenopathy, and marked fatigue. A peripheral blood smear shows atypical lymphocytes. Heterophile antibody test is positive. Which complication should be avoided during recovery?

Prolonged sun exposure
Contact sports (Correct answer)
Eating spicy foods
Swimming in chlorinated pools

Correct answer: Contact sports

Infectious mononucleosis (EBV) can cause splenomegaly, making contact sports dangerous due to risk of splenic rupture, which is the most serious complication.

Question 64: A dialysis patient develops fever, chills, and hypotension during a hemodialysis session. What is the most likely cause?

Hemolysis
Dialysis disequilibrium syndrome
Catheter-related bloodstream infection (Correct answer)
Air embolism

Correct answer: Catheter-related bloodstream infection

Fever, rigors, and hypotension during dialysis most commonly indicate catheter-related bloodstream infection.

Question 65: A patient on mechanical ventilation has high peak airway pressures but normal plateau pressures. Which condition best explains this finding?

ARDS
Kinked endotracheal tube (Correct answer)
Pulmonary fibrosis
Auto-PEEP

Correct answer: Kinked endotracheal tube

High peak with normal plateau pressure indicates increased airway resistance (not decreased compliance), classically caused by a kinked or partially obstructed ETT.

Question 66: You come across a patient who has a history of optic neuritis. What test should be ordered in order to rule out any more severe comorbid conditions?

Reticulocyte count
Magnetic resonance imaging (MRI) (Correct answer)
HIV
Lumbar puncture

Correct answer: Magnetic resonance imaging (MRI)

Optic neuritis, especially in a young adult, is a common initial manifestation of multiple sclerosis (MS), a severe demyelinating condition affecting the central nervous system. Magnetic resonance imaging (MRI) of the brain and orbits is the most appropriate test to identify characteristic demyelinating lesions, which are crucial for diagnosing or ruling out MS and guiding further management.

Question 67: A 45-year-old presents with chronic bilateral rhinorrhea, nasal congestion, and excessive sneezing, worst in spring. Nasal smear shows eosinophils. Skin-prick testing is positive for grass and tree pollens. What is first-line pharmacotherapy?

Oral decongestants
Oral antihistamines alone
Leukotriene receptor antagonists
Intranasal corticosteroids (Correct answer)

Correct answer: Intranasal corticosteroids

Intranasal corticosteroids are the most effective first-line treatment for moderate-to-severe allergic rhinitis, superior to antihistamines for nasal congestion and overall symptom control.

Question 68: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?

Thyroid function tests
Serum creatinine
Complete blood count only
Liver function tests (Correct answer)

Correct answer: Liver function tests

Valproic acid can cause hepatotoxicity (particularly in children < 2 years) and pancreatitis; LFTs and amylase/lipase should be monitored.

Question 69: A 60-year-old man presents with gynecomastia, small firm testes, and infertility. Karyotype reveals 47,XXY. Which hormone pattern is expected?

Normal FSH and LH, normal testosterone
Low FSH and LH, low testosterone
Elevated testosterone, low FSH
Elevated FSH and LH, low testosterone (Correct answer)

Correct answer: Elevated FSH and LH, low testosterone

Klinefelter syndrome causes primary testicular failure with elevated gonadotropins (FSH, LH) due to absent feedback, and low testosterone.

Question 70: A 32-year-old woman presents with pleuritic chest pain, malar rash, oral ulcers, and arthralgias. Lab work shows anti-dsDNA antibodies and low complement (C3/C4). What is the most likely diagnosis?

Systemic lupus erythematosus (SLE) (Correct answer)
Sjogren's syndrome
Mixed connective tissue disease
Rheumatoid arthritis

Correct answer: Systemic lupus erythematosus (SLE)

SLE is characterized by malar rash, oral ulcers, serositis (pleuritis), arthritis, and positive anti-dsDNA with low complement levels.

Question 71: A 5-year-old child presents with high fever, inspiratory stridor, drooling, and sitting in the 'tripod position.' Lateral neck X-ray shows the 'thumbprint sign.' Which organism is the most likely cause?

Parainfluenza virus
Moraxella catarrhalis
Haemophilus influenzae type b (Correct answer)
Staphylococcus aureus

Correct answer: Haemophilus influenzae type b

The 'thumbprint sign' on lateral neck X-ray indicates epiglottic enlargement caused by Haemophilus influenzae type b in unvaccinated children, a life-threatening emergency.

Question 72: What is the best practice for maintaining neurologic system performance over time?

Implement scheduled preventive maintenance (Correct answer)
Outsource all maintenance
Upgrade all equipment annually
Wait for failures before acting

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 73: A 45-year-old woman is brought in after a witnessed tonic-clonic seizure. She takes no medications. Blood glucose is 45 mg/dL. After dextrose administration, the seizure does not recur. What is the most appropriate next step?

Start long-term antiepileptic drug therapy
Perform emergent MRI brain
Treat underlying hypoglycemia cause; no antiepileptic drug needed (Correct answer)
Admit for 24-hour video EEG monitoring

Correct answer: Treat underlying hypoglycemia cause; no antiepileptic drug needed

A provoked seizure secondary to an identifiable metabolic cause (hypoglycemia) does not require antiepileptic drug therapy; correction of the underlying cause is sufficient.

Question 74: A 30-year-old woman with Hashimoto thyroiditis is euthyroid. She asks about her risk for other autoimmune conditions. Which condition is she at increased risk for?

Vitiligo and type 1 diabetes (Correct answer)
Cushing disease
Hyperaldosteronism
Type 2 diabetes mellitus

Correct answer: Vitiligo and type 1 diabetes

Hashimoto thyroiditis is associated with other organ-specific autoimmune diseases including type 1 DM, vitiligo, and Addison disease.

Question 75: A 52-year-old postmenopausal woman is found to have a unilocular, thin-walled 4 cm ovarian cyst on transvaginal ultrasound. CA-125 is normal. What is the most appropriate next step?

Laparoscopic biopsy
Repeat ultrasound in 6-12 weeks (Correct answer)
CT abdomen and pelvis
Immediate surgical resection

Correct answer: Repeat ultrasound in 6-12 weeks

A simple unilocular cyst ≤5 cm with normal CA-125 in a postmenopausal woman warrants surveillance with repeat ultrasound in 6-12 weeks per ACOG guidelines.

Question 76: Which of the following features best differentiates essential tremor from Parkinson tremor?

Essential tremor is an action/postural tremor that worsens at rest (Correct answer)
Essential tremor is a resting tremor that improves with intention
Essential tremor improves with levodopa
Essential tremor is associated with cogwheel rigidity

Correct answer: Essential tremor is an action/postural tremor that worsens at rest

Essential tremor is a kinetic/postural tremor that occurs during movement and is suppressed at rest, whereas Parkinson tremor is a resting 'pill-rolling' tremor.

Question 77: A 62-year-old male with a history of gout presents with acute swollen red first MTP joint. Synovial fluid analysis reveals negatively birefringent needle-shaped crystals. What is the treatment of choice for the acute attack?

Probenecid
Allopurinol
Indomethacin or colchicine (Correct answer)
Methotrexate

Correct answer: Indomethacin or colchicine

Acute gout attacks are treated with NSAIDs (e.g., indomethacin) or colchicine; urate-lowering therapy like allopurinol should not be started during an acute attack.

Question 78: A neonate is diagnosed with transposition of the great arteries. Which immediate intervention maintains cardiac output prior to surgical correction?

Prostaglandin E1 infusion (Correct answer)
IV furosemide
Digoxin
Atropine

Correct answer: Prostaglandin E1 infusion

Prostaglandin E1 keeps the ductus arteriosus patent, allowing mixing of oxygenated and deoxygenated blood until definitive arterial switch operation.

Question 79: A patient presents with sudden-onset tearing chest pain radiating to the back. CT angiography confirms a Stanford Type B aortic dissection. Initial management should include:

IV labetalol and nicardipine (Correct answer)
Emergency surgical repair
Thrombolytic therapy
Emergent pericardiocentesis

Correct answer: IV labetalol and nicardipine

Uncomplicated Type B dissections (descending aorta) are managed medically with IV beta-blockers to reduce heart rate and blood pressure, limiting propagation.

Question 80: A 35-year-old woman develops sudden-onset severe headache and is found to have markedly elevated blood pressure (240/130 mmHg) with papilledema. Which agent should be avoided?

Hydralazine IV
Nitroprusside IV (Correct answer)
Labetalol IV
Nicardipine IV

Correct answer: Nitroprusside IV

Nitroprusside is metabolized to cyanide and can increase intracranial pressure, making it problematic in hypertensive emergency with neurologic involvement.

Question 81: A 28-year-old woman presents with optic neuritis and a prior episode of transverse myelitis. MRI shows periventricular white matter lesions disseminated in time and space. Which treatment reduces long-term disability?

IV methylprednisolone indefinitely
Disease-modifying therapy (e.g., interferon beta or natalizumab) (Correct answer)
Plasmapheresis every 6 months
Prednisone taper alone

Correct answer: Disease-modifying therapy (e.g., interferon beta or natalizumab)

Disease-modifying therapies reduce relapse rate and MRI lesion burden in relapsing-remitting MS; IV steroids treat acute attacks but do not alter long-term disease course.

Question 82: A patient with cirrhosis develops confusion, asterixis, and elevated ammonia. Which intervention is most appropriate?

IV thiamine administration
Lactulose to target 2-3 soft stools per day (Correct answer)
High-protein diet supplementation
Emergent liver biopsy

Correct answer: Lactulose to target 2-3 soft stools per day

Lactulose decreases ammonia production and absorption in the gut, making it the treatment of choice for hepatic encephalopathy.

Question 83: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

Bernard-Soulier syndrome
Immune thrombocytopenic purpura (Correct answer)
DIC
Thrombotic thrombocytopenic purpura

Correct answer: Immune thrombocytopenic purpura

ITP presents with isolated thrombocytopenia and normal coagulation studies, caused by autoantibodies against platelet glycoproteins.

Question 84: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

Beta-blockers
Calcium channel blockers
ACE inhibitors (Correct answer)
Thiazide diuretics

Correct answer: ACE inhibitors

ACE inhibitors reduce intraglomerular pressure and proteinuria, slowing progression of diabetic nephropathy.

Question 85: Which one of the following is NOT a symptom of serious depression?

Mania (Correct answer)
Fatigue
Hypersomnia
Anhedonia

Correct answer: Mania

Mania is a defining characteristic of bipolar disorder, not major depressive disorder. Serious depression is typically marked by symptoms such as hypersomnia (excessive sleeping), fatigue, and anhedonia (loss of pleasure or interest). Mania, characterized by an abnormally elevated or irritable mood and increased energy, is fundamentally opposite to the depressive state.

Question 86: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

Respiratory rate <12 breaths/min
Tidal volume 6 mL/kg ideal body weight (Correct answer)
FiO2 <0.40
PEEP >15 cmH2O

Correct answer: Tidal volume 6 mL/kg ideal body weight

Low tidal volume ventilation (6 mL/kg IBW) as established by the ARDSnet trial is the most evidence-based intervention to reduce VILI and mortality.

Question 87: A 50-year-old man with a history of gout presents with acute onset of severe pain and swelling of the first MTP joint. He is on hydrochlorothiazide for hypertension. What is the best initial treatment for the acute attack?

Indomethacin (Correct answer)
Allopurinol
Probenecid
Febuxostat

Correct answer: Indomethacin

NSAIDs such as indomethacin are first-line treatment for acute gouty arthritis; urate-lowering agents like allopurinol should not be started during an acute attack.

Question 88: A 55-year-old male with alcoholism presents with confusion, ophthalmoplegia, and ataxia. What is the immediate treatment?

Thiamine IV before glucose (Correct answer)
Glucose IV bolus
Haloperidol IM
Lorazepam IV

Correct answer: Thiamine IV before glucose

Wernicke encephalopathy requires IV thiamine before glucose to prevent precipitation or worsening of the syndrome in thiamine-deficient patients.

Question 89: A 17-year-old female presents with primary amenorrhea, no breast development, and streak gonads on ultrasound. Karyotype is 45,X. Which associated cardiac defect must be screened for?

Patent ductus arteriosus
Bicuspid aortic valve and coarctation of the aorta (Correct answer)
Ventricular septal defect
Tetralogy of Fallot

Correct answer: Bicuspid aortic valve and coarctation of the aorta

Turner syndrome (45,X) is associated with bicuspid aortic valve in ~30% and coarctation of the aorta in ~10% of patients, requiring cardiac screening.

Question 90: A 55-year-old presents with a painless neck mass. Fine-needle aspiration shows squamous cell carcinoma. He has a 40 pack-year smoking history and drinks alcohol daily. Nasopharyngoscopy reveals an asymmetric, ulcerated lesion in the pyriform sinus. What is the most likely primary site?

Hypopharynx (pyriform sinus) (Correct answer)
Oropharynx (tonsil)
Supraglottic larynx
Nasopharynx

Correct answer: Hypopharynx (pyriform sinus)

Pyriform sinus carcinoma of the hypopharynx commonly presents as a painless neck mass from nodal metastasis, given the rich lymphatic drainage and late local symptoms.

Question 91: A patient on heparin for 7 days develops a platelet count drop from 240,000 to 55,000 and a new lower extremity DVT. What is the diagnosis?

Heparin-induced thrombocytopenia (Correct answer)
ITP
Drug-induced aplasia
DIC

Correct answer: Heparin-induced thrombocytopenia

HIT occurs when antibodies form against the heparin-PF4 complex, paradoxically causing platelet activation and thrombosis despite low platelet counts.

Question 92: A 50-year-old male presents with fatigue, weight loss, and splenomegaly. CBC shows WBC 120,000/µL with left shift. Philadelphia chromosome (t[9;22]) is identified. What is the diagnosis?

Acute lymphoblastic leukemia
Polycythemia vera
Chronic myelogenous leukemia (Correct answer)
Essential thrombocythemia

Correct answer: Chronic myelogenous leukemia

Chronic myelogenous leukemia (CML) is characterized by the Philadelphia chromosome (BCR-ABL fusion) and markedly elevated WBC with left shift.

