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

Question 1: 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?

Amaurosis fugax due to carotid artery stenosis (Correct answer)
Optic neuritis
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 2: A 16-year-old obese male presents with left hip and knee pain and a limp. The hip is held in external rotation. What is the most likely diagnosis?

Transient synovitis
Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis (Correct answer)
Septic arthritis

Correct answer: Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) occurs in obese adolescent males, presenting with hip/knee pain and obligate external rotation of the hip; urgent surgical pinning is required.

Question 3: A 26-year-old woman at 32 weeks gestation develops sudden onset severe headache, visual disturbances, and BP 158/106 mmHg. Urinalysis shows 3+ proteinuria. Which complication must be urgently assessed?

Gestational hypertension
Chronic hypertension with superimposed preeclampsia
Eclampsia
HELLP syndrome (Correct answer)

Correct answer: HELLP syndrome

The combination of preeclampsia symptoms with severe features warrants urgent CBC, LFTs, and LDH to rule out HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).

Question 4: 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?

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

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 5: 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?

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

Correct answer: HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant of preeclampsia requiring urgent delivery.

Question 6: What is the most important professional competency for PANCE certification in eent?

Deep knowledge combined with practical application skills (Correct answer)
Speed of task completion
Ability to work alone exclusively
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 7: A patient post-MI develops a new harsh holosystolic murmur at the left sternal border with a thrill. Echo shows a step-up in oxygen saturation from right atrium to right ventricle. What is the diagnosis?

Free wall rupture
Ventricular septal defect (Correct answer)
Papillary muscle rupture
Acute mitral regurgitation

Correct answer: Ventricular septal defect

Post-MI ventricular septal defect causes a left-to-right shunt with oxygen step-up from RA to RV and presents with a harsh holosystolic murmur and thrill.

Question 8: 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?

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

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 9: 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?

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

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 10: Which approach is recommended for troubleshooting endocrine system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 11: 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
Discharge with carotid ultrasound scheduled in 2 weeks
Order CT head without contrast only

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 12: A 22-year-old presents with a 3-day history of painful vesicles on the auricle, ear canal pain, and ipsilateral facial droop. She also notes decreased taste on the anterior tongue. What is the diagnosis?

Otitis externa with nerve compression
Herpes zoster oticus (Ramsay Hunt syndrome) (Correct answer)
Bell's palsy
Malignant otitis externa

Correct answer: Herpes zoster oticus (Ramsay Hunt syndrome)

Ramsay Hunt syndrome is herpes zoster reactivation in the geniculate ganglion causing otalgia, auricular vesicles, facial palsy, and loss of taste in the anterior two-thirds of the tongue.

Question 13: 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?

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

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 14: Which EKG pattern is associated with right ventricular strain in pulmonary embolism?

Tombstone ST elevation in V1-V4
Delta wave in lateral leads
Osborn J-waves
S1Q3T3 pattern (Correct answer)

Correct answer: S1Q3T3 pattern

The S1Q3T3 pattern (S wave in lead I, Q wave and T-wave inversion in lead III) reflects acute right ventricular strain from massive pulmonary embolism.

Question 15: 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?

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
Emergent surgical debridement plus broad-spectrum IV antibiotics (Correct answer)

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

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

Correct answer: Decreased erythropoietin production

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

Question 17: 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
Oral griseofulvin (Correct answer)
Topical terbinafine cream
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 18: 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?

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

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 19: 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 20: 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 21: A 28-year-old woman has amenorrhea, galactorrhea, and a serum prolactin of 120 ng/mL. MRI shows a 7 mm pituitary lesion. First-line treatment is:

Radiation therapy
Estrogen replacement
Surgical resection
Bromocriptine or cabergoline (Correct answer)

Correct answer: Bromocriptine or cabergoline

Dopamine agonists (cabergoline preferred) are first-line for prolactinomas regardless of size.

Question 22: A patient with type 2 diabetes has an HbA1c of 9.2% and CKD stage 3 (eGFR 38 mL/min). Which medication should be avoided or used with caution?

Insulin glargine
Metformin (Correct answer)
Sitagliptin
Empagliflozin

Correct answer: Metformin

Metformin is contraindicated when eGFR <30 and requires dose reduction/caution at eGFR 30-45 due to lactic acidosis risk.

Question 23: Which dermatome corresponds to the umbilicus?

T10 (Correct answer)
T6
L1
T4

Correct answer: T10

T10 innervates the umbilicus, a landmark useful for assessing spinal cord injury level.

Question 24: A patient presents with confusion, asterixis, and jaundice. Labs show elevated ammonia, PT, and bilirubin. What is the primary mechanism of the encephalopathy?

Accumulation of ammonia causing cerebral edema (Correct answer)
Hypoglycemia from liver failure
Thiamine deficiency
Cerebral hypoperfusion from low albumin

Correct answer: Accumulation of ammonia causing cerebral edema

Hepatic encephalopathy results primarily from elevated ammonia, which crosses the blood-brain barrier and causes astrocyte swelling and cerebral dysfunction.

Question 25: A 48-year-old woman presents with thick, yellow, crumbling toenails with subungual debris and onycholysis. KOH preparation confirms dermatophyte infection. What is the preferred treatment for onychomycosis?

Oral terbinafine for 12 weeks (Correct answer)
Topical clotrimazole cream
Nail avulsion only
Topical ciclopirox lacquer

Correct answer: Oral terbinafine for 12 weeks

Oral terbinafine for 12 weeks (toenails) achieves significantly higher cure rates than topical agents for onychomycosis due to subungual penetration.

Question 26: 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?

Nummular eczema
Erythema multiforme
Lichen planus
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 27: 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?

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

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 28: 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?

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

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 29: 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
Hard, nodular prostate with digital rectal exam
Fever and elevated white blood cell count (WBC)

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 30: 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
Oral fludrocortisone
IV dextrose only
IV hydrocortisone and saline (Correct answer)

Correct answer: IV hydrocortisone and saline

Adrenal crisis requires immediate IV hydrocortisone and aggressive IV fluid resuscitation with normal saline.

Question 31: A 19-year-old female presents with amenorrhea for 4 months, fatigue, and cold intolerance. She has a BMI of 16.5 and excessive exercise. Labs: low LH, low FSH, low estradiol, normal TSH. Which diagnosis explains these findings?

Polycystic ovarian syndrome
Hypothalamic amenorrhea (Correct answer)
Hypothyroidism
Primary ovarian insufficiency

Correct answer: Hypothalamic amenorrhea

Low GnRH from hypothalamic suppression (due to low body weight/excessive exercise) leads to low LH, FSH, and estradiol with normal thyroid function.

Question 32: 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?

Chest CT to rule out metastases
Serial serum hCG monitoring until undetectable (Correct answer)
Immediate chemotherapy with methotrexate
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 33: 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?

Prior tamoxifen use
Chronic pelvic inflammatory disease
BRCA2 mutation
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 34: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

Oval fat bodies (Correct answer)
WBC casts
RBC casts
Granular casts

Correct answer: Oval fat bodies

Oval fat bodies are characteristic of nephrotic syndrome due to lipiduria from massive glomerular protein loss.

Question 35: What is the primary consideration when implementing changes to reproductive system?

Vendor preference
Impact assessment and change management (Correct answer)
Speed of implementation
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 36: In PANCE practice, what is the best approach to quality improvement in gastrointestinal?

