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

Question 1: 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?

Nonspecific interstitial pneumonia (NSIP)
Hypersensitivity pneumonitis
Cryptogenic organizing pneumonia (COP)
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 2: A 3-year-old presents with high fever, drooling, muffled voice, and refusal to open the mouth. Examination shows medial displacement of the tonsil and uvular deviation. What is the most appropriate next step?

Oral antibiotics and close outpatient follow-up
Immediate needle aspiration or incision and drainage (Correct answer)
Throat culture and wait for results
CT scan of the neck with contrast

Correct answer: Immediate needle aspiration or incision and drainage

A peritonsillar abscess with airway compromise requires immediate aspiration or incision and drainage along with IV antibiotics to relieve the abscess.

Question 3: 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 4: Which one of the following is NOT a symptom of serious depression?

Hypersomnia
Anhedonia
Fatigue
Mania (Correct answer)

Correct answer: Mania

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

Question 5: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

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

Correct answer: ACE inhibitors

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

Question 6: 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?

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

Correct answer: Systemic thrombolysis with alteplase

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

Question 7: A 25-year-old woman has recurrent episodes of unilateral throbbing headache with photophobia, phonophobia, and nausea lasting 12–24 hours. What is the acute treatment of choice?

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

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

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

Question 8: Which professional attribute is most valued in musculoskeletal within the PANCE field?

Accountability and commitment to standards (Correct answer)
Working in isolation
Avoiding challenging situations
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 9: Which approach is recommended for troubleshooting reproductive system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 10: 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?

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

Correct answer: Guillain-Barré syndrome

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

Question 11: What is the most important professional competency for PANCE certification in musculoskeletal?

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 12: 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?

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

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 13: 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?

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

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 14: 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?

Coccidioidomycosis
Blastomycosis
Histoplasmosis (Correct answer)
Aspergillosis

Correct answer: Histoplasmosis

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

Question 15: A 24-year-old woman on combined oral contraceptives for 3 years presents for a routine visit. Which absolute contraindication should prompt you to discontinue her OCP?

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

Correct answer: History of migraine with aura

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

Question 16: 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
3 years
10 years (Correct answer)
15 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 17: 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?

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

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

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

Correct answer: Limitation of elevation (inferior rectus restriction)

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

Question 19: You come across a patient who has a history of optic neuritis. What test should be ordered in order to rule out any more severe comorbid conditions?

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

Correct answer: Magnetic resonance imaging (MRI)

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

Question 20: Which professional attribute is most valued in eent within the PANCE field?

Accountability and commitment to standards (Correct answer)
Working in isolation
Avoiding challenging situations
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 21: A patient with community-acquired pneumonia has a parapneumonic effusion. Thoracentesis reveals pH 7.15, glucose 45 mg/dL, and LDH 1,200 U/L. What is the next best step?

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

Correct answer: Chest tube drainage

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

Question 22: Which approach best demonstrates mastery of eent in PANCE practice?

Relying entirely on technology
Avoiding complex scenarios
Following procedures without understanding
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 23: 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 polystyrene sulfonate
Sodium bicarbonate
Insulin with dextrose
IV calcium gluconate (Correct answer)

Correct answer: IV calcium gluconate

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

Question 24: In PANCE practice, what is the best approach to quality improvement in eent?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 25: A 48-year-old on amiodarone for 3 years develops new bilateral pulmonary infiltrates and worsening PFTs. Which mechanism best explains amiodarone pulmonary toxicity?

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

Correct answer: Direct phospholipid accumulation and oxidative injury

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

Question 26: 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
Narcolepsy with cataplexy (Correct answer)
Epilepsy
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 27: A patient with DIC has prolonged PT/aPTT, low fibrinogen, elevated D-dimer, and thrombocytopenia. Which product should be given to correct the fibrinogen level?

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

Correct answer: Cryoprecipitate

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

Question 28: A 25-year-old basketball player twists his knee and feels a pop. He develops a knee effusion within 2 hours and has a positive Lachman test. What structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

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

Question 29: A 48-year-old woman presents with hot flashes, vaginal dryness, and irregular menses for 8 months. FSH is 62 mIU/mL. She has no uterus. Which hormone replacement is appropriate?

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

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 30: 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?

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

Correct answer: Oral griseofulvin

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

Question 31: What role does collaboration play in musculoskeletal for PANCE professionals?

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

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

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

Question 32: A 3-year-old child presents with a barking cough, inspiratory stridor, and low-grade fever. Neck X-ray shows a 'steeple sign.' What is the most likely diagnosis?

Viral croup (laryngotracheobronchitis) (Correct answer)
Peritonsillar abscess
Foreign body aspiration
Epiglottitis

Correct answer: Viral croup (laryngotracheobronchitis)

Viral croup causes subglottic narrowing visible as the steeple sign on AP neck X-ray, with characteristic barking cough and inspiratory stridor.

Question 33: 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?

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

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

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

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 35: 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?

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

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 36: 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?

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

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

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

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

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

Question 38: A 55-year-old man with type 2 diabetes and a history of heart failure with reduced ejection fraction (HFrEF) needs better glycemic control. Which agent provides the most cardiovascular benefit?

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

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

Switch to a TNF inhibitor (Correct answer)
Add methotrexate
Add hydroxychloroquine
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 40: A patient with a humeral shaft fracture develops wrist drop and inability to extend the fingers. Which nerve is most likely injured?

Musculocutaneous nerve
Ulnar nerve
Median nerve
Radial nerve (Correct answer)

Correct answer: Radial nerve

The radial nerve runs in the spiral groove of the humerus and is commonly injured in mid-shaft humeral fractures, causing wrist drop and finger extension weakness.

Question 41: 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?

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

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

Pregnancy loss (~0.1-0.3%) (Correct answer)
Fetal limb reduction defects
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 43: 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
MRI or CT scan of the wrist (Correct answer)
Reassure and discharge
Splint and follow-up in 4 weeks

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 44: 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?

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

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

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
Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L (Correct answer)
Serum sodium 130 mEq/L, urine osmolality 80 mOsm/kg, urine sodium 10 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 46: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?

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

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

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

Correct answer: Decreased erythropoietin production

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

Question 48: A patient with acromegaly would most commonly present with which cardiovascular complication?

Aortic stenosis
Pericardial effusion
Left ventricular hypertrophy and cardiomyopathy (Correct answer)
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 49: 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?

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

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 50: 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:

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

Correct answer: Paraneoplastic encephalomyelitis/sensory neuronopathy

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

Question 51: A 70-year-old woman with osteoporosis fractures her vertebra after minor trauma. DEXA scan shows T-score of -2.8. Which medication reduces both vertebral and hip fracture risk?