Question 93: A 72-year-old man with heart failure has a BNP of 1,200 pg/mL. His ejection fraction is 30%. Which diuretic combination is preferred for decongestion?

Hydrochlorothiazide alone
Furosemide alone
Furosemide plus metolazone (Correct answer)
Spironolactone alone

Correct answer: Furosemide plus metolazone

Furosemide plus metolazone provides sequential nephron blockade, overcoming diuretic resistance common in advanced heart failure with low GFR.

Question 94: A 45-year-old farmer in Ohio presents with fever, chills, and a dry cough after cleaning a chicken coop. Chest X-ray shows hilar lymphadenopathy and diffuse small nodular infiltrates. Urine antigen test is positive. What is the diagnosis?

Histoplasmosis (Correct answer)
Coccidioidomycosis
Blastomycosis
Aspergillosis

Correct answer: Histoplasmosis

Histoplasmosis is endemic in the Ohio and Mississippi River valleys, spread by bird/bat droppings; urine antigen testing is the diagnostic method of choice.

Question 95: A patient has urine sodium of 10 mEq/L, urine osmolality 700 mOsm/kg, and elevated BUN. What is the most likely cause of AKI?

Acute tubular necrosis
Prerenal azotemia (Correct answer)
Glomerulonephritis
Postrenal obstruction

Correct answer: Prerenal azotemia

Low urine sodium and high urine osmolality indicate intact tubular function with appropriate sodium conservation, consistent with prerenal AKI.

Question 96: A 55-year-old presents with flank pain, gross hematuria, and a palpable mass. CT reveals a solid renal mass. What is the most likely diagnosis?

Transitional cell carcinoma
Renal cell carcinoma (Correct answer)
Angiomyolipoma
Nephroblastoma

Correct answer: Renal cell carcinoma

Renal cell carcinoma classically presents with the triad of hematuria, flank pain, and a palpable mass in adults.

Question 97: A 70-year-old woman presents with confusion, fever, and flank pain. Urinalysis shows pyuria and bacteriuria. Blood cultures are positive. She has a penicillin allergy (rash). Which antibiotic is most appropriate for gram-negative bacteremia?

Ciprofloxacin 400 mg IV (Correct answer)
Ampicillin-sulbactam IV
Clindamycin 900 mg IV
Vancomycin 15 mg/kg IV

Correct answer: Ciprofloxacin 400 mg IV

Ciprofloxacin IV is an appropriate alternative for gram-negative bacteremia (urosepsis) in patients with penicillin allergy, as fluoroquinolones cover common urinary gram-negative pathogens.

Question 98: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

Take at bedtime to reduce GI side effects
Take with calcium supplements simultaneously
Take with food to improve absorption
Take with a full glass of water and remain upright for 30 minutes (Correct answer)

Correct answer: Take with a full glass of water and remain upright for 30 minutes

Bisphosphonates must be taken with a full glass of water and the patient must remain upright for at least 30 minutes to prevent esophageal irritation.

Question 99: A 45-year-old male presents with acute monoarticular arthritis of the first MTP joint, red/hot/swollen, after a celebratory dinner. Arthrocentesis shows negatively birefringent needle-shaped crystals. What is the acute treatment?

Probenecid
Indomethacin or colchicine (Correct answer)
Methotrexate
Allopurinol

Correct answer: Indomethacin or colchicine

Acute gout is treated with NSAIDs (indomethacin), colchicine, or corticosteroids; urate-lowering agents like allopurinol are not started during acute attacks.

Question 100: A 45-year-old man with HIV (CD4 count 80 cells/μL) presents with painless, papular, violaceous lesions on his lower extremities and oral mucosa. What is the causative organism?

Human papillomavirus
Cytomegalovirus
Human herpesvirus 8 (HHV-8) (Correct answer)
Epstein-Barr virus

Correct answer: Human herpesvirus 8 (HHV-8)

Kaposi sarcoma in HIV-infected individuals is caused by HHV-8 (KSHV) and presents as violaceous vascular tumors, particularly at low CD4 counts.

Question 101: Which medication must be held when GFR falls below 30 mL/min due to risk of lactic acidosis?

Lisinopril
Atorvastatin
Metformin (Correct answer)
Amlodipine

Correct answer: Metformin

Metformin accumulates in severe CKD and inhibits hepatic mitochondrial respiration, causing life-threatening lactic acidosis.

Question 102: Which lab pattern is most consistent with prerenal azotemia?

WBC casts with low urine osmolality
Muddy brown casts with urine sodium >40 mEq/L
BUN:Cr ratio <10:1 with urine sodium >40 mEq/L
BUN:Cr ratio >20:1 with urine sodium <20 mEq/L (Correct answer)

Correct answer: BUN:Cr ratio >20:1 with urine sodium <20 mEq/L

Prerenal azotemia shows a BUN:Cr >20:1 and low urine sodium as the kidneys avidly retain sodium to restore perfusion.

Question 103: A 40-year-old presents with unilateral progressive sensorineural hearing loss, high-frequency tinnitus, and unsteadiness. MRI with gadolinium shows an enhancing cerebellopontine angle mass. What is the most likely diagnosis?

Meningioma
Facial nerve hemangioma
Vestibular schwannoma (acoustic neuroma) (Correct answer)
Epidermoid cyst

Correct answer: Vestibular schwannoma (acoustic neuroma)

Vestibular schwannoma arises from the Schwann cells of CN VIII at the internal auditory canal, presenting with unilateral sensorineural hearing loss, tinnitus, and imbalance.

Question 104: A 50-year-old man presents with multiple velvety, brown-black warty plaques on his trunk that appear 'stuck on.' They have a cerebriform surface and vary in size. What is the diagnosis?

Pigmented basal cell carcinoma
Actinic keratosis
Verruca vulgaris
Seborrheic keratosis (Correct answer)

Correct answer: Seborrheic keratosis

Seborrheic keratoses are benign, pigmented, warty growths with a 'stuck-on' appearance and horn pseudocysts on dermoscopy; they require no treatment unless symptomatic.

Question 105: A 14-year-old male presents with knee pain and a tender tibial tubercle that is worse with activity. No joint effusion. What is the diagnosis?

Legg-Calvé-Perthes disease
Osgood-Schlatter disease (Correct answer)
Patellar tendinopathy
Slipped capital femoral epiphysis

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle in adolescents during growth spurts, presenting with localized tenderness and swelling.

Question 106: A 38-year-old woman is diagnosed with BRCA1 mutation. She has completed childbearing. Which risk-reduction strategy has the greatest absolute reduction in ovarian cancer risk?

Oral contraceptive use for 5 years
Risk-reducing bilateral salpingo-oophorectomy (Correct answer)
Annual pelvic ultrasound and CA-125 screening
Prophylactic tamoxifen

Correct answer: Risk-reducing bilateral salpingo-oophorectomy

Risk-reducing bilateral salpingo-oophorectomy reduces ovarian cancer risk by >95% in BRCA1 carriers and is the most effective prevention strategy.

Question 107: A 60-year-old man on lithium for 15 years presents with polyuria and polydipsia. Urine osmolality remains low after water deprivation but increases after desmopressin. What is the diagnosis?

SIADH
Central diabetes insipidus (Correct answer)
Primary polydipsia
Nephrogenic diabetes insipidus

Correct answer: Central diabetes insipidus

Response to desmopressin indicates central (not nephrogenic) DI; lithium can cause nephrogenic DI, but response to ADH analog points to central.

Question 108: A 70-year-old woman presents with sudden painless vision loss in one eye described as 'a curtain coming down.' Fundoscopy shows a pale retina with a cherry-red spot at the macula. What is the diagnosis?

Retinal vein occlusion
Vitreous hemorrhage
Central retinal artery occlusion (Correct answer)
Retinal detachment

Correct answer: Central retinal artery occlusion

Central retinal artery occlusion presents with sudden painless vision loss, pale ischemic retina, and cherry-red spot at the fovea.

Question 109: A 55-year-old man with type 2 diabetes and a history of heart failure with reduced ejection fraction (HFrEF) needs better glycemic control. Which agent provides the most cardiovascular benefit?

Empagliflozin (SGLT-2 inhibitor) (Correct answer)
Sitagliptin
Pioglitazone
Glipizide

Correct answer: Empagliflozin (SGLT-2 inhibitor)

SGLT-2 inhibitors like empagliflozin have demonstrated significant reduction in HF hospitalizations and cardiovascular mortality in patients with HFrEF.

Question 110: What is the primary consideration when implementing changes to neurologic system?

Impact assessment and change management (Correct answer)
Personal convenience
Speed of implementation
Vendor preference

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 111: A 45-year-old male with ankylosing spondylitis has back pain unresponsive to two NSAIDs after 3 months. What is the next appropriate treatment?

Switch to a TNF inhibitor (Correct answer)
Add methotrexate
Increase NSAID dose indefinitely
Add hydroxychloroquine

Correct answer: Switch to a TNF inhibitor

TNF inhibitors (e.g., adalimumab, etanercept) are the next step in ankylosing spondylitis after failure of NSAIDs, as conventional DMARDs are not effective for axial disease.

Question 112: A 40-year-old man presents with recurrent painful oral aphthous ulcers, genital ulcerations, and uveitis. Which additional finding would confirm the diagnosis of Behçet disease?

HLA-B27 positivity
Anti-dsDNA antibodies
Positive ANA titer
Positive pathergy test (Correct answer)

Correct answer: Positive pathergy test

A positive pathergy test (formation of a papule or pustule after minor skin injury) supports the diagnosis of Behçet disease along with oral/genital ulcers and uveitis.

Question 113: A 45-year-old guy is being checked because he feels weak and weary and has experienced indications of sexual dysfunction. The reading is 100/60 mmHg for him. Physical examination reveals thinning pubic, axillary, and facial hair. Laboratory tests reveal lower levels of testosterone, thyroxine, and the luteinizing and follicle-stimulating hormones; the thyroid-stimulating hormone level is within acceptable ranges. Which of the subsequent diagnoses is most likely?

Hyperprolactinemia
Diabetes mellitus
Hypothyroidism
Hypopituitarism (Correct answer)

Correct answer: Hypopituitarism

The p-value is a statistical measure that helps determine whether the observed results in a clinical trial are statistically significant. It represents the probability of obtaining results as extreme as, or more extreme than, the observed results, assuming the null hypothesis (no effect or difference) is true. A low p-value (typically <0.05) indicates that the results are unlikely to be due to chance, suggesting statistical significance.

Question 114: A 3-year-old boy is brought in for evaluation of a painless scrotal mass. Transillumination is positive. What is the most likely diagnosis?

Inguinal hernia
Hydrocele (Correct answer)
Epididymitis
Testicular torsion

Correct answer: Hydrocele

A hydrocele is a fluid-filled sac around the testis that transilluminates and is typically painless in young children.

Question 115: A 24-year-old woman on combined oral contraceptives for 3 years presents for a routine visit. Which absolute contraindication should prompt you to discontinue her OCP?

History of migraine with aura (Correct answer)
Irregular menstrual cycles
Mild migraines without aura
Family history of ovarian cancer

Correct answer: History of migraine with aura

Migraine with aura is an absolute contraindication to combined estrogen-containing contraceptives due to increased risk of ischemic stroke.

Question 116: A 6-year-old child presents with a single circular patch of hair loss on the scalp with broken-off hairs at the scalp surface ('black dots') and mild scaling. Wood's lamp examination is negative. What is the treatment of choice?

Topical selenium sulfide shampoo alone
Topical terbinafine cream
Oral griseofulvin (Correct answer)
Intralesional triamcinolone

Correct answer: Oral griseofulvin

Tinea capitis requires oral antifungal therapy (griseofulvin or terbinafine) because topical agents cannot penetrate the hair follicle adequately.

Question 117: A newborn develops erythematous macules and papules with surrounding flares on the trunk and extremities within 24–48 hours of birth. Wright stain of pustule contents shows eosinophils. What is the diagnosis?

Transient neonatal pustular melanosis
Neonatal herpes simplex
Miliaria rubra
Erythema toxicum neonatorum (Correct answer)

Correct answer: Erythema toxicum neonatorum

Erythema toxicum neonatorum is a benign, self-limiting rash in newborns characterized by eosinophil-filled pustules on Wright stain, requiring no treatment.

Question 118: A 25-year-old woman presents with fever, bilateral joint pain (wrists, knees), skin lesions (pustules on erythematous base), and tenosynovitis of the right hand. Cervical cultures are positive. What is the most appropriate treatment?

Azithromycin 1 g PO single dose
Ceftriaxone 1 g IV/IM daily × 7 days (Correct answer)
Penicillin V 500 mg PO QID × 10 days
Doxycycline 100 mg PO BID × 7 days

Correct answer: Ceftriaxone 1 g IV/IM daily × 7 days

Disseminated gonococcal infection (DGI) causing septic arthritis-dermatitis syndrome is treated with ceftriaxone 1 g IV/IM daily for 7 days.

Question 119: A 30-year-old presents with recurrent episodes of severe unilateral eye pain, redness, and halos around lights. Each episode lasts 2-3 hours and resolves spontaneously. IOP during an attack is 45 mmHg. What is the treatment of choice for long-term prevention?

Laser peripheral iridotomy (Correct answer)
Systemic acetazolamide indefinitely
Trabeculectomy
Topical timolol daily

Correct answer: Laser peripheral iridotomy

Laser peripheral iridotomy creates an opening in the iris to relieve pupillary block and prevent recurrent acute angle-closure glaucoma attacks.

Question 120: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

Yolk sac tumor (Correct answer)
Embryonal carcinoma
Seminoma
Leydig cell tumor

Correct answer: Yolk sac tumor

Yolk sac tumors (endodermal sinus tumors) are the most common testicular tumor in young males and are associated with markedly elevated AFP.

Question 121: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?

Left circumflex artery
Right coronary artery (Correct answer)
Left main coronary artery
Left anterior descending artery

Correct answer: Right coronary artery

The right coronary artery supplies the inferior wall, SA node, and AV node; its occlusion causes inferior STEMI with bradycardia and hypotension.