Use data-driven methods with measurable outcomes (Correct answer)
Make changes without measuring results
Wait for problems to occur before acting
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 37: A 28-year-old man presents with scaly, hypopigmented macules on his trunk that become more prominent after sun exposure. KOH preparation shows 'spaghetti and meatballs' hyphae. What organism is responsible?

Candida albicans
Malassezia furfur (Correct answer)
Microsporum canis
Trichophyton rubrum

Correct answer: Malassezia furfur

Tinea versicolor is caused by Malassezia furfur, a lipophilic yeast that produces the classic 'spaghetti and meatballs' pattern on KOH prep.

Question 38: A 65-year-old man with hypertension and diabetes presents with exertional dyspnea and preserved ejection fraction (60%). BNP is elevated. What is the most likely diagnosis?

Constrictive pericarditis
Dilated cardiomyopathy
Restrictive cardiomyopathy
Heart failure with preserved ejection fraction (HFpEF) (Correct answer)

Correct answer: Heart failure with preserved ejection fraction (HFpEF)

HFpEF is characterized by symptoms of heart failure with EF ≥50%, commonly seen in elderly patients with hypertension and diabetes who have impaired diastolic relaxation.

Question 39: 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
Pericardiocentesis (Correct answer)
Emergent dialysis
IV furosemide

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

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

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 41: A 60-year-old man presents with symmetric morning stiffness lasting over 1 hour, swelling of MCPs and PIPs, and positive anti-CCP antibodies. What is the first-line DMARD therapy?

Methotrexate (Correct answer)
Leflunomide
Hydroxychloroquine
Sulfasalazine

Correct answer: Methotrexate

Methotrexate is the anchor DMARD for rheumatoid arthritis due to its efficacy, tolerability, and long track record.

Question 42: A 22-year-old woman presents with painful genital ulcers, tender inguinal lymphadenopathy, and dysuria. PCR confirms HSV-2 primary infection. What treatment reduces future recurrence frequency?

Topical cidofovir
Daily oral valacyclovir suppressive therapy (Correct answer)
Topical acyclovir ointment
Single-dose oral famciclovir

Correct answer: Daily oral valacyclovir suppressive therapy

Daily suppressive therapy with valacyclovir (or acyclovir) reduces HSV-2 recurrences by approximately 70–80% and decreases viral shedding.

Question 43: What is the value of continuing education in eent 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 44: 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
Cryptogenic organizing pneumonia (COP)
Nonspecific interstitial pneumonia (NSIP)
Idiopathic pulmonary fibrosis (IPF) (Correct answer)

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 45: A 35-year-old woman develops erythematous papules and pustules on her central face, persistent flushing with alcohol or spicy food, and telangiectasias. She has no comedones. What is the diagnosis?

Acne vulgaris
Rosacea (Correct answer)
Sebaceous hyperplasia
Perioral dermatitis

Correct answer: Rosacea

Rosacea presents with central facial erythema, flushing triggers, telangiectasias, and inflammatory papulopustules but notably lacks comedones.

Question 46: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

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

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 47: 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
Emergency MRI of the spine and neurosurgical consult (Correct answer)
Lumbar X-ray

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 48: Which approach best demonstrates mastery of dermatology in PANCE practice?

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

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 49: 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 50: 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
Retinal detachment
Central retinal artery occlusion (Correct answer)

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 51: Which of the following is the most appropriate initial management for a patient presenting with acute upper GI bleeding and hemodynamic instability?

Emergent upper endoscopy immediately
IV fluid resuscitation and blood transfusion, then endoscopy (Correct answer)
Oral PPI therapy and observation
Surgical consultation without prior endoscopy

Correct answer: IV fluid resuscitation and blood transfusion, then endoscopy

Hemodynamically unstable patients require initial resuscitation with IV fluids and blood products before proceeding to urgent upper endoscopy within 24 hours.

Question 52: What role does collaboration play in musculoskeletal for PANCE professionals?

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

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 53: A 65-year-old woman with RA on methotrexate develops bilateral hip pain worsened by weight-bearing. X-ray shows subchondral collapse. What complication has occurred?

Trochanteric bursitis
Septic arthritis
Stress fracture
Avascular necrosis (Correct answer)

Correct answer: Avascular necrosis

Long-term corticosteroid use (often used in RA management) is a major risk factor for avascular necrosis of the femoral head, presenting with subchondral collapse on imaging.

Question 54: 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?

Vancomycin 15 mg/kg IV
Ampicillin-sulbactam IV
Ciprofloxacin 400 mg IV (Correct answer)
Clindamycin 900 mg 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 55: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?

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

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

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

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 57: A construction worker presents with pain and crepitus of the shoulder with overhead activities. Neer and Hawkins-Kennedy tests are positive. What is the most likely diagnosis?

Glenohumeral instability
AC joint separation
Subacromial impingement syndrome (Correct answer)
Bicipital tendinopathy

Correct answer: Subacromial impingement syndrome

Subacromial impingement presents with positive Neer and Hawkins-Kennedy signs, pain with overhead activity, and crepitus due to compression of the rotator cuff beneath the acromion.

Question 58: A 65-year-old male with BPH and urinary retention is catheterized and drains 1,200 mL of urine. Two hours later he develops gross hematuria and hypotension. What has occurred?

Urinary tract infection
Post-obstructive diuresis with hemorrhagic cystitis (Correct answer)
Bladder rupture
Vesicoureteral reflux

Correct answer: Post-obstructive diuresis with hemorrhagic cystitis

Rapid decompression of a chronically distended bladder can cause hemorrhagic cystitis from mucosal tears and post-obstructive diuresis leading to hemodynamic instability.

Question 59: A 35-year-old male presents with recurrent episodes of severe unilateral periorbital pain lasting 45-90 minutes, associated with ipsilateral lacrimation and nasal congestion. What is the most likely diagnosis?

Cluster headache (Correct answer)
Trigeminal neuralgia
Tension headache
Migraine with aura

Correct answer: Cluster headache

Cluster headaches are severe unilateral periorbital headaches with autonomic features (lacrimation, rhinorrhea) lasting 15-180 minutes.

Question 60: A 60-year-old presents with rectal bleeding, mucus discharge, and tenesmus. Digital rectal exam reveals a rectal mass 4 cm from the anal verge. Which is the most appropriate next step?

CEA level and colonoscopy
CT scan of the abdomen and pelvis
Flexible sigmoidoscopy with biopsy (Correct answer)
MRI of the rectum

Correct answer: Flexible sigmoidoscopy with biopsy

Flexible sigmoidoscopy with biopsy is the most appropriate initial step to directly visualize and obtain tissue from a palpable rectal mass for histologic diagnosis.

Question 61: 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?

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

Correct answer: Radioactive iodine (RAI) ablation

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

Question 62: 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 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?

Eating spicy foods
Contact sports (Correct answer)
Prolonged sun exposure
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: What is the primary consideration when implementing changes to endocrine system?

Impact assessment and change management (Correct answer)
Speed of implementation
Personal convenience
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 65: A 68-year-old male presents with inability to urinate and a distended, palpable bladder. What is the most common cause in this population?

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

Correct answer: Benign prostatic hyperplasia

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

Question 66: 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?

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

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 67: 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?

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

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 68: 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?

Nicardipine IV
Nitroprusside IV (Correct answer)
Hydralazine IV
Labetalol 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 69: A patient with multiple myeloma develops worsening renal function. Which renal complication is most directly caused by light chain deposition in tubules?