Raloxifene
Calcium supplementation alone
Alendronate (Correct answer)
Calcitonin

Correct answer: Alendronate

Bisphosphonates like alendronate reduce both vertebral and non-vertebral (including hip) fracture risk and are first-line treatment for osteoporosis.

Question 52: 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?

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

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

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

Correct answer: Thiamine IV before glucose

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

Question 54: 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?

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

Correct answer: Reduce phenytoin dose

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

Question 55: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

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

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 56: A 28-year-old man presents with painless testicular swelling. Ultrasound shows a hypoechoic intratesticular mass. AFP and beta-hCG are both elevated. What is the most likely diagnosis?

Hydrocele
Seminoma
Testicular lymphoma
Nonseminomatous germ cell tumor (Correct answer)

Correct answer: Nonseminomatous germ cell tumor

Elevation of both AFP and beta-hCG indicates a nonseminomatous germ cell tumor (e.g., embryonal carcinoma, yolk sac tumor), as pure seminomas do not elevate AFP.

Question 57: A 35-year-old presents with episodic positional vertigo triggered when lying down or rolling over in bed. Episodes last less than 1 minute. Dix-Hallpike test elicits upbeat-torsional nystagmus with a latency of 5 seconds. What is the first-line treatment?

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

Correct answer: Epley canalith repositioning maneuver

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

Question 58: A 55-year-old man presents with claudication. Doppler shows ABI of 0.72 at rest, dropping to 0.45 post-exercise. What is the first-line treatment?

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

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 59: 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?

Gardnerella vaginalis
Neisseria gonorrhoeae (Correct answer)
Mycoplasma genitalium
Trichomonas 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 60: 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?

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

Correct answer: Placenta previa

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

Question 61: A 45-year-old man presents with fatigue, splenomegaly, and a WBC of 120,000/µL with a left shift. Cytogenetics reveal the Philadelphia chromosome t(9;22). What is the first-line treatment?

Interferon-alpha
Allogeneic stem cell transplant
Imatinib (Gleevec) (Correct answer)
Hydroxyurea

Correct answer: Imatinib (Gleevec)

Imatinib, a BCR-ABL tyrosine kinase inhibitor, is first-line therapy for chronic myeloid leukemia (CML) harboring the Philadelphia chromosome.

Question 62: A 25-year-old with cystic fibrosis has chronic Pseudomonas aeruginosa colonization. Which inhaled antibiotic is approved for chronic suppressive therapy in this setting?

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

Correct answer: Inhaled tobramycin

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

Question 63: 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?

Sitagliptin
Insulin glargine
Empagliflozin
Metformin (Correct answer)

Correct answer: Metformin

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

Question 64: A patient on mechanical ventilation has high peak airway pressures but normal plateau pressures. Which condition best explains this finding?

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

Correct answer: Kinked endotracheal tube

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

Question 65: A 55-year-old diabetic patient presents with a painless foot ulcer over the plantar surface of the first metatarsal head. Pulses are intact. What is the primary etiology?

Peripheral arterial disease
Osteomyelitis
Venous insufficiency
Peripheral neuropathy (Correct answer)

Correct answer: Peripheral neuropathy

Neuropathic ulcers in diabetics occur at pressure points (plantar metatarsal heads) due to loss of protective sensation from peripheral neuropathy.

Question 66: A 15-year-old presents with bilateral nasal polyps. No history of asthma or aspirin sensitivity. A sweat chloride test is ordered. What underlying condition is being screened for?

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

Correct answer: Cystic fibrosis

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

Question 67: A 72-year-old man has a PSA of 18 ng/mL. Prostate biopsy shows Gleason score 4+4=8 in 8 of 12 cores. Bone scan shows no metastases. Which treatment is most appropriate?

Observation with PSA monitoring
Androgen deprivation therapy alone
Active surveillance
Radical prostatectomy or radiation with androgen deprivation therapy (Correct answer)

Correct answer: Radical prostatectomy or radiation with androgen deprivation therapy

High-risk localized prostate cancer (Gleason ≥8, PSA >20, or clinical T3) requires definitive local therapy (surgery or radiation) combined with androgen deprivation therapy.

Question 68: A neonate born at 28 weeks gestation develops respiratory distress within 2 hours of birth. CXR shows bilateral ground-glass opacities and air bronchograms. What is the underlying pathophysiology?

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

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 69: 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?

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

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 70: 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?

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

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 71: 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 72: 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?

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

Correct answer: Low-dose prednisone

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

Question 73: A 58-year-old male presents with exertional chest pain radiating to the left arm for the past 3 weeks. EKG shows ST-segment depression in leads V4-V6. Which is the most appropriate next step?

Admit and obtain serial troponins with cardiology consult (Correct answer)
Start aspirin and schedule outpatient stress test in 2 weeks
Administer sublingual nitroglycerin and discharge
Perform exercise stress testing

Correct answer: Admit and obtain serial troponins with cardiology consult

New onset exertional chest pain with EKG changes warrants inpatient evaluation with serial cardiac biomarkers to rule out ACS.

Question 74: 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?

Rosacea (Correct answer)
Acne vulgaris
Perioral dermatitis
Sebaceous hyperplasia

Correct answer: Rosacea

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

Question 75: 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)
Small cell carcinoma
Squamous 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 76: 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 77: A 5-year-old child presents with high fever, inspiratory stridor, drooling, and sitting in the 'tripod position.' Lateral neck X-ray shows the 'thumbprint sign.' Which organism is the most likely cause?

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

Correct answer: Haemophilus influenzae type b

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

Question 78: A 7-year-old is brought in for a school screening failure. Exam reveals the left eye deviates outward when the right eye fixates. The child has no diplopia. What is the most appropriate initial management?

Referral to ophthalmology for evaluation (Correct answer)
Strabismus surgery immediately
Observation only
Patching of the dominant eye

Correct answer: Referral to ophthalmology for evaluation

Exotropia in a child requires ophthalmology referral to assess for amblyopia and determine the need for patching, glasses, or surgery.

Question 79: A 52-year-old woman presents with progressive proximal muscle weakness making it difficult to rise from a chair, a heliotrope rash on her eyelids, and Gottron papules on her knuckles. What laboratory finding is most helpful in confirming the diagnosis?

Elevated rheumatoid factor
Elevated creatine kinase (Correct answer)
Positive ANA
Elevated ESR

Correct answer: Elevated creatine kinase

Elevated creatine kinase reflects muscle inflammation and damage in dermatomyositis, making it the most useful confirmatory lab alongside the characteristic skin findings.

Question 80: 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
Prolonged sun exposure
Contact sports (Correct answer)
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 81: A previously healthy 15-month-old kid develops anxiety, starts sobbing uncontrollably, and drools a lot. He had been calmly playing with his toys just moments ago. Pulse rate is 84/min, temperature is 36.7°C (98.1°F), and respirations are 18/min. The posterior pharynx is faintly injected but otherwise clear upon physical examination. Auscultation and percussion reveal no obstruction in the lungs. Chest X-ray study results are normal. He becomes quieter after an hour, but he still drools a lot. Which of the following is the ideal course of action?