Question 122: A newborn fails to pass meconium within 48 hours of birth. Abdominal X-ray shows a distended colon with a transition zone. Rectal biopsy confirms absence of ganglion cells. What is the diagnosis?

Hirschsprung disease (Correct answer)
Imperforate anus
Anal stenosis
Meconium ileus

Correct answer: Hirschsprung disease

Hirschsprung disease is caused by absence of enteric ganglion cells (neural crest migration failure) resulting in a functional obstruction and failure to pass meconium.

Question 123: Which of the following drugs would not be recommended for a glaucoma patient to take?

Montelukast
Amitriptyline (Correct answer)
Levothyroxine
Travoprost

Correct answer: Amitriptyline

Amitriptyline, a tricyclic antidepressant, has anticholinergic properties that can cause pupillary dilation (mydriasis). This dilation can narrow the anterior chamber angle in susceptible individuals, potentially precipitating or worsening angle-closure glaucoma. Therefore, anticholinergic medications like amitriptyline are generally contraindicated or used with extreme caution in patients with glaucoma.

Question 124: A patient develops oliguria and elevated creatinine after aminoglycoside therapy. Urinalysis shows muddy brown granular casts. What is the diagnosis?

Acute tubular necrosis (Correct answer)
Acute interstitial nephritis
Prerenal azotemia
Contrast nephropathy

Correct answer: Acute tubular necrosis

Aminoglycoside nephrotoxicity causes direct tubular injury, producing the classic muddy brown granular casts of ATN.

Question 125: A 42-year-old woman is found to have a blood pressure of 176/108 mmHg. She reports episodic severe headaches, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. What is the first step in management after diagnosis?

Start calcium channel blocker and schedule surgery
Start beta-blocker immediately
Start alpha-blocker (phenoxybenzamine) first, then add beta-blocker if needed (Correct answer)
Proceed directly to surgical adrenalectomy

Correct answer: Start alpha-blocker (phenoxybenzamine) first, then add beta-blocker if needed

In pheochromocytoma, alpha-blockade must precede beta-blockade to prevent unopposed alpha-mediated hypertensive crisis.

Question 126: What is the best practice for maintaining pulmonary system performance over time?

Outsource all maintenance
Implement scheduled preventive maintenance (Correct answer)
Upgrade all equipment annually
Wait for failures before acting

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 127: A 16-year-old girl presents with primary amenorrhea. Physical exam shows normal female external genitalia but absence of pubic and axillary hair. Karyotype is 46,XY. What is the most likely diagnosis?

Turner syndrome
Congenital adrenal hyperplasia
Mayer-Rokitansky-Küster-Hauser syndrome
Complete androgen insensitivity syndrome (Correct answer)

Correct answer: Complete androgen insensitivity syndrome

Complete androgen insensitivity syndrome (46,XY) presents with female phenotype, absent uterus, and absent body hair due to inability of cells to respond to androgens.

Question 128: A 16-year-old girl presents with pruritic vesicles on her fingers, palms, and soles that seem to 'taper' deep into the skin. The condition worsens in summer. What is the diagnosis?

Tinea pedis
Scabies
Dyshidrotic eczema (pompholyx) (Correct answer)
Contact dermatitis

Correct answer: Dyshidrotic eczema (pompholyx)

Dyshidrotic eczema (pompholyx) presents with intensely pruritic, deep-seated vesicles on the palms, soles, and lateral fingers, often triggered by heat and sweating.

Question 129: A 70-year-old woman with osteoporosis is found to have a serum calcium of 10.9 mg/dL and PTH-related peptide (PTHrP) elevated. PTH is suppressed. What is the most likely etiology?

Vitamin D intoxication
Primary hyperparathyroidism
Humoral hypercalcemia of malignancy (Correct answer)
Familial hypocalciuric hypercalcemia

Correct answer: Humoral hypercalcemia of malignancy

Elevated PTHrP with suppressed PTH in an elderly patient suggests humoral hypercalcemia of malignancy.

Question 130: A 55-year-old man with a history of alcohol use disorder presents with painless jaundice, clay-colored stools, and dark urine. Ultrasound shows dilation of the common bile duct. What is the most likely cause?

Pancreatic head carcinoma (Correct answer)
Choledocholithiasis
Primary sclerosing cholangitis
Alcoholic hepatitis

Correct answer: Pancreatic head carcinoma

Painless obstructive jaundice with dilated CBD in an older patient is the classic presentation of pancreatic head carcinoma compressing the bile duct.

Question 131: A 31-year-old man and his partner have been trying to conceive for 18 months. Semen analysis shows count 8 million/mL, motility 25%, normal morphology 3%. Which condition should be excluded first?

Klinefelter syndrome
Retrograde ejaculation
Congenital absence of vas deferens
Varicocele (Correct answer)

Correct answer: Varicocele

Varicocele is the most common correctable cause of male infertility and should be the first diagnosis excluded with scrotal ultrasound and physical exam.

Question 132: What role does collaboration play in gastrointestinal for PANCE professionals?

It is only needed in emergencies
It slows down work unnecessarily
It enhances outcomes through diverse perspectives and shared expertise (Correct answer)
It reduces individual accountability

Correct answer: It enhances outcomes through diverse perspectives and shared expertise

Collaboration leverages diverse perspectives and combined expertise to achieve better outcomes than any individual could alone.

Question 133: A neonate born at 32 weeks develops respiratory distress immediately after birth with grunting, flaring, and retractions. CXR shows diffuse ground-glass opacities. What is the pathophysiology?

Meconium aspiration
Surfactant deficiency (Correct answer)
Congenital pneumonia
Transient tachypnea of the newborn

Correct answer: Surfactant deficiency

Respiratory distress syndrome (RDS) in premature neonates results from surfactant deficiency, causing diffuse atelectasis and ground-glass appearance on CXR.

Question 134: A 40-year-old woman presents with right upper quadrant pain after fatty meals, fever of 38.8°C, and jaundice. What is the most likely diagnosis?

Ascending cholangitis (Correct answer)
Choledocholithiasis
Acute cholecystitis
Hepatitis A

Correct answer: Ascending cholangitis

Charcot's triad of RUQ pain, fever, and jaundice is pathognomonic for ascending cholangitis caused by biliary obstruction and infection.

Question 135: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?

Decreased DLCO with normal spirometry
Flattening of both inspiratory and expiratory loops on flow-volume curve (Correct answer)
Decreased FEV1/FVC with normal TLC
Increased RV with normal FEV1/FVC

Correct answer: Flattening of both inspiratory and expiratory loops on flow-volume curve

Fixed upper airway obstruction flattens both the inspiratory and expiratory limbs of the flow-volume loop due to fixed resistance regardless of effort.

Question 136: A 50-year-old presents with progressive hearing loss and a mass behind the ear with pulsatile tinnitus. CT shows a destructive lesion at the jugular foramen. What is the most likely diagnosis?

Cholesteatoma
Glomus jugulare tumor (Correct answer)
Acoustic neuroma
Meningioma

Correct answer: Glomus jugulare tumor

Glomus jugulare tumors are paragangliomas arising from the jugular bulb, presenting with pulsatile tinnitus and lower cranial nerve deficits with jugular foramen destruction on imaging.

Question 137: When examining a patient who has known benign prostatic hyperplasia, what would you anticipate finding?

Rubbery prostate with digital rectal exam (Correct answer)
Patient report of painful urination
Fever and elevated white blood cell count (WBC)
Hard, nodular prostate with digital rectal exam

Correct answer: Rubbery prostate with digital rectal exam

Benign prostatic hyperplasia (BPH) involves a non-cancerous enlargement of the prostate gland. During a digital rectal exam (DRE), a prostate affected by BPH typically feels symmetrically enlarged, smooth, and rubbery. A hard, nodular prostate would be a more concerning finding, suggestive of prostate cancer.

Question 138: A 50-year-old presents with symmetric ascending weakness starting in the legs 2 weeks after a GI illness. Deep tendon reflexes are absent. CSF shows elevated protein with normal cell count (albuminocytologic dissociation). What is the diagnosis?

Guillain-Barré syndrome (Correct answer)
Multiple sclerosis
ALS
Myasthenia gravis

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome is an autoimmune demyelinating polyneuropathy characterized by ascending weakness, areflexia, and albuminocytologic dissociation in CSF.

Question 139: A 48-year-old on amiodarone for 3 years develops new bilateral pulmonary infiltrates and worsening PFTs. Which mechanism best explains amiodarone pulmonary toxicity?

Obstructive bronchiolitis from mucosal deposition
Granulomatous inflammation identical to sarcoidosis
IgE-mediated hypersensitivity reaction
Direct phospholipid accumulation and oxidative injury (Correct answer)

Correct answer: Direct phospholipid accumulation and oxidative injury

Amiodarone and its metabolite desethylamiodarone accumulate in lysosomes, causing phospholipidosis and oxidative lung injury.

Question 140: A 55-year-old woman is found to have a diastolic murmur at the left sternal border that increases with inspiration. What is the most likely diagnosis?

Mitral stenosis
Tricuspid stenosis
Pulmonary regurgitation (Correct answer)
Aortic regurgitation

Correct answer: Pulmonary regurgitation

Pulmonary regurgitation produces a diastolic murmur at the left sternal border that increases with inspiration (Carvallo sign) due to increased right-sided flow.

Question 141: A patient with a distal radius fracture develops loss of thumb opposition and thenar atrophy 3 months after casting. Which nerve is involved?

Ulnar nerve
Radial nerve
Median nerve (Correct answer)
Anterior interosseous nerve

Correct answer: Median nerve

The median nerve innervates the thenar muscles and provides thumb opposition; it can be compressed in carpal tunnel syndrome, which is a known complication of distal radius fractures.

Question 142: A 68-year-old man presents with sudden onset of left-sided weakness and slurred speech that resolved completely within 45 minutes. MRI shows no infarct. What is the most appropriate next step?

Admit for urgent evaluation and stroke risk stratification (Correct answer)
Start aspirin and statin, arrange outpatient follow-up in 1 week
Order CT head without contrast only
Discharge with carotid ultrasound scheduled in 2 weeks

Correct answer: Admit for urgent evaluation and stroke risk stratification

TIA carries high early stroke risk; urgent inpatient or rapid outpatient evaluation within 24 hours with ABCD2 scoring, imaging, and cardiac monitoring is indicated.

Question 143: A patient with type 2 diabetes and CKD stage 3 requires glucose-lowering therapy. Which agent is contraindicated due to risk of lactic acidosis?

Metformin (Correct answer)
Glipizide
Empagliflozin
Sitagliptin

Correct answer: Metformin

Metformin is contraindicated when eGFR is below 30 mL/min due to risk of lactic acidosis from impaired renal clearance.

Question 144: A 22-year-old female presents with joint pain, a butterfly rash, and oral ulcers. Labs show positive ANA, anti-dsDNA, and low complement levels. What is the most likely diagnosis?

Sjögren syndrome
Systemic lupus erythematosus (Correct answer)
Dermatomyositis
Rheumatoid arthritis

Correct answer: Systemic lupus erythematosus

SLE is confirmed by anti-dsDNA antibodies, low complement, malar rash, arthritis, and oral ulcers meeting ACR criteria.

Question 145: A 55-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows grade 1 endometrioid adenocarcinoma. Which is the most significant risk factor she likely has?

BRCA2 mutation
Chronic pelvic inflammatory disease
Prior tamoxifen use
Unopposed estrogen exposure (Correct answer)

Correct answer: Unopposed estrogen exposure

Unopposed estrogen exposure (obesity, anovulation, exogenous estrogen without progesterone) is the most common risk factor for type I endometrioid endometrial carcinoma.

Question 146: A 45-year-old woman presents with acute onset of right upper quadrant pain, fever, and jaundice. Her labs show elevated total bilirubin, alkaline phosphatase, and WBC of 18,000. What is the most likely diagnosis?

Acute cholecystitis
Ascending cholangitis (Correct answer)
Pancreatitis
Acute hepatitis

Correct answer: Ascending cholangitis

Charcot's triad (RUQ pain, fever, jaundice) is classic for ascending cholangitis, indicating biliary obstruction with infection.

Question 147: A 35-year-old patient with HIV (CD4 count 150 cells/µL) presents with painless white plaques on the lateral tongue that cannot be scraped off. What is the most likely diagnosis?

Lichen planus
Oral candidiasis (thrush)
Oral hairy leukoplakia (Correct answer)
Aphthous ulcers

Correct answer: Oral hairy leukoplakia

Oral hairy leukoplakia, caused by EBV reactivation, appears as non-removable white plaques on the lateral tongue and is an AIDS-defining condition marker in HIV patients.

Question 148: A 45-year-old patient presents with sudden painless vision loss in one eye described as a 'curtain coming down.' Fundoscopic exam reveals a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

Retinal detachment
Vitreous hemorrhage
Central retinal vein occlusion
Central retinal artery occlusion (Correct answer)

Correct answer: Central retinal artery occlusion

Central retinal artery occlusion presents with sudden painless monocular vision loss, pale retina with cherry-red macula due to ischemia from loss of blood supply.

Question 149: A 25-year-old woman has an intensely pruritic, vesicular rash on the extensor surfaces of her elbows and knees. IgA deposits are found at the dermal-epidermal junction. What is the associated systemic condition?

Celiac disease (Correct answer)
Crohn disease
Type 1 diabetes mellitus
Systemic lupus erythematosus

Correct answer: Celiac disease

Dermatitis herpetiformis with IgA deposits is strongly associated with celiac disease (gluten-sensitive enteropathy).

Question 150: A 60-year-old with poorly controlled diabetes presents with right-sided facial pain, purulent nasal discharge, and black necrotic tissue visible in the nasal cavity. CT shows bony erosion of the turbinates. What organism is most likely responsible?

Mucor species (Correct answer)
Aspergillus fumigatus
Pseudomonas aeruginosa
Staphylococcus aureus

Correct answer: Mucor species

Mucormycosis (rhino-orbital-cerebral) is a life-threatening fungal infection in diabetics and immunocompromised patients, causing black necrotic tissue and bony invasion.