IgA nephropathy
Cast nephropathy (Correct answer)
Minimal change disease
Renal artery stenosis

Correct answer: Cast nephropathy

Bence-Jones proteins (free light chains) precipitate in renal tubules, causing tubular injury and cast nephropathy (myeloma kidney).

Question 70: 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?

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

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 71: 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?

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

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 72: A 55-year-old man presents with red, scaling patches in the groin and axillae with central clearing. KOH preparation is positive for branching hyphae. What is the most appropriate treatment?

Topical mupirocin
Topical clotrimazole (Correct answer)
Oral doxycycline
Oral griseofulvin

Correct answer: Topical clotrimazole

Tinea cruris (dermatophyte infection of the groin) is treated with topical antifungals such as clotrimazole or terbinafine; oral therapy is reserved for resistant or extensive cases.

Question 73: 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
Azithromycin 1g orally single dose
Doxycycline 100mg twice daily for 7 days
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 74: 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 75: 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?

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

Correct answer: Furosemide plus metolazone

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

Question 76: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Schistocytes (Correct answer)
Bite cells
Spherocytes
Target cells

Correct answer: Schistocytes

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

Question 77: What constitutes a risk factor for endometriosis development?

Delayed childbearing (Correct answer)
Short periods
Lengthened menstrual cycles
Multiple pregnancies

Correct answer: Delayed childbearing

Delayed childbearing is a significant risk factor for endometriosis because it increases the number of menstrual cycles a woman experiences throughout her reproductive life. Each menstrual cycle provides an opportunity for endometrial tissue to reflux and implant outside the uterus, contributing to the development and progression of endometriosis. Other factors like early menarche and short, heavy periods also increase exposure to menstrual flow.

Question 78: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

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

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 79: A 10-year-old with recurrent otitis media now has a white pearly mass visible through the tympanic membrane with a foul-smelling discharge. CT shows erosion of the ossicles. What is the diagnosis?

Tympanosclerosis
Adenoid hypertrophy
Glomus tympanicum
Cholesteatoma (Correct answer)

Correct answer: Cholesteatoma

Cholesteatoma is a destructive accumulation of keratinizing squamous epithelium in the middle ear that erodes ossicles and can extend intracranially; surgical removal is required.

Question 80: A 60-year-old woman presents with progressive difficulty climbing stairs and rising from a chair over 4 months, with proximal muscle weakness but no muscle pain. CK is mildly elevated. Which antibody is associated with dermatomyositis?

Anti-Jo-1
Anti-SRP
Anti-MDA5
Anti-Mi-2 (Correct answer)

Correct answer: Anti-Mi-2

Anti-Mi-2 antibodies are highly specific for dermatomyositis (classic DM) and correlate with a good response to treatment.

Question 81: 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?

Infectious mononucleosis
Hodgkin lymphoma (Correct answer)
Burkitt lymphoma
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 82: 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?

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

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 83: 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?

Streptococcus pneumoniae
Aspergillus fumigatus
Pseudomonas aeruginosa (Correct answer)
Staphylococcus aureus

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 84: 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 2 — perform rapid strep test
Score 3 — perform rapid strep test or empirically treat (Correct answer)
Score 4 — empirically treat with antibiotics without testing
Score 1 — no antibiotics needed

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 85: 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?

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

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 86: A 72-year-old woman presents with sudden-onset right-sided weakness and aphasia that resolved completely within 45 minutes. MRI of the brain shows no acute infarct. What is the most appropriate next step?

Admit for urgent evaluation and antiplatelet therapy (Correct answer)
Administer tPA immediately
Schedule outpatient neurology follow-up in 2 weeks
Start aspirin and discharge home

Correct answer: Admit for urgent evaluation and antiplatelet therapy

A TIA carries a high short-term stroke risk (up to 10% within 2 days), requiring urgent inpatient evaluation including imaging, cardiac monitoring, and antiplatelet therapy.

Question 87: 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:

Cervical myelopathy
Amyotrophic lateral sclerosis (Correct answer)
Syringomyelia
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 88: 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
Amphotericin B plus flucytosine (Correct answer)
Caspofungin

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 89: Which electrolyte abnormality is most characteristic of primary hyperaldosteronism (Conn syndrome)?

Hyperkalemia and hypernatremia
Hypokalemia and hypertension (Correct answer)
Hyponatremia and hypotension
Hyperkalemia and hypotension

Correct answer: Hypokalemia and hypertension

Excess aldosterone causes sodium retention and potassium wasting, producing hypokalemia with hypertension.

Question 90: 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 91: Which finding is MOST specific for exudative pleural effusion using Light's criteria?

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

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 92: 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)
No treatment needed until delivery
Check maternal antibody titers monthly and treat if positive
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 93: 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?

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

Correct answer: Narcolepsy with cataplexy

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

Question 94: A 35-year-old female presents with diffuse musculoskeletal pain for 6 months, fatigue, non-restorative sleep, and 14 tender points. Labs including ANA and ESR are normal. What is the diagnosis?

Fibromyalgia (Correct answer)
Rheumatoid arthritis
Systemic lupus erythematosus
Polymyalgia rheumatica

Correct answer: Fibromyalgia

Fibromyalgia is characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and multiple tender points with normal laboratory findings.

Question 95: 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?

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

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 96: What is the fundamental principle behind reproductive system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 97: 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)
Streptococcus pneumoniae
Klebsiella 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 98: A patient with MEN1 syndrome would most likely have which combination of tumors?

Pheochromocytoma, parathyroid adenoma, meningioma
Pituitary adenoma, pancreatic islet tumor, parathyroid hyperplasia (Correct answer)
Pheochromocytoma, medullary thyroid cancer, hyperparathyroidism
Medullary thyroid cancer, pheochromocytoma, mucosal neuromas

Correct answer: Pituitary adenoma, pancreatic islet tumor, parathyroid hyperplasia

MEN1 (Wermer syndrome) involves the 3 Ps: pituitary adenoma, pancreatic islet tumors, and parathyroid hyperplasia.

Question 99: A 28-year-old white male in generally good health has had dull testicular pain for the past two weeks. He denies penile discharge, and the scrotum is non-erythematous, he is negative for sexually transmitted infections. Which do you believe?

Testicular cancer (Correct answer)
Hydrocele
Epididymitis
Spermatocele

Correct answer: Testicular cancer

In a young male, persistent dull testicular pain without signs of infection (no discharge, non-erythematous scrotum, negative STIs) should raise suspicion for testicular cancer. While other conditions can cause testicular pain, testicular cancer often presents with a painless mass or a dull ache/heaviness, making it a crucial diagnosis to rule out promptly in this demographic.

Question 100: A 35-year-old presents with episodic peptic ulcers refractory to PPI therapy and diarrhea. Fasting serum gastrin is 1,200 pg/mL. What is the most likely diagnosis?

Zollinger-Ellison syndrome (Correct answer)
H. pylori gastritis
VIPoma
Autoimmune gastritis

Correct answer: Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is caused by a gastrin-secreting tumor (gastrinoma), leading to massively elevated gastrin, multiple refractory peptic ulcers, and diarrhea.

Question 101: 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
Epidermoid cyst
Facial nerve hemangioma
Vestibular schwannoma (acoustic neuroma) (Correct answer)

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 102: A congenital hip dislocation diagnosis is made.