Barium swallow x-ray study
Administration of syrup of ipecac
Insertion of a nasogastric tube
Esophagogastroduodenoscopy (Correct answer)

Correct answer: Esophagogastroduodenoscopy

The sudden onset of anxiety, uncontrollable crying, and profuse drooling in a previously healthy child, especially with normal respiratory findings, strongly suggests an esophageal foreign body. The persistent drooling indicates an obstruction or irritation preventing normal swallowing. An esophagogastroduodenoscopy (EGD) is the definitive procedure to both diagnose and remove an esophageal foreign body.

Question 82: A 33-year-old woman presents with cyclic mastalgia, nipple discharge, and palpable breast nodularity that varies with her menstrual cycle. What is the most likely diagnosis?

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

Correct answer: Fibrocystic breast changes

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

Question 83: 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)
Hand-foot-mouth disease
Herpes zoster (shingles)
Eczema herpeticum

Correct answer: Primary varicella (chickenpox)

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

Question 84: Which of the following features best differentiates essential tremor from Parkinson tremor?

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

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

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

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 86: A 16-year-old girl presents with severe dysmenorrhea since menarche. Pelvic exam is normal. NSAIDs provide minimal relief. What is the most appropriate next treatment?

Opioid analgesics
GnRH agonist therapy
Combined oral contraceptive pills (Correct answer)
Laparoscopy to rule out endometriosis

Correct answer: Combined oral contraceptive pills

Combined oral contraceptives are second-line therapy for primary dysmenorrhea after NSAIDs fail, suppressing ovulation and reducing prostaglandin-mediated uterine cramping.

Question 87: 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 vivax
Plasmodium falciparum (Correct answer)
Plasmodium malariae
Plasmodium ovale

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

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

Correct answer: IV labetalol and nicardipine

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

Question 89: Which of the following drugs would not be recommended for a glaucoma patient to take?

Amitriptyline (Correct answer)
Levothyroxine
Montelukast
Travoprost

Correct answer: Amitriptyline

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

Question 90: 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?

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

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 91: 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?

Hemophilia A
Antiphospholipid syndrome (Correct answer)
Factor VIII deficiency
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 92: 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?

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

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

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

Correct answer: Central diabetes insipidus

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

Question 94: Which finding on DEXA scan defines osteoporosis (not osteopenia)?

T-score above -1.0
T-score between -1.0 and -2.5
T-score of -2.5 or below (Correct answer)
Z-score below -2.0

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 95: 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 to serum protein ratio >0.5
Pleural fluid LDH >200 U/L

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 96: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hyperphosphatemia (Correct answer)
Hypernatremia
Hypokalemia
Hypercalcemia

Correct answer: Hyperphosphatemia

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

Question 97: 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?

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

Correct answer: Vancomycin 125 mg PO QID × 10 days

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

Question 98: A 60-year-old male smoker presents with a persistent cough, hemoptysis, and a 4 cm hilar mass on CXR. Biopsy shows small dark cells with nuclear molding and necrosis. What is the cell type?

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

Correct answer: Small cell lung cancer

Small cell lung cancer (SCLC) is a neuroendocrine tumor with characteristic small dark cells, nuclear molding, and central/hilar location strongly associated with smoking.

Question 99: A 55-year-old presents with progressive bilateral sensorineural hearing loss, tinnitus, and episodic vertigo lasting 20 minutes to several hours. Audiometry shows low-frequency hearing loss. What is the most likely diagnosis?

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

Correct answer: Ménière's disease

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

Question 100: 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?

Hydroxychloroquine
Leflunomide
Sulfasalazine
Methotrexate (Correct answer)

Correct answer: Methotrexate

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

Question 101: Which dermatome corresponds to the umbilicus?

L1
T6
T4
T10 (Correct answer)

Correct answer: T10

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

Question 102: A 72-year-old woman has a T-score of -2.7 on DEXA scan with no prior fracture. She is currently taking calcium and vitamin D. What is the most appropriate additional therapy?

Oral bisphosphonate (e.g., alendronate) (Correct answer)
Calcitonin nasal spray
Estrogen replacement therapy
Teriparatide injection

Correct answer: Oral bisphosphonate (e.g., alendronate)

A T-score ≤ -2.5 meets WHO criteria for osteoporosis, and bisphosphonates are the first-line pharmacologic treatment.

Question 103: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

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

Correct answer: Yolk sac tumor

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

Question 104: 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?

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

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 105: 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
Repeat ultrasound in 4 weeks
Serial serum hCG monitoring until undetectable (Correct answer)
Immediate chemotherapy with methotrexate

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 106: 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?

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

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 107: 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?

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

Correct answer: Phosphodiesterase-5 inhibitors (sildenafil)

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

Question 108: 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?

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

Correct answer: Laser peripheral iridotomy

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

Question 109: Graves disease is caused by which mechanism?

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

Correct answer: Stimulating antibodies against the TSH receptor

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

Question 110: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?

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

Correct answer: Right coronary artery

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

Question 111: A 5-year-old child presents with periorbital edema, frothy urine, and hypoalbuminemia. Urinalysis shows 4+ protein but no blood. What is the most common histologic finding on renal biopsy in this age group?

IgA nephropathy
Focal segmental glomerulosclerosis
Minimal change disease (Correct answer)
Membranous nephropathy

Correct answer: Minimal change disease

Minimal change disease accounts for ~90% of nephrotic syndrome in children aged 1-8 years and shows effacement of podocyte foot processes on electron microscopy.

Question 112: 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 113: What is the primary consideration when implementing changes to pulmonary 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 114: Which physical exam finding is pathognomonic for constrictive pericarditis?

Kussmaul sign (Correct answer)
Pulsus paradoxus >10 mmHg
Friction rub
S3 gallop

Correct answer: Kussmaul sign

Kussmaul sign (paradoxical rise in JVP with inspiration) is the hallmark of constrictive pericarditis due to impaired right heart filling against a rigid pericardium.

Question 115: A 70-year-old farmer presents with a pearly, rolled-edge nodule with telangiectasias on his nose that occasionally bleeds. What is the first-line treatment?

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

Correct answer: Mohs micrographic surgery

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

Question 116: 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?

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

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

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

Correct answer: Dactylitis

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

Question 118: What role does collaboration play in dermatology for PANCE professionals?

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

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

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

Question 119: A 52-year-old man has a serum calcium of 11.8 mg/dL, PTH of 95 pg/mL, and is asymptomatic. What is the most likely diagnosis?