Question 151: A 55-year-old man presents with claudication. Doppler shows ABI of 0.72 at rest, dropping to 0.45 post-exercise. What is the first-line treatment?

Supervised exercise therapy and cilostazol (Correct answer)
Compression stockings
Warfarin anticoagulation
Immediate revascularization

Correct answer: Supervised exercise therapy and cilostazol

Supervised exercise rehabilitation plus cilostazol (a phosphodiesterase inhibitor) is first-line for claudication from PAD, improving walking distance and quality of life.

Question 152: A 50-year-old woman presents with shoulder pain and inability to abduct the arm past 90 degrees. MRI shows a full-thickness supraspinatus tear. What is the most appropriate initial management?

Physical therapy and NSAIDs for 6-12 weeks (Correct answer)
Corticosteroid injection only
Immediate surgical repair
Sling immobilization for 8 weeks

Correct answer: Physical therapy and NSAIDs for 6-12 weeks

Most rotator cuff tears are initially managed conservatively with physical therapy and anti-inflammatory medications; surgery is reserved for refractory cases or large acute tears.

Question 153: How does donepezil function when used to treat Alzheimer's disease?

Acetylcholinesterase inhibitor (Correct answer)
Glutamate antagonist
Acetyl/butyryl cholinesterase inhibitor
Cholinesterase and nicotinic receptor stimulation modulator

Correct answer: Acetylcholinesterase inhibitor

Donepezil is an acetylcholinesterase inhibitor. It works by preventing the breakdown of acetylcholine, a neurotransmitter crucial for memory and learning, in the brain. By increasing the availability of acetylcholine, donepezil helps to improve cholinergic function and alleviate some cognitive symptoms associated with Alzheimer's disease.

Question 154: A 38-year-old man presents with recurrent kidney stones. 24-hour urine shows elevated uric acid. He has a history of gout. What is the most appropriate long-term preventive measure for his kidney stones?

Increase dietary protein intake
Urinary alkalinization with potassium citrate and allopurinol (Correct answer)
Restrict fluid intake
Start hydrochlorothiazide

Correct answer: Urinary alkalinization with potassium citrate and allopurinol

Uric acid stones form in acidic urine; urinary alkalinization with potassium citrate raises urine pH to dissolve/prevent stones, and allopurinol reduces uric acid production.

Question 155: Which of the following is the gold standard for diagnosing esophageal motility disorders such as achalasia?

Barium swallow esophagram
CT scan of the chest
Upper endoscopy
Esophageal manometry (Correct answer)

Correct answer: Esophageal manometry

Esophageal manometry is the definitive test for diagnosing achalasia, showing absence of peristalsis and failure of the LES to relax.

Question 156: A 63-year-old woman with known CAD presents 30 minutes after onset of crushing chest pain. EKG shows 3 mm ST elevation in leads II, III, aVF. Door-to-balloon time capability is 45 minutes. Best treatment?

Thrombolytics (tPA)
Heparin drip alone
Urgent CABG
Primary percutaneous coronary intervention (PCI) (Correct answer)

Correct answer: Primary percutaneous coronary intervention (PCI)

Primary PCI is the preferred reperfusion strategy for STEMI when door-to-balloon time is ≤90 minutes, offering superior outcomes over thrombolytics.

Question 157: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

Vitamin D
Vitamin B12
Vitamin C (Correct answer)
Vitamin K

Correct answer: Vitamin C

Vitamin C deficiency (scurvy) impairs collagen synthesis, causing perifollicular hemorrhage, gingival bleeding, and corkscrew hairs.

Question 158: A patient with recurrent DVT has a prolonged aPTT that does not correct with a 1:1 mixing study. What is the most likely diagnosis?

Heparin contamination
Factor VIII deficiency
Hemophilia A
Antiphospholipid syndrome (Correct answer)

Correct answer: Antiphospholipid syndrome

Failure to correct on mixing study indicates an inhibitor; lupus anticoagulant in antiphospholipid syndrome is the most common cause.

Question 159: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

Iron deficiency secondary to venesection
Uremic pruritus from secondary erythrocytosis
Histamine release from basophils and mast cells triggered by water (Correct answer)
Dry skin from hyperviscosity

Correct answer: Histamine release from basophils and mast cells triggered by water

Aquagenic pruritus in PV is caused by histamine release from increased basophils and mast cells upon water contact.

Question 160: A 15-year-old presents with bilateral nasal polyps. No history of asthma or aspirin sensitivity. A sweat chloride test is ordered. What underlying condition is being screened for?

Primary ciliary dyskinesia
Churg-Strauss vasculitis
Cystic fibrosis (Correct answer)
Allergic rhinitis

Correct answer: Cystic fibrosis

Bilateral nasal polyps in a child or adolescent should prompt evaluation for cystic fibrosis, as nasal polyposis occurs in up to 50% of CF patients.

Question 161: A 68-year-old presents with gradual bilateral vision loss. Fundoscopic exam reveals drusen deposits and geographic atrophy in the macular region but no hemorrhage or exudate. What type of macular degeneration does this represent?

Dry (atrophic) AMD (Correct answer)
Wet (exudative) AMD
Diabetic macular edema
Central serous chorioretinopathy

Correct answer: Dry (atrophic) AMD

Dry AMD is characterized by drusen and geographic atrophy without neovascularization or hemorrhage; it accounts for 90% of AMD cases and progresses slowly.

Question 162: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?

Bisphosphonate plus calcium and vitamin D (Correct answer)
Calcium and vitamin D alone
Teriparatide alone
Raloxifene

Correct answer: Bisphosphonate plus calcium and vitamin D

Glucocorticoid-induced osteoporosis is prevented and treated with bisphosphonate therapy plus calcium and vitamin D supplementation for patients on chronic steroids.

Question 163: A 60-year-old woman presents with proximal muscle weakness affecting her hips and shoulders, difficulty rising from a chair, and elevated CK and aldolase. ANA and anti-Jo-1 are positive. What is the diagnosis?

Polymyositis (Correct answer)
Fibromyalgia
Myasthenia gravis
Polymyalgia rheumatica

Correct answer: Polymyositis

Polymyositis presents with proximal muscle weakness, elevated muscle enzymes (CK, aldolase), and positive anti-Jo-1 antibodies in an inflammatory myopathy.

Question 164: A 48-year-old woman with a history of breast cancer presents with severe back pain and new bilateral leg weakness with bowel/bladder incontinence. What is the most urgent next step?

Empiric corticosteroids and discharge
Outpatient MRI in 2 weeks
Lumbar X-ray
Emergency MRI of the spine and neurosurgical consult (Correct answer)

Correct answer: Emergency MRI of the spine and neurosurgical consult

Malignant spinal cord compression is a surgical emergency requiring immediate MRI and neurosurgical evaluation to prevent permanent neurological deficits.

Question 165: A 40-year-old woman presents with heat intolerance, weight loss, tremor, and TSH <0.01 mIU/L with elevated free T4. Radioiodine uptake is diffusely increased. What is the preferred long-term treatment option in a non-pregnant patient?

Radioactive iodine (RAI) ablation (Correct answer)
IV methimazole
Thyroidectomy only
Propranolol alone

Correct answer: Radioactive iodine (RAI) ablation

RAI ablation is the preferred definitive treatment for Graves disease in non-pregnant adults in the US.

Question 166: In PANCE certification, what does redundancy in system design primarily provide?

Increased complexity
Fault tolerance and high availability (Correct answer)
Lower initial cost
Simplified maintenance

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 167: A 25-year-old man presents with bilateral cryptorchidism corrected at age 4 and now seeks fertility counseling. What is the most appropriate initial test?

Scrotal ultrasound
Testicular biopsy
Semen analysis (Correct answer)
Serum testosterone level

Correct answer: Semen analysis

Semen analysis is the first-line test for evaluating male fertility because it directly assesses sperm count, motility, and morphology.

Question 168: A patient develops worsening hypoxemia 48 hours after an aspiration event. CXR shows bilateral infiltrates with no evidence of cardiogenic edema. PaO2/FiO2 ratio is 150. How is this classified?

Acute lung injury (ALI)
Moderate ARDS
Mild ARDS
Severe ARDS (Correct answer)

Correct answer: Severe ARDS

Per Berlin definition, severe ARDS is defined by a PaO2/FiO2 ratio ≤100 mmHg with PEEP ≥5 cmH2O; PaO2/FiO2 of 150 classifies as moderate (100-200).

Question 169: Which approach is recommended for troubleshooting pulmonary system issues?

Rely solely on past experience
Wait for the problem to resolve itself
Replace all components simultaneously
Use systematic isolation and testing methods (Correct answer)

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 170: A 3-year-old presents with vesicles on an erythematous base in a dermatomal distribution on the trunk. The child's mother has active chickenpox. What is the most likely diagnosis?

Herpes zoster (shingles)
Hand-foot-mouth disease
Primary varicella (chickenpox) (Correct answer)
Eczema herpeticum

Correct answer: Primary varicella (chickenpox)

A young child exposed to varicella presenting with vesicles on an erythematous base is most consistent with primary varicella (chickenpox), not zoster (which requires prior VZV infection).

Question 171: A 55-year-old presents with slowly progressive dyspnea, pleural plaques on CT, and a restrictive pattern on PFTs. He worked in shipbuilding for 30 years. Which lung cancer type carries the highest risk in this patient?

Small cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Mesothelioma (Correct answer)

Correct answer: Mesothelioma

Asbestos exposure is the primary risk factor for malignant pleural mesothelioma, with pleural plaques being a marker of significant prior exposure.

Question 172: A 35-year-old G2P1 at 36 weeks gestation presents with painless bright red vaginal bleeding. Fetal heart tones are reassuring. What is the most likely diagnosis?

Placental abruption
Placenta previa (Correct answer)
Vasa previa
Uterine rupture

Correct answer: Placenta previa

Painless bright red vaginal bleeding in the third trimester is the hallmark of placenta previa, where the placenta overlies the cervical os.

Question 173: A 45-year-old obese woman presents with episodic RUQ pain after eating, with ultrasound showing gallstones but no wall thickening or pericholecystic fluid. What is the diagnosis?

Acute cholecystitis
Cholangitis
Biliary colic (Correct answer)
Choledocholithiasis

Correct answer: Biliary colic

Biliary colic presents with episodic RUQ pain triggered by fatty meals, but unlike acute cholecystitis, there is no fever, prolonged pain, or sonographic signs of inflammation.

Question 174: Which urine finding best differentiates nephritic syndrome from nephrotic syndrome?

RBC casts (Correct answer)
Protein >3.5 g/day
Oval fat bodies
Waxy casts

Correct answer: RBC casts

RBC casts indicate glomerular hematuria from inflammation and are the hallmark of nephritic syndrome.

Question 175: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?

Active TB disease
Prior BCG vaccination causing false-negative TST
Prior BCG vaccination causing false-positive TST but not IGRA (Correct answer)
HIV-induced anergy causing false-negative IGRA

Correct answer: Prior BCG vaccination causing false-positive TST but not IGRA

BCG vaccination causes false-positive TST reactions but does not affect IGRA results, which are BCG-unaffected because they use ESAT-6 and CFP-10 antigens absent from BCG.

Question 176: A 25-year-old male presents after a fall on an outstretched hand with anatomical snuffbox tenderness. X-ray is negative. What is the next best step?

Reassure and discharge
MRI or CT scan of the wrist (Correct answer)
Splint and follow-up in 4 weeks
Immediate surgical referral

Correct answer: MRI or CT scan of the wrist

Anatomical snuffbox tenderness suggests scaphoid fracture; MRI or CT is needed when X-ray is negative because scaphoid fractures can be occult and risk avascular necrosis if untreated.

Question 177: A 55-year-old man has a 3-month history of progressive distal lower extremity weakness, areflexia, and glove-and-stocking sensory loss. Nerve conduction studies show reduced amplitudes and slow velocities. What is the most likely diagnosis?

Chronic inflammatory demyelinating polyneuropathy (CIDP) (Correct answer)
Amyotrophic lateral sclerosis
Guillain-Barré syndrome
Multiple sclerosis

Correct answer: Chronic inflammatory demyelinating polyneuropathy (CIDP)

CIDP presents with progressive or relapsing symmetric limb weakness, areflexia, and demyelinating features on nerve conduction studies lasting > 8 weeks.

Question 178: A newborn has ambiguous genitalia, hyponatremia, hyperkalemia, and low cortisol. 17-hydroxyprogesterone is markedly elevated. What is the most likely diagnosis?

Congenital hypothyroidism
Adrenal adenoma
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (Correct answer)
Primary hyperaldosteronism

Correct answer: Congenital adrenal hyperplasia due to 21-hydroxylase deficiency

21-hydroxylase deficiency is the most common form of CAH, causing cortisol and aldosterone deficiency with androgen excess and markedly elevated 17-OHP.

Question 179: Which finding on osmotic fragility testing is most characteristic of hereditary spherocytosis?

Increased osmotic fragility (Correct answer)
Decreased osmotic fragility
Normal fragility with normal MCHC
Target cells with low fragility

Correct answer: Increased osmotic fragility

Spherocytes lack the normal biconcave disc shape, causing increased osmotic fragility as they lyse more easily in hypotonic solutions.

Question 180: A 45-year-old man with HIV (CD4 count 80 cells/µL) presents with dyspnea, dry cough, and bilateral interstitial infiltrates on CXR. LDH is elevated. What is the most likely diagnosis?

Pneumocystis jirovecii pneumonia (Correct answer)
Cytomegalovirus pneumonitis
Tuberculosis
Bacterial pneumonia

Correct answer: Pneumocystis jirovecii pneumonia

PCP is the most common opportunistic pulmonary infection in HIV patients with CD4 <200, presenting with bilateral interstitial infiltrates and elevated LDH.

Question 181: A 52-year-old has splenomegaly, WBC of 85,000 with basophilia, and a Philadelphia chromosome on cytogenetics. What is the diagnosis?