At 6 months of age
At birth (Correct answer)
In utero
At 6 weeks of age

Correct answer: At birth

Developmental dysplasia of the hip (DDH), formerly known as congenital hip dislocation, should ideally be diagnosed at birth or during the neonatal period. Early detection through physical examination maneuvers like the Ortolani and Barlow tests is crucial. Prompt diagnosis allows for non-surgical interventions, such as bracing, which are highly effective in correcting the condition and preventing long-term complications.

Question 103: A 30-year-old marathon runner collapses during a race. His ECG shows deep T-wave inversions in V1-V4 and epsilon waves. What is the most likely diagnosis?

Arrhythmogenic right ventricular cardiomyopathy (ARVC) (Correct answer)
Brugada syndrome
Hypertrophic cardiomyopathy
Long QT syndrome

Correct answer: Arrhythmogenic right ventricular cardiomyopathy (ARVC)

ARVC is characterized by epsilon waves, T-wave inversions in right precordial leads, and fatty replacement of the right ventricular myocardium, causing ventricular arrhythmias.

Question 104: 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?

Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days (Correct answer)
Ciprofloxacin 500 mg PO + doxycycline 100 mg PO BID × 7 days
Ceftriaxone 250 mg IM + azithromycin 1 g PO
Penicillin G 4.8 million units IM + probenecid

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 105: 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?

Sarcoidosis (Correct answer)
Lymphoma
Mesothelioma
Tuberculosis

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 106: In PANCE practice, what is the best approach to quality improvement in dermatology?

Make changes without measuring results
Wait for problems to occur before acting
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 107: A 65-year-old male with a history of NSAID use presents with a duodenal ulcer. Which of the following locations is most common for duodenal ulcers?

Junction of the pylorus and duodenum
Posterior wall of the duodenal bulb
Second portion of the duodenum
Anterior wall of the first part of the duodenum (Correct answer)

Correct answer: Anterior wall of the first part of the duodenum

The majority of duodenal ulcers occur on the anterior wall of the first part (bulb) of the duodenum, where acid exposure is highest.

Question 108: A 28-year-old woman at 10 weeks gestation presents with severe nausea, vomiting, and a uterus larger than expected for gestational age. β-hCG is markedly elevated. Ultrasound shows a 'snowstorm' pattern. What is the diagnosis?

Twin gestation
Ectopic pregnancy
Threatened abortion
Complete hydatidiform mole (Correct answer)

Correct answer: Complete hydatidiform mole

A complete hydatidiform mole presents with markedly elevated β-hCG, uterine size larger than dates, and a classic snowstorm ultrasound pattern.

Question 109: 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?

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

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 110: 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?

Emergent neurosurgical decompression
High-dose corticosteroids
Therapeutic hypothermia (whole-body cooling) (Correct answer)
IV phenobarbital only

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 111: 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?

5 years
15 years
10 years (Correct answer)
3 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 112: What is the value of continuing education in musculoskeletal for PANCE professionals?

It replaces workplace experience
It keeps professionals current with evolving standards and practices (Correct answer)
It is primarily a social activity
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 113: 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?

Catheter-directed thrombolysis only
Surgical embolectomy as first-line
Anticoagulation with unfractionated heparin alone
Systemic thrombolysis with alteplase (Correct answer)

Correct answer: Systemic thrombolysis with alteplase

Massive PE with hemodynamic compromise and no contraindications is the primary indication for systemic thrombolysis with alteplase.

Question 114: A patient with acromegaly would most commonly present with which cardiovascular complication?

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

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 115: A 30-year-old woman presents with a butterfly rash, joint pain, oral ulcers, and a positive ANA with anti-dsDNA antibodies. Which complication is most likely to determine her long-term prognosis?

Serositis
Photosensitivity
Dermatitis
Lupus nephritis (Correct answer)

Correct answer: Lupus nephritis

Lupus nephritis is the most serious complication of SLE and the leading cause of morbidity and mortality, requiring close monitoring of renal function.

Question 116: Which of the following is NOT a feature of irritable bowel syndrome (IBS)?

Abdominal pain relieved by defecation
Nocturnal diarrhea awakening the patient (Correct answer)
Bloating and flatulence
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 117: 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
Von Willebrand disease type 3
Hemophilia B

Correct answer: Hemophilia A

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

Question 118: What is the best practice for maintaining endocrine system performance over time?

Outsource all maintenance
Wait for failures before acting
Upgrade all equipment annually
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 119: A 50-year-old man is found to have a serum calcium of 9.0 mg/dL and PTH of 12 pg/mL (low). He complains of muscle cramps and perioral tingling. Which condition is most likely?

Secondary hyperparathyroidism
Familial hypocalciuric hypercalcemia
Hypoparathyroidism (Correct answer)
Primary hyperparathyroidism

Correct answer: Hypoparathyroidism

Low PTH with low-normal calcium and symptoms of hypocalcemia (cramps, tingling) is consistent with hypoparathyroidism.

Question 120: 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?

Alport syndrome
Nephrotic syndrome — minimal change disease (Correct answer)
IgA nephropathy
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 121: A 52-year-old has splenomegaly, WBC of 85,000 with basophilia, and a Philadelphia chromosome on cytogenetics. What is the diagnosis?

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

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 122: 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?

Digoxin
Hydralazine
Amlodipine
Spironolactone (Correct answer)

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 123: 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
Admit for 24-hour video EEG monitoring
Treat underlying hypoglycemia cause; no antiepileptic drug needed (Correct answer)
Perform emergent MRI brain

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 124: 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?

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

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 125: 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
Congenital absence of vas deferens
Retrograde ejaculation
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 126: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hypercalcemia
Hyperphosphatemia (Correct answer)
Hypokalemia
Hypernatremia

Correct answer: Hyperphosphatemia

Impaired phosphate excretion in CKD leads to hyperphosphatemia, which also drives secondary hyperparathyroidism.

Question 127: 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 128: 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?

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

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 129: A 44-year-old woman is newly diagnosed with stage II cervical cancer. HPV genotyping shows HPV-18. Which treatment modality is most appropriate?

Cone biopsy with close surveillance
Radiation alone
Radical hysterectomy alone
Concurrent cisplatin-based chemotherapy and radiation (Correct answer)

Correct answer: Concurrent cisplatin-based chemotherapy and radiation

Stage II cervical cancer is treated with concurrent cisplatin-based chemoradiation, which improves survival compared to radiation alone.

Question 130: 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 131: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?

Prior BCG vaccination causing false-negative TST
Active TB disease
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 132: What is the first-line treatment for newly diagnosed warm autoimmune hemolytic anemia?

Splenectomy
Corticosteroids (Correct answer)
Rituximab
Intravenous immunoglobulin

Correct answer: Corticosteroids

Corticosteroids suppress autoantibody production and are the initial treatment of choice for warm AIHA.

Question 133: Which approach is recommended for troubleshooting cardiovascular system issues?

Rely solely on past experience
Wait for the problem to resolve itself
Use systematic isolation and testing methods (Correct answer)
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 134: 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
Epstein-Barr virus
Human herpesvirus 8 (HHV-8) (Correct answer)

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 135: A patient with autosomal dominant polycystic kidney disease asks about the most life-threatening extrarenal complication. What is it?

Pancreatic cysts
Intracranial berry aneurysm (Correct answer)
Mitral valve prolapse
Hepatic cysts

Correct answer: Intracranial berry aneurysm

Intracranial berry aneurysms occur in ~10% of ADPKD patients and are the most dangerous extrarenal manifestation due to subarachnoid hemorrhage risk.

Question 136: 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?