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

Correct answer: Primary hyperparathyroidism

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

Question 120: 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
Clindamycin 900 mg IV
Ciprofloxacin 400 mg IV (Correct answer)

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 121: 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?

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

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 122: A patient presents with a painless penile ulcer with clean base and raised indurated edges. Dark-field microscopy of the lesion reveals spirochetes. Which antibiotic is first-line treatment?

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

Correct answer: Penicillin G benzathine 2.4 million units IM single dose

Primary syphilis caused by Treponema pallidum is treated with a single IM dose of penicillin G benzathine 2.4 million units.

Question 123: A 6-year-old child is brought in for evaluation of a 3-day sore throat, fever of 38.9°C, and enlarged anterior cervical lymph nodes. No cough is present. What is the Centor score and recommended management?

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

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 124: 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
Malignant otitis externa
Bell's palsy
Herpes zoster oticus (Ramsay Hunt syndrome) (Correct answer)

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 125: 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?

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

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

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

Question 126: 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
Trichophyton rubrum
Malassezia furfur (Correct answer)
Microsporum canis

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 127: A patient with chronic atrial flutter is found to have a ventricular rate of 150 bpm with a sawtooth pattern at 300 bpm. Which medication would most reliably convert this to sinus rhythm?

Digoxin
Ibutilide (Correct answer)
Verapamil
Metoprolol

Correct answer: Ibutilide

Ibutilide, a class III antiarrhythmic, is highly effective for chemical cardioversion of atrial flutter, with conversion rates of approximately 60-70%.

Question 128: 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?

DIC
ITP
Drug-induced aplasia
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 129: A 25-year-old man presents with bilateral cryptorchidism corrected at age 4 and now seeks fertility counseling. What is the most appropriate initial test?

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

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

Copy what other organizations do without analysis
Wait for problems to occur before acting
Use data-driven methods with measurable outcomes (Correct answer)
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 131: A 28-year-old female presents with amenorrhea, galactorrhea, and headaches. Labs show elevated prolactin. MRI reveals a pituitary mass. What is the first-line treatment?

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

Correct answer: Bromocriptine or cabergoline

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

Question 132: Which finding on osmotic fragility testing is most characteristic of hereditary spherocytosis?

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

Correct answer: Increased osmotic fragility

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

Question 133: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

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

Correct answer: Vitamin C

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

Question 134: A patient with multiple myeloma develops worsening renal function. Which renal complication is most directly caused by light chain deposition in tubules?

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

Correct answer: Cast nephropathy

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

Question 135: A 10-year-old develops cola-colored urine and periorbital edema 2 weeks after a strep throat infection. What is the diagnosis?

Focal segmental glomerulosclerosis
IgA nephropathy
Minimal change disease
Poststreptococcal glomerulonephritis (Correct answer)

Correct answer: Poststreptococcal glomerulonephritis

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

Question 136: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

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

Correct answer: Oval fat bodies

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

Question 137: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

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

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

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

Question 138: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 139: 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?

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

Correct answer: Pseudomonas aeruginosa

Malignant (necrotizing) external otitis in diabetics is almost exclusively caused by Pseudomonas aeruginosa, which can extend to cause skull base osteomyelitis and cranial nerve palsies.

Question 140: A 48-year-old male presents with sudden severe 'thunderclap' headache described as the worst of his life. CT head is negative. What is the next most appropriate step?

Perform MRI brain with gadolinium
Discharge with sumatriptan for migraine
Perform lumbar puncture to detect xanthochromia (Correct answer)
Order ESR and CRP for temporal arteritis

Correct answer: Perform lumbar puncture to detect xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture detecting xanthochromia is required to exclude SAH when CT is negative.

Question 141: Which of the following statements about end-of-life concerns for cystic fibrosis patients is accurate?

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

Correct answer: Palliative care should be discussed

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

Question 142: 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
Cholesteatoma (Correct answer)
Adenoid hypertrophy
Glomus tympanicum

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

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

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

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

Question 144: A 40-year-old woman presents with heat intolerance, weight loss, tremor, and TSH <0.01 mIU/L with elevated free T4. Radioiodine uptake is diffusely increased. What is the preferred long-term treatment option in a non-pregnant patient?

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

Correct answer: Radioactive iodine (RAI) ablation

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

Question 145: 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?

Check maternal antibody titers monthly and treat if positive
No treatment needed until delivery
Administer Rh immunoglobulin at 28 weeks and within 72 hours postpartum if infant is Rh-positive (Correct answer)
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 146: A 34-year-old woman presents with weight gain, cold intolerance, constipation, and dry skin. TSH is 18 mIU/L and free T4 is low. Anti-TPO antibodies are positive. What is the most likely diagnosis?

Iodine deficiency hypothyroidism
Graves disease
Hashimoto thyroiditis (Correct answer)
Subacute thyroiditis

Correct answer: Hashimoto thyroiditis

Hashimoto thyroiditis (autoimmune) is the most common cause of primary hypothyroidism in the US, characterized by elevated TSH, low T4, and positive anti-TPO antibodies.

Question 147: A 16-year-old girl presents with primary amenorrhea. Physical exam shows normal female external genitalia but absence of pubic and axillary hair. Karyotype is 46,XY. What is the most likely diagnosis?

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

Correct answer: Complete androgen insensitivity syndrome

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

Question 148: 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?

Methotrexate
Allopurinol
Probenecid
Indomethacin or colchicine (Correct answer)

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 149: A congenital hip dislocation diagnosis is made.

At birth (Correct answer)
In utero
At 6 months of age
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 150: Which laboratory finding is most characteristic of acute pancreatitis?

Elevated direct bilirubin
Elevated alkaline phosphatase
Elevated lipase >3x upper limit of normal (Correct answer)
Elevated ALT and AST

Correct answer: Elevated lipase >3x upper limit of normal

Serum lipase elevated more than three times the upper limit of normal is the most sensitive and specific marker for acute pancreatitis.

Question 151: A 14-year-old male presents with knee pain and a tender tibial tubercle that is worse with activity. No joint effusion. What is the diagnosis?

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

Correct answer: Osgood-Schlatter disease

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

Question 152: A 47-year-old man has been pushing his lawn mower for the past three weeks while experiencing chest pain. He states he has never been treated for similar symptoms and has no problems presently. He smoked one pack each day for twenty years until giving it up seven years ago. Physical examination results are typical. Electrocardiograms don't reveal any anomalies. Which of the following first diagnostic tests is most appropriate?

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

Correct answer: Exercise stress test

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

Question 153: Which of the following is the gold standard for diagnosing esophageal motility disorders such as achalasia?