Myelofibrosis
Chronic myelogenous leukemia (Correct answer)
Acute myeloid leukemia
Polycythemia vera

Correct answer: Chronic myelogenous leukemia

CML is characterized by the BCR-ABL fusion gene (Philadelphia chromosome t(9;22)) and presents with leukocytosis, basophilia, and splenomegaly.

Question 182: A 25-year-old male presents with urethral discharge and dysuria. Gram stain shows gram-negative intracellular diplococci. Which antibiotic regimen is currently recommended by CDC guidelines?

Ciprofloxacin 500mg orally single dose
Doxycycline 100mg twice daily for 7 days
Azithromycin 1g orally single dose
Ceftriaxone 500mg IM single dose plus doxycycline 100mg twice daily for 7 days (Correct answer)

Correct answer: Ceftriaxone 500mg IM single dose plus doxycycline 100mg twice daily for 7 days

Current CDC guidelines recommend ceftriaxone 500 mg IM (or 1g if weight ≥150 kg) plus doxycycline (if chlamydia not excluded) for uncomplicated gonorrhea.

Question 183: An 8-year-old child develops facial edema and frothy urine. Urinalysis shows 4+ protein. Serum albumin is 1.8 g/dL. No hematuria or hypertension. What is the most likely diagnosis?

Nephrotic syndrome — minimal change disease (Correct answer)
IgA nephropathy
Alport syndrome
Post-streptococcal glomerulonephritis

Correct answer: Nephrotic syndrome — minimal change disease

Minimal change disease is the most common cause of nephrotic syndrome in children, presenting with massive proteinuria, hypoalbuminemia, and edema without hematuria.

Question 184: A patient with end-stage renal disease on dialysis develops hypotension with distended neck veins and muffled heart sounds. CXR shows enlarged cardiac silhouette. Immediate management is:

IV fluid bolus
IV furosemide
Emergent dialysis
Pericardiocentesis (Correct answer)

Correct answer: Pericardiocentesis

Beck's triad (hypotension, JVD, muffled heart sounds) indicates cardiac tamponade, which requires immediate pericardiocentesis to relieve life-threatening pericardial pressure.

Question 185: A 25-year-old presents with sudden severe headache, photophobia, and vision loss in the right eye. Slit-lamp exam shows cells and flare in the anterior chamber. Fundoscopic exam is limited by haze but shows disc hyperemia. What condition should be suspected?

Bacterial conjunctivitis with iritis
Acute angle-closure glaucoma
Optic neuritis
Uveitis (anterior and posterior) (Correct answer)

Correct answer: Uveitis (anterior and posterior)

Panuveitis (anterior and posterior uveitis) presents with anterior chamber cells/flare, vitreous haze, and disc changes requiring urgent ophthalmologic evaluation.

Question 186: A 25-year-old with cystic fibrosis has chronic Pseudomonas aeruginosa colonization. Which inhaled antibiotic is approved for chronic suppressive therapy in this setting?

Inhaled tobramycin (Correct answer)
Inhaled ciprofloxacin oral solution
Inhaled azithromycin
Inhaled amphotericin B

Correct answer: Inhaled tobramycin

Inhaled tobramycin (TOBI) is FDA-approved for chronic suppressive therapy of P. aeruginosa in cystic fibrosis patients aged 6 years and older.

Question 187: A 2-year-old presents with sudden onset of choking followed by persistent unilateral wheezing and decreased breath sounds on the right. The child is now afebrile and in no respiratory distress. Chest X-ray shows right-sided hyperinflation. What is the next step?

Rigid bronchoscopy for foreign body removal (Correct answer)
Chest CT scan
Antibiotic therapy for pneumonia
Bronchodilator treatment and observation

Correct answer: Rigid bronchoscopy for foreign body removal

Aspirated foreign body in the airway presents with unilateral air trapping and requires rigid bronchoscopy for definitive removal under controlled conditions.

Question 188: Which of the following statements about end-of-life concerns for cystic fibrosis patients is accurate?

Most patients will live their 50s and 60s
Lung transplantation is not an option
Palliative care should be discussed (Correct answer)
All of the above

Correct answer: Palliative care should be discussed

Cystic fibrosis is a progressive, life-limiting disease that significantly impacts quality of life as it advances. Palliative care focuses on providing relief from symptoms, pain, and stress of a serious illness, aiming to improve quality of life for both the patient and their family. Discussing palliative care early is crucial for CF patients to ensure their values and preferences are honored throughout their disease trajectory, even alongside curative treatments like lung transplantation.

Question 189: A 45-year-old construction worker develops slowly progressive bilateral hand weakness with wasting of thenar and hypothenar muscles, fasciculations, and hyperreflexia. The most likely diagnosis is:

Amyotrophic lateral sclerosis (Correct answer)
Syringomyelia
Cervical myelopathy
Multifocal motor neuropathy

Correct answer: Amyotrophic lateral sclerosis

ALS presents with combined upper (hyperreflexia, spasticity) and lower (fasciculations, weakness, atrophy) motor neuron signs without sensory involvement.

Question 190: A 22-year-old female with hypermobile joints presents with recurrent shoulder dislocations. Anterior apprehension test is positive. What is the most common direction of glenohumeral instability?

Anterior (Correct answer)
Posterior
Inferior
Multidirectional

Correct answer: Anterior

Anterior shoulder instability is the most common type, often due to labral tears (Bankart lesion) following trauma or repetitive stress in hypermobile individuals.

Question 191: A 30-year-old male presents with unilateral heel pain at the plantar surface, worse with the first steps in the morning, improving after walking. Tenderness at the calcaneal insertion. What is the diagnosis?

Retrocalcaneal bursitis
Stress fracture of calcaneus
Achilles tendinopathy
Plantar fasciitis (Correct answer)

Correct answer: Plantar fasciitis

Plantar fasciitis presents with plantar heel pain worst with first morning steps (post-static dyskinesia), caused by microtears at the calcaneal insertion of the plantar fascia.

Question 192: A 32-year-old woman with PCOS desires contraception and treatment of acne and hirsutism. Which combined oral contraceptive ingredient provides the most anti-androgenic benefit?

Levonorgestrel
Norethindrone
Drospirenone (Correct answer)
Norgestrel

Correct answer: Drospirenone

Drospirenone has anti-androgenic and antimineralocorticoid properties, making it the preferred progestin component for PCOS patients with hyperandrogenic symptoms.

Question 193: A 55-year-old male with a 40-pack-year smoking history presents with hemoptysis, weight loss, and a hilar mass on CXR. His serum calcium is 11.8 mg/dL. Which lung cancer type is most likely?

Small cell carcinoma
Large cell carcinoma
Adenocarcinoma
Squamous cell carcinoma (Correct answer)

Correct answer: Squamous cell carcinoma

Squamous cell carcinoma is centrally located, associated with smoking, and classically causes hypercalcemia via PTHrP secretion.

Question 194: A patient with Parkinson disease develops visual hallucinations after starting a new medication. Which drug is the most likely culprit?

Trihexyphenidyl
Pramipexole (Correct answer)
Carbidopa-levodopa
Amantadine

Correct answer: Pramipexole

Dopamine agonists such as pramipexole are the most common cause of hallucinations in Parkinson disease patients.

Question 195: A 66-year-old woman has a blood pressure of 158/96 mmHg at two separate visits. She has a history of type 2 diabetes and microalbuminuria. Which antihypertensive is most appropriate as first-line therapy?

Lisinopril (Correct answer)
Amlodipine
Hydrochlorothiazide
Metoprolol

Correct answer: Lisinopril

ACE inhibitors (e.g., lisinopril) are first-line in diabetic patients with hypertension and microalbuminuria because they provide renoprotection beyond blood pressure lowering.

Question 196: Which professional attribute is most valued in musculoskeletal within the PANCE field?

Working in isolation
Accountability and commitment to standards (Correct answer)
Prioritizing personal convenience
Avoiding challenging situations

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 197: A 55-year-old woman presents with bilateral knee pain worsened by climbing stairs and improved with rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Rheumatoid arthritis
Osteoarthritis (Correct answer)
Gout
Pseudogout

Correct answer: Osteoarthritis

Osteoarthritis presents with pain worsened by activity, relieved by rest, and X-ray findings of joint space narrowing, subchondral sclerosis, and osteophytes.

Question 198: A 65-year-old woman on alendronate for 5 years asks about continuing therapy. What is the most serious rare adverse effect associated with long-term bisphosphonate use?

Adrenal suppression
Hypomagnesemia
Atypical femur fracture (Correct answer)
Hypercalcemia

Correct answer: Atypical femur fracture

Long-term bisphosphonate use is associated with atypical subtrochanteric or diaphyseal femur fractures.

Question 199: Which approach is recommended for troubleshooting neurologic system issues?

Use systematic isolation and testing methods (Correct answer)
Rely solely on past experience
Wait for the problem to resolve itself
Replace all components simultaneously

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 200: A 70-year-old farmer presents with a pearly, rolled-edge nodule with telangiectasias on his nose that occasionally bleeds. What is the first-line treatment?

Topical imiquimod
Punch biopsy and observe
Cryotherapy
Mohs micrographic surgery (Correct answer)

Correct answer: Mohs micrographic surgery

Basal cell carcinoma on high-risk areas like the nose is best treated with Mohs surgery to achieve clear margins while sparing maximal tissue.

Question 201: A 25-year-old presents with painless, progressive bilateral sensorineural hearing loss since age 12. He has no family history of hearing loss. He is found to have hematuria on urinalysis. Renal biopsy shows thinning of the glomerular basement membrane with a split lamina densa. What syndrome is this?

Alport syndrome (Correct answer)
Waardenburg syndrome
Usher syndrome
Pendred syndrome

Correct answer: Alport syndrome

Alport syndrome is an X-linked disorder of type IV collagen causing sensorineural hearing loss and nephritis with characteristic lamina densa splitting on electron microscopy.

Question 202: A 50-year-old woman presents with Wickham striae on the buccal mucosa and violaceous, flat-topped papules on the flexor wrists. The lesions are intensely pruritic. What is the first-line treatment?

Oral antihistamines alone
Systemic antifungals
Topical calcineurin inhibitors
High-potency topical corticosteroids (Correct answer)

Correct answer: High-potency topical corticosteroids

Lichen planus is treated first-line with high-potency topical corticosteroids for cutaneous lesions; mucosal disease may require intralesional or systemic steroids.

Question 203: Which of the following best differentiates central from obstructive sleep apnea on polysomnography?

Apnea duration longer than 10 seconds
Oxygen desaturation to less than 88%
More than 5 events per hour of sleep
Absence of respiratory effort during apneic episodes (Correct answer)

Correct answer: Absence of respiratory effort during apneic episodes

Central sleep apnea is defined by cessation of both airflow and respiratory effort, whereas obstructive events have persistent thoracoabdominal effort.

Question 204: A 30-year-old IV drug user presents with fever, new holosystolic murmur at the right sternal border, and multiple septic pulmonary emboli on CT scan. Which organism is most commonly responsible for right-sided endocarditis in IV drug users?

Enterococcus faecalis
Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus (Correct answer)

Correct answer: Staphylococcus aureus

Staphylococcus aureus is the most common cause of right-sided infective endocarditis in IV drug users, typically affecting the tricuspid valve.

Question 205: What role does collaboration play in musculoskeletal for PANCE professionals?

It is only needed in emergencies
It reduces individual accountability
It enhances outcomes through diverse perspectives and shared expertise (Correct answer)
It slows down work unnecessarily

Correct answer: It enhances outcomes through diverse perspectives and shared expertise

Collaboration leverages diverse perspectives and combined expertise to achieve better outcomes than any individual could alone.

Question 206: Which of the following is the most appropriate first-line treatment for Helicobacter pylori eradication in the US?

Omeprazole alone for 8 weeks
Metronidazole + ciprofloxacin for 10 days
Bismuth + metronidazole + tetracycline for 7 days
Omeprazole + amoxicillin + clarithromycin for 14 days (Correct answer)

Correct answer: Omeprazole + amoxicillin + clarithromycin for 14 days

Triple therapy with a PPI plus amoxicillin and clarithromycin for 14 days remains the standard first-line H. pylori regimen in regions with acceptable clarithromycin resistance rates.

Question 207: A 45-year-old patient who received a renal transplant 6 months ago presents with fever, dyspnea, and non-productive cough. CT chest shows bilateral ground-glass opacities. BAL with Gomori methenamine silver stain reveals cysts. What is the treatment?

Caspofungin
Fluconazole
Amphotericin B
Trimethoprim-sulfamethoxazole (Correct answer)

Correct answer: Trimethoprim-sulfamethoxazole

Pneumocystis jirovecii pneumonia (PCP) in immunocompromised patients is treated with high-dose trimethoprim-sulfamethoxazole (TMP-SMX) as first-line therapy.

Question 208: In PANCE practice, what is the best approach to quality improvement in gastrointestinal?

Wait for problems to occur before acting
Use data-driven methods with measurable outcomes (Correct answer)
Make changes without measuring results
Copy what other organizations do without analysis

Correct answer: Use data-driven methods with measurable outcomes

Data-driven quality improvement with measurable outcomes ensures that changes actually produce the intended improvements and can be verified.

Question 209: A 35-year-old runner presents with pain at the inferior pole of the patella that worsens with jumping. No effusion is present. What is the most likely diagnosis?

Prepatellar bursitis
Patellofemoral syndrome
Osgood-Schlatter disease
Patellar tendinopathy (Correct answer)

Correct answer: Patellar tendinopathy

Patellar tendinopathy (jumper's knee) presents with focal tenderness at the inferior patellar pole, exacerbated by jumping and resisted knee extension.

Question 210: A 65-year-old woman presents with bilateral shoulder and hip girdle aching, morning stiffness over 1 hour, and ESR of 85 mm/hr. Muscle strength is normal. What is the first-line treatment?

NSAIDs alone
Low-dose prednisone (Correct answer)
Physical therapy alone
Methotrexate

Correct answer: Low-dose prednisone

Polymyalgia rheumatica responds dramatically to low-dose prednisone (15-20 mg/day), which is both diagnostic and therapeutic; strength is preserved unlike in myositis.