Administer emergency contraception
Inform the patient of the error only if she becomes pregnant
Immediately inform the patient of the error (Correct answer)
Inform the donor of the error only if the patient 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 137: 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 138: A 19-year-old has her first generalized tonic-clonic seizure. Post-ictal she is confused and has a bitten tongue. EEG shows generalized spike-and-wave discharges at 3–4 Hz. What is the most appropriate initial medication?

Carbamazepine
Oxcarbazepine
Ethosuximide
Valproic acid (Correct answer)

Correct answer: Valproic acid

Valproic acid is first-line for juvenile myoclonic epilepsy and generalized epilepsies with tonic-clonic seizures; carbamazepine can worsen generalized epilepsies.

Question 139: A 48-year-old man is found to have a total cholesterol of 280, LDL 190, HDL 38, and triglycerides 250. He has no cardiovascular disease. What is the primary treatment target?

Lower triglycerides with fibrate
Lower LDL with high-intensity statin (Correct answer)
Lower total cholesterol with bile acid sequestrant
Raise HDL with niacin

Correct answer: Lower LDL with high-intensity statin

High-intensity statin therapy targeting LDL reduction is the primary intervention for primary prevention in patients with LDL ≥190 mg/dL per ACC/AHA guidelines.

Question 140: A 70-year-old has macrocytic anemia, glossitis, and neurologic symptoms. Labs show elevated methylmalonic acid and homocysteine. What is the deficiency?

Pyridoxine
Vitamin B12 (Correct answer)
Thiamine
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 141: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

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

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 142: A 45-year-old woman presents with a salmon-colored, well-demarcated plaque with silvery scale on her elbows and knees. Which finding would most likely be seen on biopsy?

Acanthosis with parakeratosis and Munro microabscesses (Correct answer)
Perivascular lymphocytic infiltrate with plasma cells
Spongiosis with eosinophilic infiltrate
Interface dermatitis with vacuolar change

Correct answer: Acanthosis with parakeratosis and Munro microabscesses

Psoriasis classically shows acanthosis, parakeratosis, and Munro microabscesses (neutrophils in the stratum corneum).

Question 143: 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 hydroxychloroquine
Add methotrexate
Increase NSAID dose indefinitely

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 144: 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 145: 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?

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

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 146: Which murmur is best heard at the left sternal border and increases with inspiration?

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

Correct answer: Tricuspid regurgitation

Tricuspid regurgitation is heard at the left lower sternal border and increases with inspiration (Carvallo's sign) due to increased venous return.

Question 147: A 40-year-old diver presents with right ear pain and conductive hearing loss after a dive to 30 meters. Otoscopy shows a hemotympanum. What is the diagnosis?

Barotrauma (ear squeeze) (Correct answer)
Otitis externa
Otitis media
Perilymphatic fistula

Correct answer: Barotrauma (ear squeeze)

Middle ear barotrauma occurs when pressure cannot equalize across the tympanic membrane during descent, causing hemorrhage into the middle ear (hemotympanum).

Question 148: 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?

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

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

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

Correct answer: Direct phospholipid accumulation and oxidative injury

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

Question 150: A 70-year-old woman presents with a firm, painless, flesh-colored papule on her lower eyelid that has grown slowly over 2 years. The border is irregular and there is perineural invasion on biopsy. What subtype of cutaneous cancer is most aggressive?

Morpheaform (sclerosing) basal cell carcinoma (Correct answer)
Nodular basal cell carcinoma
Pigmented BCC
Superficial BCC

Correct answer: Morpheaform (sclerosing) basal cell carcinoma

Morpheaform (sclerosing) BCC has the most aggressive behavior, with subclinical extension and perineural invasion, requiring Mohs surgery for adequate margins.

Question 151: Which of the following is the most common cause of Cushing syndrome in clinical practice?

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

Correct answer: Exogenous corticosteroid use

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

Question 152: Which professional attribute is most valued in musculoskeletal within the PANCE field?

Prioritizing personal convenience
Accountability and commitment to standards (Correct answer)
Working in isolation
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 153: 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?

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

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

Using the newest technology exclusively
Following a single vendor solution
Balancing performance, reliability, and efficiency (Correct answer)
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 155: Which documentation is essential when working with reproductive system in PANCE?

Only verbal notes
General descriptions without specifics
Detailed technical specifications and as-built diagrams (Correct answer)
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 156: 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 ovale
Plasmodium malariae
Plasmodium vivax
Plasmodium falciparum (Correct answer)

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 157: 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?

Febuxostat
Allopurinol
Indomethacin (Correct answer)
Probenecid

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 158: 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?

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

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 159: 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?

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

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

Vitamin B12
Vitamin D
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 161: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

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

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

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

Correct answer: ACE inhibitors

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

Question 163: A 30-year-old woman presents with polyuria, polydipsia, and a serum sodium of 155 mEq/L. Urine osmolality remains low after water deprivation but rises with desmopressin administration. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

Response to desmopressin confirms central diabetes insipidus, as ADH deficiency is corrected by exogenous desmopressin.

Question 164: 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
Psoriatic arthritis
Seropositive rheumatoid arthritis (Correct answer)
Systemic lupus erythematosus

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

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

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

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

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 167: 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?

Phosphodiesterase-5 inhibitors (sildenafil) (Correct answer)
Prostacyclin analogs (epoprostenol)
Endothelin receptor antagonists (bosentan)
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 168: 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
Continue antibiotics and repeat thoracentesis in 48 hours
Intrapleural fibrinolytics only
Chest tube drainage (Correct answer)

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 169: A chest X-ray shows a unilateral pleural effusion. Thoracentesis fluid analysis reveals: LDH 320 U/L (serum LDH 180 U/L), protein 4.2 g/dL (serum protein 6.8 g/dL). How is this effusion classified?

Transudate — consistent with heart failure
Exudate — pleural LDH > 2/3 upper limit of normal serum LDH (Correct answer)
Indeterminate — requires repeat sampling
Transudate — pleural/serum protein ratio < 0.5

Correct answer: Exudate — pleural LDH > 2/3 upper limit of normal serum LDH

By Light's criteria, pleural LDH > 2/3 the upper limit of normal serum LDH (or pleural/serum LDH ratio > 0.6) classifies the effusion as an exudate.

Question 170: 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?

Acyclovir 800 mg PO 5 times daily × 7–10 days
Valacyclovir 1000 mg PO TID × 7 days (Correct answer)
Famciclovir 500 mg PO TID × 7 days
Oseltamivir 75 mg BID × 5 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 171: A 68-year-old woman presents with polyuria, polydipsia, constipation, and confusion. Labs show calcium of 13.8 mg/dL and PTH is elevated. What is the most common cause of this presentation?

Primary hyperparathyroidism (Correct answer)
Vitamin D toxicity
Sarcoidosis
Malignancy-associated hypercalcemia

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism is the most common cause of asymptomatic and symptomatic hypercalcemia with elevated PTH, typically due to a parathyroid adenoma.

Question 172: 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?

Indomethacin or colchicine (Correct answer)
Allopurinol
Probenecid
Methotrexate

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 173: 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?

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

Correct answer: Antiphospholipid syndrome

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

Question 174: 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
Erythema nodosum (Correct answer)
Ankylosing spondylitis
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 175: 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?

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

Correct answer: Homocystinuria

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

Question 176: 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?

Angiomyolipoma
Transitional cell carcinoma
Renal cell carcinoma (Correct answer)
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 177: Which documentation is essential when working with endocrine system in PANCE?

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

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 178: 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?