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

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

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

Correct answer: Hemophilia A

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

Question 155: 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)
Oral candidiasis (thrush)
Aphthous ulcers

Correct answer: Oral hairy leukoplakia

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

Question 156: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

Prepare for emergent cesarean delivery (Correct answer)
Apply fetal scalp electrode for better monitoring
Amnioinfusion
Administer terbutaline and reassess

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

Vitamin B12 (Correct answer)
Folate
Pyridoxine
Thiamine

Correct answer: Vitamin B12

Elevated methylmalonic acid distinguishes B12 deficiency from folate deficiency, since only B12 is required in the MMA metabolic pathway.

Question 158: 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)
Acute pancreatitis
Perforated peptic ulcer
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 159: 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
Samter's triad (AERD) (Correct answer)
Kartagener syndrome
Churg-Strauss 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 160: A 55-year-old male presents with dysphagia to solids that has progressed to liquids over 3 months, with a 15-lb weight loss. Which diagnosis is most likely?

Zenker diverticulum
Esophageal spasm
Esophageal adenocarcinoma (Correct answer)
Achalasia

Correct answer: Esophageal adenocarcinoma

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

Question 161: A 45-year-old patient presents with sudden painless vision loss in one eye described as a 'curtain coming down.' Fundoscopic exam reveals a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

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

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 162: A 25-year-old woman with MVP presents with palpitations. Holter monitor shows frequent PVCs. She is anxious about her condition. First-line treatment is:

Amiodarone
Flecainide
Catheter ablation
Beta-blocker (Correct answer)

Correct answer: Beta-blocker

Beta-blockers are first-line for symptomatic PVCs in MVP as they suppress ectopy, reduce anxiety-triggered adrenergic activity, and have a favorable safety profile.

Question 163: 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-Mi-2 (Correct answer)
Anti-MDA5

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 164: 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?

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

Correct answer: Valacyclovir 1000 mg PO TID × 7 days

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

Question 165: What is the best practice for maintaining reproductive system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 166: Which of the following is the most appropriate initial management for a patient presenting with acute upper GI bleeding and hemodynamic instability?

Oral PPI therapy and observation
IV fluid resuscitation and blood transfusion, then endoscopy (Correct answer)
Emergent upper endoscopy immediately
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 167: A 30-year-old man develops a targetoid lesion with a central blister after starting sulfonamide antibiotics. The lesion is localized to the palms. What is the most likely diagnosis?

Erythema multiforme (Correct answer)
Toxic epidermal necrolysis
Fixed drug eruption
Stevens-Johnson syndrome

Correct answer: Erythema multiforme

Erythema multiforme presents with classic targetoid (iris) lesions, often triggered by drugs or HSV, and is typically limited to acral surfaces.

Question 168: A 60-year-old man presents with a brown-black lesion with asymmetry, irregular border, color variegation, and diameter of 7 mm on his back. Biopsy confirms melanoma with Breslow thickness of 1.2 mm. What is the recommended surgical margin?

3 cm margin
0.5 cm margin
1 cm margin (Correct answer)
2 cm margin

Correct answer: 1 cm margin

For melanoma with Breslow thickness 1.01–2.0 mm, a 1 cm surgical margin is recommended per NCCN guidelines.

Question 169: 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?

24 hours
12 hours
15 hours (Correct answer)
8 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 170: A 60-year-old man has sudden severe 'thunderclap' headache reaching peak intensity in seconds. CT head is negative. What is the next best step?

Discharge with NSAIDs for presumed tension headache
EEG to rule out seizure
MRI brain with gadolinium
Lumbar puncture to evaluate for xanthochromia (Correct answer)

Correct answer: Lumbar puncture to evaluate for xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; LP is required to detect xanthochromia or blood in the CSF when CT is negative.

Question 171: What is an endoscopic retrograde cholangiopancreatography's (ERCP) most common complication?

Aspiration
Cholangitis
Perforation
Pancreatitis (Correct answer)

Correct answer: Pancreatitis

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

Question 172: A 22-year-old female with hypermobile joints presents with recurrent shoulder dislocations. Anterior apprehension test is positive. What is the most common direction of glenohumeral instability?

Anterior (Correct answer)
Inferior
Multidirectional
Posterior

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 173: Which of the following helps the reader of the study determine whether the outcomes in a randomized, double-blind, placebo-controlled clinical trial are statistically significant?

Number of biases in the stud
Odds ratio
Relative risk
P value (Correct answer)

Correct answer: P value

The p-value is a crucial statistical measure used to determine the statistical significance of results in a clinical trial. It indicates the probability of observing the study's results (or more extreme results) if the null hypothesis were true (i.e., if there were no real effect or difference between groups). A low p-value (typically <0.05) suggests that the observed results are unlikely to have occurred by chance, thus indicating statistical significance.

Question 174: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Schistocytes (Correct answer)
Spherocytes
Target cells
Bite cells

Correct answer: Schistocytes

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

Question 175: A 65-year-old woman on alendronate for 5 years asks about continuing therapy. What is the most serious rare adverse effect associated with long-term bisphosphonate use?

Atypical femur fracture (Correct answer)
Adrenal suppression
Hypomagnesemia
Hypercalcemia

Correct answer: Atypical femur fracture

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

Question 176: A 25-year-old presents with painless, progressive bilateral sensorineural hearing loss since age 12. He has no family history of hearing loss. He is found to have hematuria on urinalysis. Renal biopsy shows thinning of the glomerular basement membrane with a split lamina densa. What syndrome is this?

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

Correct answer: Alport syndrome

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

Question 177: 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?

Bicuspid aortic valve and coarctation of the aorta (Correct answer)
Ventricular septal defect
Tetralogy of Fallot
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 178: 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?

Inferior vena cava filter placement
Rivaroxaban (Correct answer)
Unfractionated heparin infusion with warfarin bridge
Alteplase thrombolysis

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 179: 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?

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

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 180: 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?

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

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 181: 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?

Disease-modifying therapy (e.g., interferon beta or natalizumab) (Correct answer)
Plasmapheresis every 6 months
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 182: 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?

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

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 183: 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
Emergency MRI of the spine and neurosurgical consult (Correct answer)
Outpatient MRI in 2 weeks
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 184: A 45-year-old male with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?

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

Correct answer: Thiamine 100 mg IV before glucose

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

Question 185: A patient with chronic low back pain and left leg radiculopathy has weakness of ankle dorsiflexion and great toe extension. Which nerve root is most likely affected?

L3
S1
L5 (Correct answer)
L4

Correct answer: L5

L5 nerve root compression causes weakness of ankle dorsiflexion (tibialis anterior) and great toe extension (extensor hallucis longus).

Question 186: 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?

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

Correct answer: Cluster headache

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

Question 187: 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?

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

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 188: A 68-year-old male presents with polyuria, polydipsia, and blurred vision. Random plasma glucose is 380 mg/dL. HbA1c is 11.2%. He has no ketones. Which management is most appropriate at this time?