Question 211: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L (Correct answer)
Serum sodium 125 mEq/L, urine osmolality 60 mOsm/kg, urine sodium 5 mEq/L
Serum sodium 130 mEq/L, urine osmolality 80 mOsm/kg, urine sodium 10 mEq/L
Serum sodium 132 mEq/L, urine osmolality 100 mOsm/kg, urine sodium 8 mEq/L

Correct answer: Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L

SIADH features hyponatremia with inappropriately concentrated urine (>100 mOsm/kg) and high urine sodium (>20 mEq/L).

Question 212: A patient with chronic alcohol use presents with hematemesis. Upper endoscopy reveals tortuous, dilated veins at the gastroesophageal junction. What is the mechanism of this finding?

Coagulopathy from liver disease
Aortoenteric fistula
Direct erosion of the mucosa by alcohol
Increased portal venous pressure causing portosystemic shunting (Correct answer)

Correct answer: Increased portal venous pressure causing portosystemic shunting

Esophageal varices develop when portal hypertension causes blood to shunt through portosystemic collaterals including the submucosal esophageal veins.

Question 213: A 62-year-old has fatigue, back pain, hypercalcemia, anemia, and a serum M-protein spike on SPEP. What is the most likely diagnosis?

Multiple myeloma (Correct answer)
Chronic lymphocytic leukemia
Waldenstrom macroglobulinemia
Metastatic prostate cancer

Correct answer: Multiple myeloma

Multiple myeloma presents with the CRAB criteria (hypercalcemia, renal failure, anemia, bone lesions) plus an M-protein spike.

Question 214: Which of the following is NOT a feature of irritable bowel syndrome (IBS)?

Bloating and flatulence
Nocturnal diarrhea awakening the patient (Correct answer)
Abdominal pain relieved by defecation
Alternating diarrhea and constipation

Correct answer: Nocturnal diarrhea awakening the patient

Nocturnal diarrhea that awakens the patient is a red flag suggesting organic disease, not IBS, which is a functional disorder that does not cause nighttime symptoms.

Question 215: A 68-year-old male presents with inability to urinate and a distended, palpable bladder. What is the most common cause in this population?

Bladder carcinoma
Urethral stricture
Benign prostatic hyperplasia (Correct answer)
Neurogenic bladder

Correct answer: Benign prostatic hyperplasia

Benign prostatic hyperplasia is the most common cause of acute urinary retention in men over 50.

Question 216: A patient presents with watery diarrhea, hypokalemia, and achlorhydria. CT shows a pancreatic mass. Which hormone is most likely responsible?

Glucagon
Somatostatin
Gastrin
Vasoactive intestinal peptide (VIP) (Correct answer)

Correct answer: Vasoactive intestinal peptide (VIP)

VIPoma secretes vasoactive intestinal peptide causing profuse watery diarrhea, hypokalemia, and achlorhydria — known as WDHA or Verner-Morrison syndrome.

Question 217: A patient with community-acquired pneumonia has a parapneumonic effusion. Thoracentesis reveals pH 7.15, glucose 45 mg/dL, and LDH 1,200 U/L. What is the next best step?

Thoracoscopic debridement
Intrapleural fibrinolytics only
Chest tube drainage (Correct answer)
Continue antibiotics and repeat thoracentesis in 48 hours

Correct answer: Chest tube drainage

A pH <7.20, glucose <60 mg/dL, and elevated LDH indicate a complicated parapneumonic effusion requiring chest tube drainage.

Question 218: A 32-year-old hiker presents 3 weeks after returning from New England with a bull's-eye rash (erythema migrans), fever, and arthralgias. What is the most appropriate treatment?

Ceftriaxone 2 g IV daily × 14 days
Doxycycline 100 mg PO BID × 14–21 days (Correct answer)
Azithromycin 500 mg PO daily × 7 days
Amoxicillin 500 mg PO TID × 21 days

Correct answer: Doxycycline 100 mg PO BID × 14–21 days

Doxycycline is the first-line treatment for early Lyme disease (erythema migrans stage) in adults, given for 14–21 days.

Question 219: A 70-year-old male smoker presents with a 3-cm solitary pulmonary nodule found incidentally on chest X-ray. What characteristic would MOST suggest a benign lesion?

Doubling time of 90 days
Popcorn calcification pattern (Correct answer)
Upper lobe location
Irregular spiculated margins

Correct answer: Popcorn calcification pattern

Popcorn calcification is characteristic of pulmonary hamartoma and is a reliable benign pattern, along with central, laminated, or diffuse calcification.

Question 220: A 40-year-old lady is undergoing in vitro fertilization procedures with her husband's sperm and eggs that were removed from her body. 15% of attempts at conception will be successful for the patient. The physician assistant learns from reading the patient's records that the patient was unintentionally implanted with a fertilized egg from another couple 24 hours prior. Which of the following is the physician assistant's best line of action?

Immediately inform the patient of the error (Correct answer)
Administer emergency contraception
Inform the donor of the error only if the patient becomes pregnant
Inform the patient of the error only if she becomes pregnant

Correct answer: Immediately inform the patient of the error

This situation involves a serious medical error and a breach of ethical principles, particularly patient autonomy and honesty. The physician assistant has an immediate ethical and legal obligation to inform the patient of the error, regardless of whether she becomes pregnant. This allows the patient to make informed decisions about her care, future, and potential legal recourse, upholding transparency and trust in the medical relationship.

Question 221: A neonate born at 28 weeks gestation develops respiratory distress within 2 hours of birth. CXR shows bilateral ground-glass opacities and air bronchograms. What is the underlying pathophysiology?

Meconium aspiration
Transient tachypnea of the newborn
Congenital pneumonia
Surfactant deficiency (Correct answer)

Correct answer: Surfactant deficiency

Respiratory distress syndrome in premature infants results from surfactant deficiency, leading to alveolar collapse and the characteristic ground-glass appearance.

Question 222: A 50-year-old male with psoriasis presents with sausage digits, asymmetric joint pain, and nail pitting. RF is negative. Which pattern of joint involvement is described?

Axial-only disease
Dactylitis (Correct answer)
Monoarticular arthritis
Symmetric polyarthritis

Correct answer: Dactylitis

Dactylitis (sausage digits) is a hallmark of psoriatic arthritis, caused by inflammation of the entire digit including flexor tendons and joint synovium.

Question 223: A 70-year-old hypertensive patient presents with sudden unilateral vision loss that lasted 10 minutes and resolved completely. Fundoscopic exam is normal. What is this episode called and what is the first-line imaging study?

Migraine equivalent; MRI of the brain
Central retinal artery occlusion; CT angiography
Amaurosis fugax; carotid duplex ultrasound (Correct answer)
Optic neuritis; MRI of the brain

Correct answer: Amaurosis fugax; carotid duplex ultrasound

Amaurosis fugax (transient monocular blindness from carotid emboli) requires urgent carotid duplex ultrasound to evaluate for significant ipsilateral carotid stenosis.

Question 224: A 55-year-old male presents with sudden onset of severe 'tearing' chest pain radiating to the back. BP is 180/100 mmHg in the right arm and 160/90 in the left. Which diagnosis is most likely?

Acute MI
Aortic dissection (Correct answer)
Pulmonary embolism
Esophageal rupture

Correct answer: Aortic dissection

Aortic dissection classically presents with tearing chest pain radiating to the back and a blood pressure differential between arms.

Question 225: A 25-year-old man presents with tall stature, long limbs, lens dislocation, and aortic root dilation. Which endocrine/metabolic condition is associated with this phenotype?

Homocystinuria (Correct answer)
Klinefelter syndrome
Acromegaly
Multiple endocrine neoplasia type 1

Correct answer: Homocystinuria

Homocystinuria (enzyme deficiency) causes a Marfanoid habitus with lens dislocation downward and thrombotic risk, distinguishing it from Marfan syndrome.

Question 226: A 19-year-old male presents with multiple firm, flesh-colored, umbilicated papules in the groin and inner thighs after sexual contact. What is the causative agent?

Molluscum contagiosum virus (poxvirus) (Correct answer)
Human papillomavirus
Treponema pallidum
Herpes simplex virus type 2

Correct answer: Molluscum contagiosum virus (poxvirus)

Molluscum contagiosum is caused by a poxvirus and presents with firm, umbilicated, flesh-colored papules; genital involvement in adults is sexually transmitted.

Question 227: A 60-year-old patient who recently completed a 10-day course of antibiotics for a respiratory infection develops profuse watery diarrhea. Stool testing reveals the causative toxin. Which antibiotic is the preferred first-line treatment for mild-to-moderate disease?

Vancomycin 125 mg PO QID × 10 days (Correct answer)
Rifaximin 550 mg PO TID × 14 days
Fidaxomicin 200 mg PO BID × 10 days
Metronidazole 500 mg PO TID × 10 days

Correct answer: Vancomycin 125 mg PO QID × 10 days

Oral vancomycin 125 mg QID for 10 days is now the preferred first-line treatment for mild-to-moderate Clostridioides difficile infection per current IDSA guidelines.

Question 228: A 35-year-old presents with chronic nasal congestion, facial pressure, anosmia, and nasal polyps visible on anterior rhinoscopy. He has a history of aspirin sensitivity and asthma. What triad does this represent?

Kartagener syndrome
Wegener's granulomatosis
Churg-Strauss syndrome
Samter's triad (AERD) (Correct answer)

Correct answer: Samter's triad (AERD)

Samter's triad (aspirin-exacerbated respiratory disease) consists of nasal polyps, asthma, and aspirin/NSAID sensitivity due to aberrant arachidonic acid metabolism.

Question 229: A 35-year-old woman has episodes of sudden muscle weakness triggered by laughter. She also reports excessive daytime sleepiness. What is the most likely diagnosis?

Hypokalemic periodic paralysis
Epilepsy
Multiple sclerosis
Narcolepsy with cataplexy (Correct answer)

Correct answer: Narcolepsy with cataplexy

Narcolepsy with cataplexy presents with excessive daytime sleepiness and sudden loss of muscle tone triggered by strong emotions.

Question 230: A 6-year-old child is brought in for evaluation of a 3-day sore throat, fever of 38.9°C, and enlarged anterior cervical lymph nodes. No cough is present. What is the Centor score and recommended management?

Score 3 — perform rapid strep test or empirically treat (Correct answer)
Score 1 — no antibiotics needed
Score 2 — perform rapid strep test
Score 4 — empirically treat with antibiotics without testing

Correct answer: Score 3 — perform rapid strep test or empirically treat

Exudate, tender anterior cervical lymphadenopathy, fever, and absence of cough each score 1 point (age <15 adds 1), giving a score of 3-4, warranting strep testing or empiric treatment.

Question 231: A 50-year-old male smoker presents with weight loss, hemoptysis, and hyponatremia (Na 122 mEq/L). Chest CT shows a central hilar mass. Which cell type is most likely responsible for his electrolyte abnormality?

Large cell carcinoma
Small cell carcinoma (Correct answer)
Adenocarcinoma
Squamous cell carcinoma

Correct answer: Small cell carcinoma

Small cell lung carcinoma is the most common cause of SIADH-mediated hyponatremia due to ectopic ADH secretion.

Question 232: Which finding is MOST specific for exudative pleural effusion using Light's criteria?

Pleural fluid protein >3 g/dL
Pleural fluid to serum protein ratio >0.5
Pleural fluid LDH >200 U/L
Pleural fluid LDH to serum LDH ratio >0.6 (Correct answer)

Correct answer: Pleural fluid LDH to serum LDH ratio >0.6

A pleural fluid/serum LDH ratio >0.6 is one of Light's three criteria; meeting any one criterion classifies the effusion as an exudate.

Question 233: A 19-year-old sexually active woman is diagnosed with her second episode of chlamydial cervicitis within 6 months. Her partner was treated after the first episode. What additional step is most critical now?

Test for HIV and other STIs (Correct answer)
Initiate long-term suppressive azithromycin
Refer for colposcopy
Switch to a different antibiotic class for treatment

Correct answer: Test for HIV and other STIs

Repeat STI infections increase risk of HIV and other sexually transmitted infections, making comprehensive STI testing including HIV essential at this visit.

Question 234: Which type of construction sees the highest rate of ectopic pregnancies?

Cervix
Uterine cornu
Fallopian tube (Correct answer)
Pelvic cavity

Correct answer: Fallopian tube

The vast majority of ectopic pregnancies, over 95%, occur in the fallopian tube, most commonly in the ampulla. The fallopian tubes are narrow and can be damaged or obstructed, preventing the fertilized egg from reaching the uterus and leading to implantation outside the uterine cavity.

Question 235: A patient with acromegaly would most commonly present with which cardiovascular complication?

Left ventricular hypertrophy and cardiomyopathy (Correct answer)
Mitral valve prolapse
Aortic stenosis
Pericardial effusion

Correct answer: Left ventricular hypertrophy and cardiomyopathy

Excess GH/IGF-1 in acromegaly causes left ventricular hypertrophy and acromegalic cardiomyopathy, the leading cause of death.

Question 236: A patient with COPD has a resting PaO2 of 54 mmHg and cor pulmonale. What is the minimum daily duration of supplemental oxygen required to improve mortality?

15 hours (Correct answer)
8 hours
12 hours
24 hours

Correct answer: 15 hours

The NOTT trial established that at least 15 hours per day of supplemental oxygen reduces mortality in hypoxemic COPD patients.

Question 237: What is the value of continuing education in eent for PANCE professionals?

It is primarily a social activity
It is only needed for recertification
It keeps professionals current with evolving standards and practices (Correct answer)
It replaces workplace experience

Correct answer: It keeps professionals current with evolving standards and practices

Continuing education ensures professionals stay current with the latest developments, standards, and best practices in their field.

Question 238: A newborn is found to have bilious vomiting on day 2 of life. X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

Meconium ileus
Hirschsprung disease
Duodenal atresia (Correct answer)
Pyloric stenosis

Correct answer: Duodenal atresia

Duodenal atresia produces the classic double bubble sign (distended stomach and proximal duodenum) and presents with bilious vomiting in the first 24-48 hours.