Virchow node (Correct answer)
Sister Mary Joseph node
Blumer shelf
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 179: 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?

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

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 180: 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?

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

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 181: 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
Patellar tendinopathy (Correct answer)
Osgood-Schlatter disease
Patellofemoral syndrome

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 182: A right-handed patient has an infarct of the left middle cerebral artery territory. Which deficit is most expected?

Bilateral lower extremity weakness
Left hemiplegia with neglect
Right hemiplegia with expressive aphasia (Correct answer)
Left homonymous hemianopia only

Correct answer: Right hemiplegia with expressive aphasia

Left MCA stroke in a right-handed person causes contralateral (right) hemiplegia and Broca or global aphasia since language centers are in the left hemisphere.

Question 183: 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?

Calcium oxalate (Correct answer)
Uric acid
Cystine
Struvite

Correct answer: Calcium oxalate

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

Question 184: A 35-year-old woman has episodic hypertension, headache, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. Which imaging is most appropriate next?

Nuclear stress test
Ultrasound of the thyroid
CT or MRI of the abdomen/pelvis (Correct answer)
Chest X-ray

Correct answer: CT or MRI of the abdomen/pelvis

CT or MRI of the abdomen/pelvis is used to localize pheochromocytoma after biochemical confirmation.

Question 185: Which of the following features best differentiates essential tremor from Parkinson tremor?

Essential tremor improves with levodopa
Essential tremor is a resting tremor that improves with intention
Essential tremor is an action/postural tremor that worsens at rest (Correct answer)
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 186: A 45-year-old with silicosis develops a new cavitary upper lobe lesion. Which organism is most likely responsible?

Mycobacterium tuberculosis (Correct answer)
Streptococcus pneumoniae
Aspergillus fumigatus
Pseudomonas aeruginosa

Correct answer: Mycobacterium tuberculosis

Silicosis dramatically increases susceptibility to tuberculosis, which preferentially causes upper lobe cavitary lesions.

Question 187: 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?

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

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

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

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 189: A 40-year-old woman presents with exertional dyspnea and a loud S1 with an opening snap. Echocardiogram shows a mitral valve area of 1.2 cm². What is the preferred intervention?

Mitral valve replacement
Percutaneous mitral balloon valvuloplasty (Correct answer)
Anticoagulation alone
Beta-blocker therapy alone

Correct answer: Percutaneous mitral balloon valvuloplasty

Percutaneous mitral balloon valvuloplasty is the procedure of choice for symptomatic severe mitral stenosis with favorable valve morphology (pliable, non-calcified leaflets).

Question 190: In PANCE practice, what is the best approach to quality improvement in eent?

Copy what other organizations do without analysis
Make changes without measuring results
Use data-driven methods with measurable outcomes (Correct answer)
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 191: A 40-year-old male with chronic kidney disease stage 3 presents with lab values: sodium 138, potassium 5.8, bicarbonate 18, BUN 42, creatinine 2.4. Which acid-base disturbance is present?

Anion gap metabolic acidosis (Correct answer)
Metabolic alkalosis
Respiratory acidosis
Non-anion gap metabolic acidosis

Correct answer: Anion gap metabolic acidosis

CKD causes accumulation of uremic acids (phosphate, sulfate, urate) creating an elevated anion gap metabolic acidosis.

Question 192: A 60-year-old diabetic male presents with severe left-sided otalgia, purulent otorrhea, and granulation tissue visible in the external auditory canal. He has facial nerve palsy. CT shows cortical bone erosion at the skull base. What is the most likely organism?

Aspergillus niger
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; facial nerve palsy indicates skull base osteomyelitis requiring prolonged IV antipseudomonal therapy.

Question 193: 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?

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

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 194: A 30-year-old woman with known asthma presents to the ED with severe bronchospasm unresponsive to two doses of albuterol. Which medication is most appropriate next?

IV aminophylline
IV magnesium sulfate (Correct answer)
Oral prednisone 40 mg
Inhaled ipratropium bromide

Correct answer: IV magnesium sulfate

IV magnesium sulfate relaxes bronchial smooth muscle and is indicated for severe acute asthma refractory to initial bronchodilator therapy.

Question 195: 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
Neisseria meningitidis (Correct answer)
Haemophilus influenzae

Correct answer: Neisseria meningitidis

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

Question 196: 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?

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

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

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

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 198: What is the fundamental principle behind pulmonary system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 199: 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)
Auto-PEEP
Pulmonary fibrosis

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 200: 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?

Acute cholecystitis
Ascending cholangitis (Correct answer)
Hepatitis A
Choledocholithiasis

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 201: 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?

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

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 202: 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?

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

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 203: 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?

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

Correct answer: Humoral hypercalcemia of malignancy

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

Question 204: A 6-year-old presents with 5 days of fever, purulent nasal discharge, and periorbital edema. CT scan shows opacification of the ethmoid sinuses and a subperiosteal abscess along the medial orbital wall. What is the most appropriate management?

Topical nasal decongestants and systemic steroids
IV antibiotics and urgent surgical drainage (Correct answer)
IV antibiotics alone without surgery
Oral amoxicillin-clavulanate and close follow-up

Correct answer: IV antibiotics and urgent surgical drainage

Subperiosteal orbital abscess secondary to ethmoid sinusitis requires IV antibiotics plus urgent surgical drainage to prevent optic nerve compression and vision loss.

Question 205: 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?

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

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 206: On his fingertips, a 26-year-old male has 3 to 4 cm depigmented irregular patches that have been there for the past two months and appear to be becoming bigger. What is probably taking place with this patient?

Chronic fungal infection with underlying disease
Acute infection with a virus
Too much sun exposure
Loss of skin melanocytes with unclear cause (Correct answer)

Correct answer: Loss of skin melanocytes with unclear cause

The description of 3-4 cm depigmented, irregular, and growing patches on the fingertips is characteristic of vitiligo. Vitiligo is an autoimmune condition where the body's immune system attacks and destroys melanocytes, the cells responsible for producing skin pigment. This leads to the appearance of white patches on the skin, and its cause is often unclear but involves autoimmune mechanisms.

Question 207: 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?

Acoustic neuroma
Meningioma
Glomus jugulare tumor (Correct answer)
Cholesteatoma

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 208: 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?

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

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 209: A 28-year-old woman presents with cyclic pelvic pain, dyspareunia, and infertility. Laparoscopy reveals powder-burn lesions on the peritoneum. Which mechanism best explains her infertility?

Cervical stenosis blocking sperm entry
Distorted pelvic anatomy and inflammatory cytokines impairing implantation (Correct answer)
Autoimmune destruction of oocytes
Anovulation due to elevated prolactin

Correct answer: Distorted pelvic anatomy and inflammatory cytokines impairing implantation

Endometriosis causes infertility through distorted pelvic anatomy, peritoneal inflammation, and cytokine-mediated impairment of fertilization and implantation.

Question 210: 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?

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

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

Sitagliptin
Metformin (Correct answer)
Empagliflozin
Glipizide

Correct answer: Metformin

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

Question 212: A 45-year-old woman presents with weight gain, cold intolerance, and constipation. TSH is 12 mIU/L and free T4 is low. Which medication is first-line treatment?

Methimazole
Levothyroxine (Correct answer)
Radioactive iodine
Propylthiouracil

Correct answer: Levothyroxine

Levothyroxine (synthetic T4) is the first-line treatment for hypothyroidism.