Metformin monotherapy and lifestyle modification
Lifestyle changes alone for 3 months before starting medication
Sulfonylurea alone
Insulin therapy plus metformin (Correct answer)

Correct answer: Insulin therapy plus metformin

Symptomatic hyperglycemia with HbA1c >10% warrants insulin therapy at diagnosis, often combined with metformin, to achieve timely glycemic control.

Question 189: A 3-year-old boy is brought in for evaluation of a painless scrotal mass. Transillumination is positive. What is the most likely diagnosis?

Epididymitis
Hydrocele (Correct answer)
Testicular torsion
Inguinal hernia

Correct answer: Hydrocele

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

Question 190: A 34-year-old G1P0 at 41 weeks gestation has a Bishop score of 3. Induction of labor is planned. Which agent is most appropriate for cervical ripening?

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

Correct answer: Misoprostol intravaginally

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

Question 191: A 30-year-old woman with Hashimoto thyroiditis is euthyroid. She asks about her risk for other autoimmune conditions. Which condition is she at increased risk for?

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

Correct answer: Vitiligo and type 1 diabetes

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

Question 192: 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?

Epidermoid cyst
Meningioma
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 193: What is the value of continuing education in dermatology for PANCE professionals?

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

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

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

Question 194: 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?

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

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

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

Question 195: 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?

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

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 196: 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
Varicocele (Correct answer)
Retrograde ejaculation

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 197: 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)
Berylliosis
Coal workers' pneumoconiosis
Asbestosis

Correct answer: Silicosis

Silicosis presents with bilateral upper lobe nodular fibrosis, and birefringent silica crystals are seen on polarized microscopy of biopsy specimens.

Question 198: A patient with a distal radius fracture develops loss of thumb opposition and thenar atrophy 3 months after casting. Which nerve is involved?

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

Correct answer: Median nerve

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

Question 199: A 19-year-old male presents with multiple firm, flesh-colored, umbilicated papules in the groin and inner thighs after sexual contact. What is the causative agent?

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

Correct answer: Molluscum contagiosum virus (poxvirus)

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

Question 200: A 45-year-old woman presents with menorrhagia and pelvic pressure. Uterus is 14-week size on exam. Ultrasound shows multiple intramural masses. What is the most appropriate first-line pharmacologic treatment?

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

Correct answer: Levonorgestrel IUD

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

Question 201: 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
Surgical pleurodesis
Observation with supplemental oxygen
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 202: Which lab pattern is most consistent with prerenal azotemia?

WBC casts with low urine osmolality
BUN:Cr ratio >20:1 with urine sodium <20 mEq/L (Correct answer)
Muddy brown casts with urine sodium >40 mEq/L
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 203: 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?

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

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 204: 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
Hydralazine IV
Nitroprusside IV (Correct answer)
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 205: A 58-year-old man with peripheral artery disease has an ankle-brachial index (ABI) of 0.55. He has rest pain. Next best step?

Compression stockings
Start cilostazol and increase walking
Anticoagulation with heparin
Referral for revascularization (Correct answer)

Correct answer: Referral for revascularization

An ABI <0.6 with rest pain indicates critical limb ischemia (CLI), which requires urgent revascularization to prevent limb loss.

Question 206: What is the fundamental principle behind pulmonary system in the PANCE domain?

Using the newest technology exclusively
Cost minimization at all costs
Following a single vendor solution
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 207: A 5-year-old child presents with fever, malaise, and diffuse flaccid bullae with superficial skin sloughing that resembles scalded skin. Nikolsky sign is positive. What is the causative organism?

Pseudomonas aeruginosa endotoxin
HSV type 1
Staphylococcus aureus exfoliative toxin (Correct answer)
Streptococcus pyogenes exotoxin

Correct answer: Staphylococcus aureus exfoliative toxin

Staphylococcal scalded skin syndrome is caused by exfoliative toxins A and B from S. aureus that cleave desmoglein-1, causing superficial skin separation.

Question 208: Which electrolyte abnormality is most characteristic of primary hyperaldosteronism (Conn syndrome)?

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

Correct answer: Hypokalemia and hypertension

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

Question 209: 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?

Lymphoma
Sarcoidosis (Correct answer)
Tuberculosis
Histoplasmosis

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 210: What is the first-line noninvasive screening test for suspected renal artery stenosis?

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

Correct answer: Renal artery duplex ultrasound

Renal artery duplex ultrasound is the preferred initial screening modality as it avoids contrast and radiation while assessing renal artery flow.

Question 211: A 45-year-old woman is brought in after a witnessed tonic-clonic seizure. She takes no medications. Blood glucose is 45 mg/dL. After dextrose administration, the seizure does not recur. What is the most appropriate next step?

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

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

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

Question 212: 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?

Migraine with aura
Cluster headache
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 213: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 214: A 25-year-old woman presents with recurrent episodes of severe unilateral headache with photophobia, phonophobia, and nausea lasting 8-12 hours. She has no neurological deficits. What is the best abortive therapy?

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

Correct answer: Sumatriptan 50 mg orally

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

Question 215: 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?

Optic neuritis; MRI of the brain
Migraine equivalent; MRI of the brain
Central retinal artery occlusion; CT angiography
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 216: On auscultation, a patient has a harsh systolic murmur that increases in intensity with the Valsalva maneuver. Which condition is most likely?

Mitral regurgitation
Hypertrophic obstructive cardiomyopathy (HOCM) (Correct answer)
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 217: 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
Physical therapy and NSAIDs for 6-12 weeks (Correct answer)
Sling immobilization for 8 weeks

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

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

Question 218: 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
MRI of the rectum
Flexible sigmoidoscopy with biopsy (Correct answer)

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 219: A 28-year-old woman at 32 weeks gestation develops blood pressure of 156/104 mmHg, 3+ proteinuria, and a severe headache. Which medication is the first-line treatment for seizure prophylaxis?

Lorazepam
Labetalol
Magnesium sulfate (Correct answer)
Phenytoin

Correct answer: Magnesium sulfate

Magnesium sulfate is the drug of choice for prevention and treatment of eclamptic seizures in women with severe preeclampsia.

Question 220: 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)
Oral amoxicillin-clavulanate and close follow-up
IV antibiotics alone without surgery

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 221: 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?

Ethosuximide
Valproic acid (Correct answer)
Carbamazepine
Oxcarbazepine

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 222: 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?

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

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 223: A patient with type 1 diabetes develops sudden confusion, diaphoresis, and tremors. Blood glucose is 42 mg/dL. What is the most appropriate immediate intervention?

Start IV dextrose 50%
Administer IV insulin
Administer glucagon IM
Give 15-20g of fast-acting carbohydrates (Correct answer)

Correct answer: Give 15-20g of fast-acting carbohydrates

The rule of 15 (15g fast carbs, recheck in 15 min) is first-line for a conscious hypoglycemic patient.