Question 239: A 55-year-old man presents with low back pain radiating down the posterior leg to the foot, worsened by sitting and relieved by standing. Straight leg raise is positive at 40°. What is the most likely diagnosis?

Lumbar spinal stenosis
Piriformis syndrome
Cauda equina syndrome
L4-L5 disc herniation (Correct answer)

Correct answer: L4-L5 disc herniation

A positive straight leg raise test at less than 45° is highly sensitive for lumbar disc herniation causing nerve root compression and radiculopathy.

Question 240: A 75-year-old man has a rough, scaly, erythematous papule on a sun-damaged area of his face. Biopsy shows atypical keratinocytes confined to the epidermis. What is the diagnosis?

Actinic keratosis
Bowen disease (Correct answer)
Squamous cell carcinoma
Seborrheic keratosis

Correct answer: Bowen disease

Bowen disease (SCC in situ) shows full-thickness epidermal atypia without dermal invasion, distinguishing it from invasive SCC; it is treated with topical 5-FU, PDT, or excision.

Question 241: What is the primary consideration when implementing changes to endocrine system?

Impact assessment and change management (Correct answer)
Speed of implementation
Vendor preference
Personal convenience

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 242: A 45-year-old woman presents with menorrhagia and pelvic pressure. Uterus is 14-week size on exam. Ultrasound shows multiple intramural masses. What is the most appropriate first-line pharmacologic treatment?

Combined oral contraceptives
Levonorgestrel IUD (Correct answer)
GnRH agonist indefinitely
Danazol

Correct answer: Levonorgestrel IUD

The levonorgestrel IUD (Mirena) is first-line pharmacologic therapy for fibroid-related menorrhagia, reducing bleeding by up to 90%.

Question 243: What is the most important professional competency for PANCE certification in eent?

Speed of task completion
Ability to work alone exclusively
Memorization of all reference materials
Deep knowledge combined with practical application skills (Correct answer)

Correct answer: Deep knowledge combined with practical application skills

Professional competency requires both deep knowledge of the subject matter and the ability to apply that knowledge in practical situations.

Question 244: Which of the following is the most common cause of Cushing syndrome in clinical practice?

Adrenal adenoma
Pituitary adenoma (Cushing disease)
Exogenous corticosteroid use (Correct answer)
Ectopic ACTH production

Correct answer: Exogenous corticosteroid use

Iatrogenic Cushing syndrome from exogenous glucocorticoid use is the most common cause overall.

Question 245: Which approach is recommended for troubleshooting cardiovascular system issues?

Wait for the problem to resolve itself
Replace all components simultaneously
Rely solely on past experience
Use systematic isolation and testing methods (Correct answer)

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 246: A 28-year-old African American male develops hemolytic anemia after starting primaquine for malaria prophylaxis. What is the underlying enzyme deficiency?

Methemoglobin reductase deficiency
Pyruvate kinase deficiency
Hereditary spherocytosis
G6PD deficiency (Correct answer)

Correct answer: G6PD deficiency

G6PD deficiency causes episodic hemolysis triggered by oxidative stressors like primaquine, dapsone, or fava beans.

Question 247: A 22-year-old presents with sudden onset unilateral chest pain and dyspnea. He is tall and thin with no prior medical history. CXR shows a 25% pneumothorax. What is the appropriate management?

Simple aspiration or small-bore chest tube (Correct answer)
Surgical pleurodesis
Needle decompression followed by chest tube
Observation with supplemental oxygen

Correct answer: Simple aspiration or small-bore chest tube

A primary spontaneous pneumothorax >20% in a symptomatic patient warrants simple aspiration or small-bore chest tube; observation is reserved for <20% with minimal symptoms.

Question 248: A 33-year-old woman presents with cyclic mastalgia, nipple discharge, and palpable breast nodularity that varies with her menstrual cycle. What is the most likely diagnosis?

Phyllodes tumor
Fibroadenoma
Fibrocystic breast changes (Correct answer)
Intraductal papilloma

Correct answer: Fibrocystic breast changes

Fibrocystic breast changes are the most common benign breast condition, characterized by cyclic pain, nodularity, and cyst formation that fluctuates with the menstrual cycle.

Question 249: A 60-year-old presents with recurrent hemoptysis, and CT shows a central endobronchial lesion. Biopsy reveals squamous cell carcinoma. Which paraneoplastic syndrome is most associated with this tumor type?

Eaton-Lambert syndrome
Hypercalcemia due to PTHrP secretion (Correct answer)
SIADH causing hyponatremia
Cushing syndrome from ectopic ACTH

Correct answer: Hypercalcemia due to PTHrP secretion

Squamous cell carcinoma of the lung is the most common cause of hypercalcemia of malignancy via PTHrP secretion.

Question 250: What is the primary consideration when implementing changes to pulmonary system?

Impact assessment and change management (Correct answer)
Personal convenience
Speed of implementation
Vendor preference

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 251: A 26-year-old woman with no prenatal care delivers a term infant. The neonate develops purulent conjunctivitis at 5 days of life. Gram stain shows intracellular gram-negative diplococci. What is the treatment?

Oral azithromycin
IV ceftriaxone (Correct answer)
Topical ciprofloxacin drops
Topical erythromycin ointment

Correct answer: IV ceftriaxone

Neonatal gonococcal ophthalmia (caused by N. gonorrhoeae presenting at 2-5 days) requires IV ceftriaxone because topical therapy alone is insufficient for this serious infection.

Question 252: What role does collaboration play in eent for PANCE professionals?

It slows down work unnecessarily
It is only needed in emergencies
It reduces individual accountability
It enhances outcomes through diverse perspectives and shared expertise (Correct answer)

Correct answer: It enhances outcomes through diverse perspectives and shared expertise

Collaboration leverages diverse perspectives and combined expertise to achieve better outcomes than any individual could alone.

Question 253: A 38-year-old woman at 20 weeks gestation undergoes amniocentesis. Which complication should be discussed as the most significant risk?

Fetal limb reduction defects
Pregnancy loss (~0.1-0.3%) (Correct answer)
Placental abruption
Preterm labor

Correct answer: Pregnancy loss (~0.1-0.3%)

The primary risk of mid-trimester amniocentesis is pregnancy loss, occurring in approximately 0.1-0.3% of procedures when performed by experienced operators.

Question 254: A 67-year-old man with BPH presents with inability to void, suprapubic distension, and a post-void residual of 800 mL on ultrasound. What is the most immediate intervention?

Urethral catheterization (Correct answer)
Emergent cystoscopy
Suprapubic aspiration
Start tamsulosin and reassess in 48 hours

Correct answer: Urethral catheterization

Acute urinary retention requires immediate relief via urethral catheterization to decompress the bladder and prevent renal injury.

Question 255: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Bite cells
Target cells
Schistocytes (Correct answer)
Spherocytes

Correct answer: Schistocytes

Schistocytes (fragmented RBCs) form when red cells are mechanically sheared by fibrin strands or damaged endothelium in microangiopathic conditions.

Question 256: Which approach best demonstrates mastery of gastrointestinal in PANCE practice?

Applying principles to novel situations with sound judgment (Correct answer)
Avoiding complex scenarios
Relying entirely on technology
Following procedures without understanding

Correct answer: Applying principles to novel situations with sound judgment

True mastery involves understanding underlying principles well enough to apply them to new and unfamiliar situations with professional judgment.

Question 257: On lumbar puncture in bacterial meningitis, which CSF finding best distinguishes it from viral meningitis?

Elevated opening pressure
Glucose < 45 mg/dL with elevated protein (Correct answer)
Xanthochromia
Lymphocytic pleocytosis

Correct answer: Glucose < 45 mg/dL with elevated protein

Bacterial meningitis characteristically shows low CSF glucose (< 45 mg/dL or CSF:serum ratio < 0.4) and markedly elevated protein, unlike viral meningitis.

Question 258: A patient on warfarin presents with an INR of 8.0 and active bleeding. What is the most appropriate immediate treatment?

Hold warfarin and recheck INR in 24 hours
Administer vitamin K only
Transfuse fresh frozen plasma only
Administer 4-factor PCC and IV vitamin K (Correct answer)

Correct answer: Administer 4-factor PCC and IV vitamin K

Life-threatening bleeding with supratherapeutic INR requires 4-factor prothrombin complex concentrate (PCC) plus IV vitamin K for rapid reversal.

Question 259: A patient with DIC has prolonged PT/aPTT, low fibrinogen, elevated D-dimer, and thrombocytopenia. Which product should be given to correct the fibrinogen level?

Fresh frozen plasma
Packed red blood cells
Cryoprecipitate (Correct answer)
Platelet transfusion

Correct answer: Cryoprecipitate

Cryoprecipitate is rich in fibrinogen, factor VIII, vWF, and factor XIII and is the preferred product to correct hypofibrinogenemia in DIC.

Question 260: A 40-year-old female presents with fatigue, constipation, and cold intolerance. TSH is 12 µIU/mL, free T4 is low. Anti-TPO antibodies are elevated. What is the most likely diagnosis?

Subacute thyroiditis
Secondary hypothyroidism
Hashimoto thyroiditis (Correct answer)
Graves disease

Correct answer: Hashimoto thyroiditis

Hashimoto thyroiditis is autoimmune hypothyroidism characterized by elevated TSH, low T4, and positive anti-TPO antibodies.

Question 261: Which test is most appropriate for diagnosing Clostridioides difficile infection?

Stool Gram stain
Colonoscopy showing pseudomembranes
PCR for C. difficile toxin genes (Correct answer)
Stool culture for C. difficile

Correct answer: PCR for C. difficile toxin genes

Nucleic acid amplification tests (NAAT/PCR) for C. difficile toxin genes are the most sensitive and specific initial diagnostic test for C. diff infection.

Question 262: A patient has colicky flank pain radiating to the groin, hematuria, and nausea. KUB shows a radiopaque stone at the ureterovesical junction. What is the most common stone type?

Cystine
Calcium oxalate (Correct answer)
Struvite
Uric acid

Correct answer: Calcium oxalate

Calcium oxalate stones are the most common nephrolithiasis type, appearing radiopaque on plain film.

Question 263: Which of the following is the recommended screening interval for colonoscopy in an average-risk patient with no findings on initial screening at age 50?

10 years (Correct answer)
15 years
3 years
5 years

Correct answer: 10 years

Current guidelines recommend repeat colonoscopy in 10 years for average-risk patients with a normal (no polyps) initial screening colonoscopy.

Question 264: A 55-year-old diabetic presents with fever, crepitus, and rapidly spreading necrosis of the scrotum and perineum. CT shows subcutaneous gas. What is the immediate management priority?

Emergent surgical debridement plus broad-spectrum IV antibiotics (Correct answer)
Start IV vancomycin and piperacillin-tazobactam and observe for 24 hours
Culture the wound and start targeted antibiotic monotherapy
Hyperbaric oxygen therapy as definitive treatment

Correct answer: Emergent surgical debridement plus broad-spectrum IV antibiotics

Fournier's gangrene (necrotizing fasciitis of the perineum) requires immediate surgical debridement as the cornerstone of treatment, combined with broad-spectrum IV antibiotics; delay increases mortality significantly.

Question 265: A 35-year-old woman has had a rash on her legs for the previous three weeks. No known infectious contacts exist. Her bladder infection was treated with trimethoprim-sulfamethoxazole a month ago. A generalized rash is visible on the shins, left medial ankle, and right medial calf during physical examination. Tender, diffuse, and returning to the same spots, the rash is. A couple of the lesions show bruise-like characteristics. Which of the subsequent diagnoses is most likely?

Lichen planus
Nummular eczema
Erythema multiforme
Erythema nodosum (Correct answer)

Correct answer: Erythema nodosum

The combination of red, tender nodules on the anterior lower legs (erythema nodosum), bilateral hilar adenopathy on chest X-ray, iritis, and systemic symptoms like malaise, dyspnea, and low-grade fever is highly characteristic of sarcoidosis. Erythema nodosum is a common cutaneous manifestation of sarcoidosis, a multisystem granulomatous disease.

Question 266: A 32-year-old woman at 38 weeks gestation develops severe headache, BP 165/110, and RUQ pain. Labs show thrombocytopenia, elevated LFTs, and low haptoglobin. What is the diagnosis?

HELLP syndrome (Correct answer)
Preeclampsia without severe features
Acute fatty liver of pregnancy
Gestational hypertension

Correct answer: HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant of preeclampsia requiring urgent delivery.

Question 267: A patient with hypertrophic obstructive cardiomyopathy (HOCM) experiences syncope. Which intervention would WORSEN outflow obstruction?

Leg elevation
IV fluid bolus
Beta-blocker administration
Amyl nitrite inhalation (Correct answer)

Correct answer: Amyl nitrite inhalation

Amyl nitrite causes vasodilation and decreases preload and afterload, which worsens HOCM outflow obstruction by allowing greater septal apposition to the anterior mitral leaflet.

Question 268: In PANCE certification, what does redundancy in system design primarily provide?

Simplified maintenance
Fault tolerance and high availability (Correct answer)
Lower initial cost
Increased complexity

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 269: In PANCE certification, what does redundancy in system design primarily provide?

Fault tolerance and high availability (Correct answer)
Simplified maintenance
Lower initial cost
Increased complexity

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 270: A 45-year-old male with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?

Glucose 50% IV bolus
Naloxone 0.4 mg IV
Thiamine 100 mg IV before glucose (Correct answer)
Folic acid 1 mg IV

Correct answer: Thiamine 100 mg IV before glucose

Wernicke encephalopathy requires immediate thiamine before glucose to prevent precipitating or worsening the condition.

Question 271: Which finding on DEXA scan defines osteoporosis (not osteopenia)?

Z-score below -2.0
T-score between -1.0 and -2.5
T-score of -2.5 or below (Correct answer)
T-score above -1.0

Correct answer: T-score of -2.5 or below

Osteoporosis is defined by a T-score of -2.5 or lower on DEXA scan.

Question 272: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hypercalcemia
Hypernatremia
Hypokalemia
Hyperphosphatemia (Correct answer)

Correct answer: Hyperphosphatemia

Impaired phosphate excretion in CKD leads to hyperphosphatemia, which also drives secondary hyperparathyroidism.