Question 213: 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
Postrenal obstruction
Prerenal azotemia (Correct answer)
Glomerulonephritis

Correct answer: Prerenal azotemia

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

Question 214: Which professional attribute is most valued in dermatology within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 215: A patient has microcytic anemia, low serum ferritin, low serum iron, and elevated TIBC. What is the diagnosis?

Sideroblastic anemia
Iron deficiency anemia (Correct answer)
Anemia of chronic disease
Thalassemia minor

Correct answer: Iron deficiency anemia

Low ferritin, low serum iron, and elevated TIBC are the hallmark lab findings of iron deficiency anemia.

Question 216: 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)
Focal segmental glomerulosclerosis
Minimal change disease
IgA nephropathy

Correct answer: Poststreptococcal glomerulonephritis

Poststreptococcal GN typically follows strep pharyngitis by 1–3 weeks and presents with hematuria and edema.

Question 217: Which of the following is the most appropriate first-line treatment for Helicobacter pylori eradication in the US?

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

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 218: A 40-year-old African American woman presents with bilateral hilar lymphadenopathy, uveitis, and erythema nodosum. Serum ACE level is elevated. What is the most likely diagnosis?

Histoplasmosis
Lymphoma
Sarcoidosis (Correct answer)
Tuberculosis

Correct answer: Sarcoidosis

The triad of bilateral hilar lymphadenopathy, uveitis, and erythema nodosum with elevated ACE is classic for sarcoidosis, which has higher prevalence in African Americans.

Question 219: 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?

Aspergillosis
Histoplasmosis (Correct answer)
Blastomycosis
Coccidioidomycosis

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 220: 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?

Ceftriaxone 500 mg IM single dose
Doxycycline 100 mg PO BID × 14 days
Penicillin G benzathine 2.4 million units IM single dose (Correct answer)
Azithromycin 1 g PO 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 221: 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?

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

Correct answer: Small cell carcinoma

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

Question 222: A newborn is noted to have a unilateral nasal obstruction with failure to pass a catheter through the right nostril. The infant becomes cyanotic while feeding but pinks up when crying. What is the diagnosis?

Deviated nasal septum
Choanal atresia (Correct answer)
Congenital turbinate hypertrophy
Nasal encephalocele

Correct answer: Choanal atresia

Choanal atresia is a congenital blockage of the posterior nasal aperture; neonates are obligate nasal breathers, so they become cyanotic feeding (nose only) but improve when crying (mouth open).

Question 223: What is the primary consideration when implementing changes to pulmonary system?

Impact assessment and change management (Correct answer)
Speed of implementation
Personal convenience
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 224: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

Amnioinfusion
Administer terbutaline and reassess
Apply fetal scalp electrode for better monitoring
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 225: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

Serum sodium 130 mEq/L, urine osmolality 80 mOsm/kg, urine sodium 10 mEq/L
Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L (Correct answer)
Serum sodium 132 mEq/L, urine osmolality 100 mOsm/kg, urine sodium 8 mEq/L
Serum sodium 125 mEq/L, urine osmolality 60 mOsm/kg, urine sodium 5 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 226: 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?

Drospirenone (Correct answer)
Norgestrel
Norethindrone
Levonorgestrel

Correct answer: Drospirenone

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

Question 227: 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?

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

Correct answer: Ulcerative colitis

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

Question 228: Which documentation is essential when working with cardiovascular system in PANCE?

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

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 229: 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?

Fluconazole
Caspofungin
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 230: Which urine finding best differentiates nephritic syndrome from nephrotic syndrome?

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

Correct answer: RBC casts

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

Question 231: 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?

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

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 232: 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?

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

Correct answer: Systemic lupus erythematosus

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

Question 233: 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
Streptococcus viridans
Staphylococcus aureus (Correct answer)
Staphylococcus epidermidis

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 234: 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?

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

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 235: Which approach best demonstrates mastery of gastrointestinal 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 236: 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
Optic neuritis
Acute angle-closure glaucoma
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 237: 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?

Presbycusis
Cholesteatoma
Ossicular chain disruption from trauma
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 238: 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 hairy leukoplakia (Correct answer)
Aphthous ulcers
Oral candidiasis (thrush)

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 239: What is the fundamental principle behind neurologic system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 240: 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?

Loss of elastic recoil causing dynamic airway collapse (Correct answer)
Mucus gland hyperplasia obstructing large airways
Bronchial smooth muscle hypertrophy
Alveolar wall thickening reducing diffusion capacity

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 241: 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)
Waldenstrom macroglobulinemia
Chronic lymphocytic leukemia
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 242: A patient with Parkinson disease develops visual hallucinations after starting a new medication. Which drug is the most likely culprit?

Pramipexole (Correct answer)
Trihexyphenidyl
Amantadine
Carbidopa-levodopa

Correct answer: Pramipexole

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

Question 243: 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 244: Which cranial nerve is responsible for the corneal reflex afferent limb?

CN V (ophthalmic branch) (Correct answer)
CN VII
CN VI
CN III

Correct answer: CN V (ophthalmic branch)

The afferent limb of the corneal reflex is mediated by CN V1 (ophthalmic branch of trigeminal nerve); the efferent limb is CN VII (facial nerve).

Question 245: 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?

Peripheral arterial disease
Lumbar spinal stenosis (Correct answer)
L4 disc herniation
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 246: 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?

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

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 247: Which documentation is essential when working with pulmonary system in PANCE?

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

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 248: 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?

Estrogen-only therapy (Correct answer)
Combined estrogen-progestin therapy
Progestin-only therapy
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 249: 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
Hereditary spherocytosis
Pyruvate kinase deficiency
G6PD deficiency (Correct answer)

Correct answer: G6PD deficiency

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

Question 250: 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
Cauda equina syndrome
Piriformis 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 251: A patient with CKD has a serum potassium of 6.4 mEq/L and peaked T-waves on ECG. What is the first intervention?

Sodium bicarbonate
Sodium polystyrene sulfonate
IV calcium gluconate (Correct answer)
Insulin with dextrose

Correct answer: IV calcium gluconate

IV calcium gluconate immediately stabilizes the cardiac membrane when ECG changes are present in hyperkalemia.

Question 252: A 72-year-old woman presents with a 6-month history of progressive memory loss, gait disturbance, and urinary incontinence. CT shows enlarged ventricles out of proportion to cortical atrophy. What is the diagnosis?

Vascular dementia
Normal pressure hydrocephalus (Correct answer)
Alzheimer disease
Lewy body dementia

Correct answer: Normal pressure hydrocephalus

Normal pressure hydrocephalus presents with the triad of gait apraxia, cognitive decline, and urinary incontinence with ventriculomegaly disproportionate to atrophy.

Question 253: 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?

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

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 254: 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?

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

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 255: 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?

8 hours
12 hours
15 hours (Correct answer)
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 256: 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?

Silicosis (Correct answer)
Coal workers' pneumoconiosis
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 257: What is the first-line noninvasive screening test for suspected renal artery stenosis?

CT angiography
MR angiography
Renal artery duplex ultrasound (Correct answer)
Conventional arteriography

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 258: Which finding on DEXA scan defines osteoporosis (not osteopenia)?

T-score between -1.0 and -2.5
Z-score below -2.0
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 259: A patient with a distal radius fracture develops loss of thumb opposition and thenar atrophy 3 months after casting. Which nerve is involved?

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

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 260: 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 261: 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 >20:1 with urine sodium <20 mEq/L (Correct answer)
BUN:Cr ratio <10:1 with urine sodium >40 mEq/L

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 262: 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?