Question 224: An 8-year-old boy presents with pubic hair and testicular enlargement. Bone age is advanced. LH and FSH are elevated. What is the most likely diagnosis?

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

Correct answer: Central (gonadotropin-dependent) precocious puberty

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

Question 225: A 68-year-old male presents with inability to urinate and a distended, palpable bladder. What is the most common cause in this population?

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

Correct answer: Benign prostatic hyperplasia

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

Question 226: An 8-year-old child presents with honey-crusted erosions around the nares and mouth. Gram stain shows gram-positive cocci in clusters. What is the most appropriate treatment?

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

Correct answer: Topical mupirocin or oral cephalexin

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

Question 227: A child develops oliguria, microangiopathic hemolytic anemia, and thrombocytopenia after a bloody diarrheal illness. What is the diagnosis?

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

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

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

Correct answer: Absence of respiratory effort during apneic episodes

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

Question 229: 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
Start aspirin and discharge home
Schedule outpatient neurology follow-up in 2 weeks

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 230: 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
Myelofibrosis
Polycythemia vera
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 231: 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
Seropositive rheumatoid arthritis (Correct answer)
Systemic lupus erythematosus
Psoriatic arthritis

Correct answer: Seropositive rheumatoid arthritis

Anti-CCP antibody is more specific than RF for RA; a positive anti-CCP with negative RF still qualifies as seropositive RA by current classification criteria.

Question 232: 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
Antibiotic therapy for pneumonia
Bronchodilator treatment and observation
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 233: A 4-year-old boy presents with a 3-day history of fever, bilateral conjunctivitis, strawberry tongue, cracked lips, a polymorphous rash, and cervical lymphadenopathy. What is the most important complication to prevent?

Meningitis
Acute rheumatic fever
Coronary artery aneurysms (Correct answer)
Glomerulonephritis

Correct answer: Coronary artery aneurysms

Kawasaki disease can cause coronary artery aneurysms, the most serious complication, which is prevented by early treatment with IVIG and aspirin.

Question 234: What is the best practice for maintaining endocrine system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 235: 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?

Diabetes mellitus
Hypopituitarism (Correct answer)
Hyperprolactinemia
Hypothyroidism

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 236: What is the most important professional competency for PANCE certification in dermatology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 237: A 50-year-old male smoker presents with weight loss, hemoptysis, and hyponatremia (Na 122 mEq/L). Chest CT shows a central hilar mass. Which cell type is most likely responsible for his electrolyte abnormality?

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

Correct answer: Small cell carcinoma

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

Question 238: A 75-year-old man has a rough, scaly, erythematous papule on a sun-damaged area of his face. Biopsy shows atypical keratinocytes confined to the epidermis. What is the diagnosis?

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

Correct answer: Bowen disease

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

Question 239: A 60-year-old with poorly controlled diabetes presents with right-sided facial pain, purulent nasal discharge, and black necrotic tissue visible in the nasal cavity. CT shows bony erosion of the turbinates. What organism is most likely responsible?

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

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 240: A 50-year-old presents with jaundice, pale stools, dark urine, and a palpable, non-tender gallbladder. Which condition is most likely?

Acute cholecystitis
Choledocholithiasis
Primary sclerosing cholangitis
Pancreatic head carcinoma (Correct answer)

Correct answer: Pancreatic head carcinoma

Courvoisier's sign (painless palpable gallbladder with obstructive jaundice) suggests malignant biliary obstruction, most commonly pancreatic head cancer.

Question 241: A patient with autosomal dominant polycystic kidney disease asks about the most life-threatening extrarenal complication. What is it?

Mitral valve prolapse
Hepatic cysts
Intracranial berry aneurysm (Correct answer)
Pancreatic 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 242: 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?

Levothyroxine (Correct answer)
Radioactive iodine
Propylthiouracil
Methimazole

Correct answer: Levothyroxine

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

Question 243: A 62-year-old has fatigue, back pain, hypercalcemia, anemia, and a serum M-protein spike on SPEP. What is the most likely diagnosis?

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

Correct answer: Multiple myeloma

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

Question 244: A patient develops oliguria and elevated creatinine after aminoglycoside therapy. Urinalysis shows muddy brown granular casts. What is the diagnosis?

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

Correct answer: Acute tubular necrosis

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

Question 245: A 55-year-old with long-standing GERD undergoes endoscopy showing replacement of squamous epithelium with columnar epithelium in the distal esophagus. What is the most serious concern with this finding?

Increased risk of aspiration pneumonia
Increased risk of esophageal adenocarcinoma (Correct answer)
Increased risk of esophageal squamous cell carcinoma
Esophageal stricture formation

Correct answer: Increased risk of esophageal adenocarcinoma

Barrett esophagus (intestinal metaplasia of the distal esophagus) is a premalignant condition that increases risk of esophageal adenocarcinoma by 30-40 fold.

Question 246: A 9-year-old presents with a painless, firm, non-tender nodule on the upper eyelid that has been present for 3 weeks. There is no erythema or purulent discharge. What is the most likely diagnosis?

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

Correct answer: Chalazion

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

Question 247: Which physical exam finding best differentiates cellulitis from necrotizing fasciitis?

Skin erythema that does not cross fascial planes
Bullae formation on the skin surface
Presence of fever and elevated WBC
Crepitus, wooden-hard texture of tissue, and disproportionate pain (Correct answer)

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

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

Correct answer: Pneumaturia (air in the urine)

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

Question 249: Which approach is recommended for troubleshooting neurologic 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 250: A 38-year-old woman is diagnosed with BRCA1 mutation. She has completed childbearing. Which risk-reduction strategy has the greatest absolute reduction in ovarian cancer risk?

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

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

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

Correct answer: Contralateral tracheal deviation with ipsilateral lung collapse

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

Question 252: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

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

Correct answer: Immune thrombocytopenic purpura

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

Question 253: 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?

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

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 254: 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?

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

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

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 256: 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?

Lymphoma
Squamous cell carcinoma
Carcinoid tumor
Adenocarcinoma (Correct answer)

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 257: 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?

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

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 258: 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?

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

Correct answer: Renal cell carcinoma

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

Question 259: 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)
Cystine
Struvite
Uric acid

Correct answer: Calcium oxalate

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

Question 260: 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
Penicillin G 4.8 million units IM + probenecid
Ceftriaxone 250 mg IM + azithromycin 1 g PO

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 261: 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?

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

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

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 263: A 50-year-old woman presents with Wickham striae on the buccal mucosa and violaceous, flat-topped papules on the flexor wrists. The lesions are intensely pruritic. What is the first-line treatment?

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

Correct answer: High-potency topical corticosteroids

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

Question 264: What is the primary consideration when implementing changes to cardiovascular 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 265: What is the value of continuing education in musculoskeletal for PANCE professionals?