Question 273: A 55-year-old diabetic patient presents with severe right ear pain, purulent otorrhea, and facial nerve palsy. CT scan shows bony erosion at the skull base. Which organism is responsible for this condition?

Aspergillus fumigatus
Pseudomonas aeruginosa (Correct answer)
Staphylococcus aureus
Streptococcus pneumoniae

Correct answer: Pseudomonas aeruginosa

Malignant (necrotizing) external otitis in diabetics is almost exclusively caused by Pseudomonas aeruginosa, which can extend to cause skull base osteomyelitis and cranial nerve palsies.

Question 274: Which of the following best distinguishes Crohn disease from ulcerative colitis on endoscopy?

Presence of pseudopolyps
Continuous mucosal involvement from the rectum
Involvement limited to the colon
Skip lesions with cobblestone appearance (Correct answer)

Correct answer: Skip lesions with cobblestone appearance

Crohn disease classically shows discontinuous skip lesions, transmural inflammation, and cobblestone mucosa due to deep fissuring ulcers, unlike UC's continuous mucosal disease.

Question 275: A patient presents with a painless penile ulcer with clean base and raised indurated edges. Dark-field microscopy of the lesion reveals spirochetes. Which antibiotic is first-line treatment?

Penicillin G benzathine 2.4 million units IM single dose (Correct answer)
Azithromycin 1 g PO single dose
Doxycycline 100 mg PO BID × 14 days
Ceftriaxone 500 mg IM single dose

Correct answer: Penicillin G benzathine 2.4 million units IM single dose

Primary syphilis caused by Treponema pallidum is treated with a single IM dose of penicillin G benzathine 2.4 million units.

Question 276: A 25-year-old presents with recurrent abdominal pain, diarrhea, and mouth sores. Labs show elevated ESR and CRP. Colonoscopy shows ileitis with skip lesions. What extraintestinal manifestation is most commonly associated with this condition?

Primary sclerosing cholangitis
Ankylosing spondylitis
Erythema nodosum (Correct answer)
Pyoderma gangrenosum

Correct answer: Erythema nodosum

Erythema nodosum (tender red nodules on the shins) is the most common extraintestinal skin manifestation of both Crohn disease and ulcerative colitis.

Question 277: Which physical exam finding best differentiates cellulitis from necrotizing fasciitis?

Skin erythema that does not cross fascial planes
Bullae formation on the skin surface
Crepitus, wooden-hard texture of tissue, and disproportionate pain (Correct answer)
Presence of fever and elevated WBC

Correct answer: Crepitus, wooden-hard texture of tissue, and disproportionate pain

Crepitus (gas in tissues), a wooden-hard texture to palpation, and pain out of proportion to appearance indicate necrotizing fasciitis requiring emergent surgical debridement.

Question 278: Which professional attribute is most valued in eent within the PANCE field?

Prioritizing personal convenience
Accountability and commitment to standards (Correct answer)
Avoiding challenging situations
Working in isolation

Correct answer: Accountability and commitment to standards

Accountability and commitment to professional standards build trust and ensure consistent, high-quality practice.

Question 279: A 30-year-old female presents with bilateral hand stiffness in the morning lasting 2 hours, fatigue, and symmetric swollen PIPs and MCPs. RF is negative but anti-CCP is positive. What is the diagnosis?

Seronegative rheumatoid arthritis
Systemic lupus erythematosus
Seropositive rheumatoid arthritis (Correct answer)
Psoriatic arthritis

Correct answer: Seropositive rheumatoid arthritis

Anti-CCP antibody is more specific than RF for RA; a positive anti-CCP with negative RF still qualifies as seropositive RA by current classification criteria.

Question 280: A 55-year-old smoker presents with progressive dyspnea and a barrel chest. Spirometry shows FEV1/FVC ratio of 0.60. Which pathophysiologic mechanism best explains his air trapping?

Bronchial smooth muscle hypertrophy
Loss of elastic recoil causing dynamic airway collapse (Correct answer)
Alveolar wall thickening reducing diffusion capacity
Mucus gland hyperplasia obstructing large airways

Correct answer: Loss of elastic recoil causing dynamic airway collapse

In emphysema, destruction of alveolar walls reduces elastic recoil, causing dynamic small airway collapse during expiration and air trapping.

Question 281: A 22-year-old sexually active woman has a positive urine hCG. Transvaginal ultrasound shows no intrauterine gestational sac, and serum hCG is 2,400 mIU/mL. What is the most appropriate next step?

Repeat hCG in 48 hours (Correct answer)
Diagnostic laparoscopy
Administer methotrexate immediately
Perform dilation and curettage

Correct answer: Repeat hCG in 48 hours

With hCG below the discriminatory zone (~3,000 mIU/mL), no intrauterine sac is expected; repeat hCG in 48 hours assesses rise pattern to distinguish ectopic from early intrauterine pregnancy.

Question 282: What is the most important professional competency for PANCE certification in dermatology?

Ability to work alone exclusively
Deep knowledge combined with practical application skills (Correct answer)
Speed of task completion
Memorization of all reference materials

Correct answer: Deep knowledge combined with practical application skills

Professional competency requires both deep knowledge of the subject matter and the ability to apply that knowledge in practical situations.

Question 283: A patient with multiple myeloma develops worsening renal function. Which renal complication is most directly caused by light chain deposition in tubules?

Cast nephropathy (Correct answer)
IgA nephropathy
Renal artery stenosis
Minimal change disease

Correct answer: Cast nephropathy

Bence-Jones proteins (free light chains) precipitate in renal tubules, causing tubular injury and cast nephropathy (myeloma kidney).

Question 284: A 50-year-old presents with jaundice, pale stools, dark urine, and a palpable, non-tender gallbladder. Which condition is most likely?

Primary sclerosing cholangitis
Acute cholecystitis
Choledocholithiasis
Pancreatic head carcinoma (Correct answer)

Correct answer: Pancreatic head carcinoma

Courvoisier's sign (painless palpable gallbladder with obstructive jaundice) suggests malignant biliary obstruction, most commonly pancreatic head cancer.

Question 285: Which documentation is essential when working with pulmonary system in PANCE?

Detailed technical specifications and as-built diagrams (Correct answer)
Marketing materials
Only verbal notes
General descriptions without specifics

Correct answer: Detailed technical specifications and as-built diagrams

Detailed technical specifications and as-built diagrams provide the accurate reference information needed for maintenance and troubleshooting.

Question 286: A 19-year-old male presents with fever, night sweats, and weight loss. Exam reveals painless cervical lymphadenopathy. Biopsy shows Reed-Sternberg cells. What is the diagnosis?

Burkitt lymphoma
Infectious mononucleosis
Hodgkin lymphoma (Correct answer)
Non-Hodgkin lymphoma

Correct answer: Hodgkin lymphoma

Reed-Sternberg cells ('owl eye' nuclei) are pathognomonic for Hodgkin lymphoma, which presents with painless lymphadenopathy and B symptoms.

Question 287: What is the first-line noninvasive screening test for suspected renal artery stenosis?

CT angiography
Conventional arteriography
Renal artery duplex ultrasound (Correct answer)
MR angiography

Correct answer: Renal artery duplex ultrasound

Renal artery duplex ultrasound is the preferred initial screening modality as it avoids contrast and radiation while assessing renal artery flow.

Question 288: A 35-year-old flight attendant develops sudden-onset pleuritic chest pain and dyspnea after a long flight. CT pulmonary angiography confirms a pulmonary embolism. She has no bleeding risk factors. What is the first-line treatment?

Alteplase thrombolysis
Inferior vena cava filter placement
Unfractionated heparin infusion with warfarin bridge
Rivaroxaban (Correct answer)

Correct answer: Rivaroxaban

Direct oral anticoagulants such as rivaroxaban are now first-line for hemodynamically stable PE due to ease of use and non-inferiority to heparin/warfarin.

Question 289: A 60-year-old man with newly diagnosed heart failure has an ejection fraction of 30%. He is already on an ACE inhibitor and a beta-blocker. Which additional agent has been shown to reduce mortality in this patient?

Hydralazine
Digoxin
Spironolactone (Correct answer)
Amlodipine

Correct answer: Spironolactone

Aldosterone antagonists (spironolactone/eplerenone) reduce mortality in HFrEF when added to ACE inhibitor and beta-blocker therapy in appropriately selected patients.

Question 290: A patient with known Addison disease presents with severe hypotension and vomiting after a flu illness. Which is the most critical immediate treatment?

Oral prednisone
IV dextrose only
IV hydrocortisone and saline (Correct answer)
Oral fludrocortisone

Correct answer: IV hydrocortisone and saline

Adrenal crisis requires immediate IV hydrocortisone and aggressive IV fluid resuscitation with normal saline.

Question 291: A patient with a pulmonary embolism develops hypotension (BP 80/50) and RV dilation on echo. She has no contraindications to thrombolytics. Which statement best describes the appropriate management?

Anticoagulation with unfractionated heparin alone
Systemic thrombolysis with alteplase (Correct answer)
Catheter-directed thrombolysis only
Surgical embolectomy as first-line

Correct answer: Systemic thrombolysis with alteplase

Massive PE with hemodynamic compromise and no contraindications is the primary indication for systemic thrombolysis with alteplase.

Question 292: A 70-year-old has macrocytic anemia, glossitis, and neurologic symptoms. Labs show elevated methylmalonic acid and homocysteine. What is the deficiency?

Thiamine
Vitamin B12 (Correct answer)
Pyridoxine
Folate

Correct answer: Vitamin B12

Elevated methylmalonic acid distinguishes B12 deficiency from folate deficiency, since only B12 is required in the MMA metabolic pathway.

Question 293: A 28-year-old male presents with a painless scrotal swelling. Urethral culture is positive for an intracellular gram-negative diplococci. He also complains of urethral discharge. Which is the recommended dual therapy per current CDC guidelines?

Ciprofloxacin 500 mg PO + doxycycline 100 mg PO BID × 7 days
Penicillin G 4.8 million units IM + probenecid
Ceftriaxone 250 mg IM + azithromycin 1 g PO
Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days (Correct answer)

Correct answer: Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days

Current CDC guidelines recommend ceftriaxone 500 mg IM (single dose) plus doxycycline 100 mg BID × 7 days for uncomplicated gonorrhea to cover co-infection with chlamydia.

Question 294: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

Apply fetal scalp electrode for better monitoring
Amnioinfusion
Administer terbutaline and reassess
Prepare for emergent cesarean delivery (Correct answer)

Correct answer: Prepare for emergent cesarean delivery

A sinusoidal fetal heart rate pattern is a Category III (abnormal) tracing indicating severe fetal compromise requiring emergent cesarean delivery.

Question 295: A 30-year-old woman at 10 weeks gestation is found to have a complete hydatidiform mole on ultrasound with a 'snowstorm' appearance. After suction curettage, what is the most important follow-up?

Immediate chemotherapy with methotrexate
Serial serum hCG monitoring until undetectable (Correct answer)
Chest CT to rule out metastases
Repeat ultrasound in 4 weeks

Correct answer: Serial serum hCG monitoring until undetectable

Serial serum hCG monitoring is mandatory after molar evacuation to detect persistent gestational trophoblastic neoplasia, which occurs in ~15-20% of complete moles.

Question 296: A 30-year-old man develops a targetoid lesion with a central blister after starting sulfonamide antibiotics. The lesion is localized to the palms. What is the most likely diagnosis?

Stevens-Johnson syndrome
Erythema multiforme (Correct answer)
Fixed drug eruption
Toxic epidermal necrolysis

Correct answer: Erythema multiforme

Erythema multiforme presents with classic targetoid (iris) lesions, often triggered by drugs or HSV, and is typically limited to acral surfaces.

Question 297: A miner presents with progressive dyspnea and bilateral upper lobe fibrosis on chest X-ray. Biopsy shows collagen nodules with birefringent crystals. What is the diagnosis?

Coal workers' pneumoconiosis
Silicosis (Correct answer)
Asbestosis
Berylliosis

Correct answer: Silicosis

Silicosis presents with bilateral upper lobe nodular fibrosis, and birefringent silica crystals are seen on polarized microscopy of biopsy specimens.

Question 298: A neonate develops seizures at 36 hours of life after a prolonged difficult delivery. Brain MRI shows restricted diffusion in watershed zones. What is the most appropriate intervention?

Therapeutic hypothermia (whole-body cooling) (Correct answer)
IV phenobarbital only
High-dose corticosteroids
Emergent neurosurgical decompression

Correct answer: Therapeutic hypothermia (whole-body cooling)

Therapeutic hypothermia (33–34°C for 72 hours) is the standard of care for hypoxic-ischemic encephalopathy in neonates ≥ 36 weeks when initiated within 6 hours of birth.

Question 299: A 28-year-old sexually active woman presents with dysuria, mucopurulent cervical discharge, and cervical motion tenderness. Nucleic acid amplification test is positive for Chlamydia trachomatis. Which additional organism must empirically be treated simultaneously?

Trichomonas vaginalis
Neisseria gonorrhoeae (Correct answer)
Mycoplasma genitalium
Gardnerella vaginalis

Correct answer: Neisseria gonorrhoeae

Pelvic inflammatory disease (PID) treatment must cover both Chlamydia trachomatis and Neisseria gonorrhoeae empirically due to frequent co-infection.

Question 300: A 10-year-old develops cola-colored urine and periorbital edema 2 weeks after a strep throat infection. What is the diagnosis?

Poststreptococcal glomerulonephritis (Correct answer)
IgA nephropathy
Minimal change disease
Focal segmental glomerulosclerosis

Correct answer: Poststreptococcal glomerulonephritis

Poststreptococcal GN typically follows strep pharyngitis by 1–3 weeks and presents with hematuria and edema.

Physician Assistant National Certifying Examination (PANCE)

The PANCE is the national certification examination administered by the NCCPA for entry-level physician assistants. It tests medical and surgical knowledge across 14 organ systems plus professional practice, and is required for initial PA licensure in the United States.

300

Questions

300 min

Time Limit

70%

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