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

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 263: 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?

Fidaxomicin 200 mg PO BID × 10 days
Vancomycin 125 mg PO QID × 10 days (Correct answer)
Metronidazole 500 mg PO TID × 10 days
Rifaximin 550 mg PO TID × 14 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 264: Which acid-base disorder is most commonly seen in end-stage renal disease?

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

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 265: 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?

Central retinal vein occlusion
Retinal detachment
Vitreous hemorrhage
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 266: 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?

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

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 267: 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?

Cytomegalovirus pneumonitis
Pneumocystis jirovecii pneumonia (Correct answer)
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 268: A 40-year-old HIV-positive patient (CD4 count 80 cells/μL) presents with headache, fever, and altered mental status. CSF India ink preparation shows encapsulated organisms. What is the treatment?

Liposomal amphotericin B plus flucytosine (Correct answer)
Ceftriaxone plus vancomycin
Acyclovir IV
Fluconazole monotherapy

Correct answer: Liposomal amphotericin B plus flucytosine

Cryptococcal meningitis is treated with induction using liposomal amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole consolidation.

Question 269: 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?

Doxycycline 100 mg PO BID × 14–21 days (Correct answer)
Ceftriaxone 2 g IV daily × 14 days
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 270: 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 271: A 70-year-old man with history of MI 10 years ago presents with a pulsatile abdominal mass. Ultrasound shows infrarenal aortic diameter of 6 cm. What is the recommended management?

Emergency surgery only if symptomatic
Elective surgical or endovascular repair (Correct answer)
Beta-blocker therapy
Watchful waiting with repeat ultrasound in 1 year

Correct answer: Elective surgical or endovascular repair

Abdominal aortic aneurysms ≥5.5 cm in men warrant elective repair due to high rupture risk; endovascular repair (EVAR) is preferred if anatomy allows.

Question 272: 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
Elevated testosterone, low FSH
Low FSH and LH, low testosterone
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 273: A 58-year-old man presents with crushing chest pain radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. Which coronary artery is most likely occluded?

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

Correct answer: Right coronary artery

ST elevations in leads II, III, and aVF indicate an inferior MI, which is most commonly caused by occlusion of the right coronary artery.

Question 274: A patient is found to have a Horner syndrome (ptosis, miosis, anhidrosis) on the right side. Which of the following is the most concerning etiology?

Cluster headache
Migraine with aura
Carotid artery dissection (Correct answer)
Benign Raeder syndrome

Correct answer: Carotid artery dissection

Carotid artery dissection can interrupt the sympathetic fibers traveling along the carotid sheath and is a life-threatening cause of Horner syndrome requiring urgent imaging.

Question 275: 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?

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

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 276: A 55-year-old man presents with dark, velvety thickening of the skin in the axillae and posterior neck. He also reports 20 lb weight loss over 2 months. What is the most important next step?

Evaluate for underlying malignancy (Correct answer)
Perform skin biopsy
Test for insulin resistance
Start topical retinoids

Correct answer: Evaluate for underlying malignancy

Acanthosis nigricans with rapid onset and weight loss suggests malignant acanthosis nigricans, most commonly associated with GI adenocarcinoma.

Question 277: 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?

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

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 278: 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)
Contrast nephropathy
Acute interstitial nephritis
Prerenal azotemia

Correct answer: Acute tubular necrosis

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

Question 279: 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?

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

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 280: 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
Add valproate for better seizure control
Reduce phenytoin dose (Correct answer)
Switch to levetiracetam immediately

Correct answer: Reduce phenytoin dose

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

Question 281: A 60-year-old presents with iron deficiency anemia, weight loss, and a change in bowel habits. Colonoscopy reveals a mass in the ascending colon. Which is the most likely histologic type?

Carcinoid tumor
Lymphoma
Adenocarcinoma (Correct answer)
Squamous cell carcinoma

Correct answer: Adenocarcinoma

Over 95% of colorectal cancers are adenocarcinomas arising from colonic epithelium, with right-sided tumors often presenting with occult bleeding and anemia.

Question 282: 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?

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

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

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

Correct answer: Fault tolerance and high availability

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

Question 284: A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. What is the immediate treatment?

Thiamine before glucose (Correct answer)
Naloxone IV push
Glucose infusion alone
Haloperidol for agitation

Correct answer: Thiamine before glucose

Wernicke encephalopathy requires immediate IV thiamine before glucose, as glucose administration can precipitate or worsen thiamine deficiency.

Question 285: Graves disease is caused by which mechanism?

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

Correct answer: Stimulating antibodies against the TSH receptor

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

Question 286: 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?

Posterior
Multidirectional
Inferior
Anterior (Correct answer)

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 287: A 3-year-old boy presents with periorbital edema, ascites, and frothy urine. Urinalysis shows 4+ proteinuria. Serum albumin is 1.8 g/dL. What is the most likely diagnosis?

Nephritic syndrome
IgA nephropathy
Nephrotic syndrome (Correct answer)
Acute tubular necrosis

Correct answer: Nephrotic syndrome

Nephrotic syndrome is characterized by massive proteinuria (>3.5g/day), hypoalbuminemia, edema, and hyperlipidemia; in children, minimal change disease is the most common cause.

Question 288: 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 289: On auscultation, a patient has a harsh systolic murmur that increases in intensity with the Valsalva maneuver. Which condition is most likely?

Hypertrophic obstructive cardiomyopathy (HOCM) (Correct answer)
Mitral regurgitation
Ventricular septal defect
Aortic stenosis

Correct answer: Hypertrophic obstructive cardiomyopathy (HOCM)

HOCM murmurs increase with Valsalva (decreased preload worsens outflow obstruction), distinguishing it from most other murmurs.

Question 290: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

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

Correct answer: Immune thrombocytopenic purpura

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

Question 291: 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?

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

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 292: 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?

Calcium and vitamin D alone
Teriparatide alone
Bisphosphonate plus calcium and vitamin D (Correct answer)
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 293: 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)
Polymyalgia rheumatica
Myasthenia gravis
Fibromyalgia

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 294: 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?

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

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 295: 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?

4-factor prothrombin complex concentrate plus vitamin K IV (Correct answer)
Protamine sulfate IV
Vitamin K 10 mg IV alone
Fresh frozen plasma 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 296: A 45-year-old male with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?

Naloxone 0.4 mg IV
Thiamine 100 mg IV before glucose (Correct answer)
Folic acid 1 mg IV
Glucose 50% IV bolus

Correct answer: Thiamine 100 mg IV before glucose

Wernicke encephalopathy requires immediate thiamine before glucose to prevent precipitating or worsening the condition.

Question 297: 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?

Pseudogout
Osteoarthritis (Correct answer)
Rheumatoid arthritis
Gout

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 298: A 45-year-old male with HIV (CD4 count 80) presents with headache, fever, and meningismus. CSF India ink preparation shows encapsulated yeast. What is the most appropriate treatment?

Trimethoprim-sulfamethoxazole
Vancomycin plus ceftriaxone
Amphotericin B plus flucytosine (Correct answer)
Fluconazole alone

Correct answer: Amphotericin B plus flucytosine

Cryptococcal meningitis in immunocompromised patients is treated with induction using amphotericin B plus flucytosine, followed by consolidation with fluconazole.

Question 299: 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?

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

Correct answer: Guillain-Barré syndrome

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

Question 300: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

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

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.

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%

To Pass

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