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

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 266: A patient with hypertrophic obstructive cardiomyopathy (HOCM) experiences syncope. Which intervention would WORSEN outflow obstruction?

Leg elevation
Beta-blocker administration
IV fluid bolus
Amyl nitrite inhalation (Correct answer)

Correct answer: Amyl nitrite inhalation

Amyl nitrite causes vasodilation and decreases preload and afterload, which worsens HOCM outflow obstruction by allowing greater septal apposition to the anterior mitral leaflet.

Question 267: A patient presents with a painless, hard, left supraclavicular lymph node and significant weight loss. Upper endoscopy reveals a gastric mass. Which eponymous finding is described?

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

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 268: A 34-year-old woman presents with a 2-week history of fatigue, weight gain, cold intolerance, and constipation. Which lab finding would you expect?

Normal TSH, low free T4
Low TSH, low free T4
Low TSH, high free T4
High TSH, low free T4 (Correct answer)

Correct answer: High TSH, low free T4

Primary hypothyroidism causes elevated TSH (pituitary compensation) and low free T4 due to decreased thyroid output.

Question 269: A 5-year-old presents with a limp and hip pain. X-ray shows flattening and fragmentation of the femoral head. Labs are normal. What is the most likely diagnosis?

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

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children, presenting with limp and X-ray showing femoral head fragmentation.

Question 270: A patient with known Addison disease presents with severe hypotension and vomiting after a flu illness. Which is the most critical immediate treatment?

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

Correct answer: IV hydrocortisone and saline

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

Question 271: Which approach best demonstrates mastery of dermatology in PANCE practice?

Following procedures without understanding
Relying entirely on technology
Avoiding complex scenarios
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 272: What is the first-line treatment for newly diagnosed warm autoimmune hemolytic anemia?

Rituximab
Corticosteroids (Correct answer)
Splenectomy
Intravenous immunoglobulin

Correct answer: Corticosteroids

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

Question 273: A 23-year-old woman presents with 3 months of secondary amenorrhea, galactorrhea, and headache. MRI shows a 12 mm pituitary mass. What is first-line treatment?

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

Correct answer: Bromocriptine or cabergoline

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

Question 274: A 65-year-old presents with progressive hoarseness of 8 weeks duration and a 15 lb weight loss. Laryngoscopy shows an ulcerated lesion of the true vocal cord with cord fixation. What staging feature does cord fixation indicate?

T4 disease — cartilage invasion
T1 disease — limited to true cord
T3 disease — fixed cord (Correct answer)
T2 disease — extension to supraglottis

Correct answer: T3 disease — fixed cord

Vocal cord fixation in laryngeal cancer indicates T3 disease regardless of tumor size, reflecting deep invasion of the paraglottic space or cricoarytenoid joint.

Question 275: A 45-year-old patient who received a renal transplant 6 months ago presents with fever, dyspnea, and non-productive cough. CT chest shows bilateral ground-glass opacities. BAL with Gomori methenamine silver stain reveals cysts. What is the treatment?

Caspofungin
Fluconazole
Amphotericin B
Trimethoprim-sulfamethoxazole (Correct answer)

Correct answer: Trimethoprim-sulfamethoxazole

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

Question 276: 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
Restrictive cardiomyopathy
Heart failure with preserved ejection fraction (HFpEF) (Correct answer)
Dilated cardiomyopathy

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

Pyruvate kinase deficiency
Hereditary spherocytosis
Methemoglobin reductase 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 278: 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?

Probenecid
Indomethacin (Correct answer)
Febuxostat
Allopurinol

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

Cost minimization at all costs
Following a single vendor solution
Balancing performance, reliability, and efficiency (Correct answer)
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 280: Which medication must be held when GFR falls below 30 mL/min due to risk of lactic acidosis?

Amlodipine
Lisinopril
Metformin (Correct answer)
Atorvastatin

Correct answer: Metformin

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

Question 281: Which approach is recommended for troubleshooting endocrine 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 282: 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?

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

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

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

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 284: 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?

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

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

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

Correct answer: Urinary alkalinization with potassium citrate and allopurinol

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

Question 286: Which of the following is the most common cause of Cushing syndrome in clinical practice?

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

Correct answer: Exogenous corticosteroid use

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

Question 287: 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?

Zanamivir 10 mg inhaled BID × 5 days
Oseltamivir 75 mg PO BID × 5 days (Correct answer)
Amantadine 100 mg PO 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 288: 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?

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

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 289: A 30-year-old woman has recurrent episodes of vertigo lasting 20–30 minutes associated with tinnitus and low-frequency hearing loss. The most likely diagnosis is:

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

Correct answer: Ménière disease

Ménière disease presents with episodic vertigo (20 min–12 hr), fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness.

Question 290: An 8-year-old boy presents with a limp and hip pain radiating to the knee for 2 months. X-ray shows flattening and sclerosis of the femoral head. What is the diagnosis?

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

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children aged 4-10, presenting with chronic hip pain, limp, and X-ray changes of femoral head collapse.

Question 291: A 35-year-old HIV-positive patient with a CD4 count of 50 cells/µL presents with headache, altered mental status, and a positive India ink stain of the CSF. Which medication is first-line induction therapy?

Fluconazole
Voriconazole
Caspofungin
Amphotericin B plus flucytosine (Correct answer)

Correct answer: Amphotericin B plus flucytosine

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

Question 292: A 63-year-old woman with known CAD presents 30 minutes after onset of crushing chest pain. EKG shows 3 mm ST elevation in leads II, III, aVF. Door-to-balloon time capability is 45 minutes. Best treatment?

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

Correct answer: Primary percutaneous coronary intervention (PCI)

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

Question 293: A 35-year-old woman has episodic hypertension, headache, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. Which imaging is most appropriate next?

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

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 294: 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?

Long QT syndrome
Arrhythmogenic right ventricular cardiomyopathy (ARVC) (Correct answer)
Hypertrophic cardiomyopathy
Brugada 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 295: Which approach best demonstrates mastery of gastrointestinal in PANCE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 296: A patient with COPD exacerbation has a PaCO2 of 65 mmHg and pH of 7.28 despite controlled oxygen therapy. Which intervention has the strongest evidence for avoiding intubation?

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

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

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

Question 297: A dialysis patient develops fever, chills, and hypotension during a hemodialysis session. What is the most likely cause?

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

Correct answer: Catheter-related bloodstream infection

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

Question 298: 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?

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

Correct answer: Homocystinuria

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

Question 299: Which approach is recommended for troubleshooting pulmonary system issues?

Replace all components simultaneously
Rely solely on past experience
Wait for the problem to resolve itself
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 300: 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?

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

Correct answer: Central diabetes insipidus

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

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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