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

Question 1: A 45-year-old male is found to have a BP of 155/95 mmHg on three separate occasions. He also has diabetes and proteinuria. What is the most appropriate antihypertensive?

Hydrochlorothiazide
Metoprolol
Amlodipine
Lisinopril (Correct answer)

Correct answer: Lisinopril

ACE inhibitors like lisinopril are first-line in diabetic patients with hypertension and proteinuria due to their renoprotective effects.

Question 2: A 42-year-old woman is found to have a blood pressure of 176/108 mmHg. She reports episodic severe headaches, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. What is the first step in management after diagnosis?

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

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

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

Question 3: 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?

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

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 4: 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?

Start aspirin and schedule outpatient stress test in 2 weeks
Administer sublingual nitroglycerin and discharge
Admit and obtain serial troponins with cardiology consult (Correct answer)
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 5: For the past four weeks, a 35-year-old African American lady has been experiencing increased malaise, dyspnea, and low-grade fever. Her iritis was just treated. Physical examination reveals modest hepatomegaly and red nodules over the anterior lower legs. An x-ray of the chest reveals bilateral hilar adenopathy. Which of the subsequent diagnoses is most likely?

Sarcoidosis (Correct answer)
Lymphoma
Mesothelioma
Tuberculosis

Correct answer: Sarcoidosis

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

Question 6: A 45-year-old woman presents with a salmon-colored, well-demarcated plaque with silvery scale on her elbows and knees. Which finding would most likely be seen on biopsy?

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

Correct answer: Acanthosis with parakeratosis and Munro microabscesses

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

Question 7: 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 8: A 32-year-old hiker presents 3 weeks after returning from New England with a bull's-eye rash (erythema migrans), fever, and arthralgias. What is the most appropriate treatment?

Ceftriaxone 2 g IV daily × 14 days
Amoxicillin 500 mg PO TID × 21 days
Doxycycline 100 mg PO BID × 14–21 days (Correct answer)
Azithromycin 500 mg PO daily × 7 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 9: A 48-year-old man with poorly controlled type 2 diabetes develops painless loss of vision in one eye. Fundoscopy shows neovascularization. What is the most appropriate next step?

Start ACE inhibitor
Urgent ophthalmology referral for laser photocoagulation (Correct answer)
Immediate insulin titration only
Prescribe corrective lenses

Correct answer: Urgent ophthalmology referral for laser photocoagulation

Proliferative diabetic retinopathy with neovascularization requires urgent ophthalmology referral for pan-retinal photocoagulation.

Question 10: A 26-year-old woman at 32 weeks gestation develops sudden onset severe headache, visual disturbances, and BP 158/106 mmHg. Urinalysis shows 3+ proteinuria. Which complication must be urgently assessed?

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

Correct answer: HELLP syndrome

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

Question 11: A 25-year-old male presents with painless enlargement of the right testis. Ultrasound shows a solid intratesticular mass. AFP is elevated. What is the most likely tumor type?

Lymphoma
Seminoma
Yolk sac tumor (Correct answer)
Leydig cell tumor

Correct answer: Yolk sac tumor

Non-seminomatous germ cell tumors (yolk sac tumor) produce AFP; seminomas do not, making AFP elevation characteristic of non-seminomatous tumors.

Question 12: What constitutes a risk factor for endometriosis development?

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

Correct answer: Delayed childbearing

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

Question 13: A child develops oliguria, microangiopathic hemolytic anemia, and thrombocytopenia after a bloody diarrheal illness. What is the diagnosis?

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

Correct answer: Hemolytic uremic syndrome

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

Question 14: 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)
Systemic antifungals
Topical calcineurin inhibitors
Oral antihistamines alone

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 15: 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?

Lateral meniscus
Anterior cruciate ligament (Correct answer)
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 16: 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?

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

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

Normal fragility with normal MCHC
Increased osmotic fragility (Correct answer)
Target cells with low fragility
Decreased osmotic 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 18: A right-handed patient has an infarct of the left middle cerebral artery territory. Which deficit is most expected?

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

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 19: 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
Hypokalemic periodic paralysis
Epilepsy
Narcolepsy with cataplexy (Correct answer)

Correct answer: Narcolepsy with cataplexy

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

Question 20: Which approach best demonstrates mastery of musculoskeletal in PANCE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 21: 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?

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

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

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 23: 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?

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

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

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

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

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

Question 25: What is an endoscopic retrograde cholangiopancreatography's (ERCP) most common complication?

Cholangitis
Pancreatitis (Correct answer)
Perforation
Aspiration

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

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

Correct answer: HELLP syndrome

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

Question 27: A 35-year-old woman presents with episodic hypertension, headache, diaphoresis, and palpitations. Plasma free metanephrines are markedly elevated. What is the most appropriate next step?

Adrenal vein sampling
24-hour urine catecholamines
CT scan of the abdomen and pelvis (Correct answer)
Start beta-blocker immediately

Correct answer: CT scan of the abdomen and pelvis

Once biochemical confirmation of pheochromocytoma is established, CT of the abdomen and pelvis is performed to localize the tumor before surgical resection.

Question 28: A 52-year-old postmenopausal woman is found to have a unilocular, thin-walled 4 cm ovarian cyst on transvaginal ultrasound. CA-125 is normal. What is the most appropriate next step?

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

Correct answer: Repeat ultrasound in 6-12 weeks

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

Question 29: What is the value of continuing education in musculoskeletal for PANCE professionals?

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

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

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

Question 30: A 40-year-old woman presents with right upper quadrant pain after fatty meals, fever of 38.8°C, and jaundice. What is the most likely diagnosis?

Hepatitis A
Ascending cholangitis (Correct answer)
Acute cholecystitis
Choledocholithiasis

Correct answer: Ascending cholangitis

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

Question 31: What is the most important professional competency for PANCE certification in musculoskeletal?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 32: 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?

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

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 33: A 68-year-old woman presents with polyuria, polydipsia, constipation, and confusion. Labs show calcium of 13.8 mg/dL and PTH is elevated. What is the most common cause of this presentation?

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

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

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

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

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

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

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

Correct answer: Amaurosis fugax; carotid duplex ultrasound

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

Question 37: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

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

Correct answer: Immune thrombocytopenic purpura

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

Question 38: 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?

Voriconazole
Fluconazole
Amphotericin B plus flucytosine (Correct answer)
Caspofungin

Correct answer: Amphotericin B plus flucytosine

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

Question 39: 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
Intraductal papilloma
Fibrocystic breast changes (Correct answer)
Fibroadenoma

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

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

Correct answer: Pancreatic head carcinoma

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

Question 41: What is the primary consideration when implementing changes to cardiovascular system?

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

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

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

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

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

Question 43: A 19-year-old male presents with fever, night sweats, and weight loss. Exam reveals painless cervical lymphadenopathy. Biopsy shows Reed-Sternberg cells. What is the diagnosis?

Burkitt lymphoma
Infectious mononucleosis
Hodgkin lymphoma (Correct answer)
Non-Hodgkin lymphoma

Correct answer: Hodgkin lymphoma

Reed-Sternberg cells ('owl eye' nuclei) are pathognomonic for Hodgkin lymphoma, which presents with painless lymphadenopathy and B symptoms.

Question 44: 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)
Placental abruption
Fetal limb reduction defects
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 45: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

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

Correct answer: Vitamin C

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

Question 46: A 68-year-old nursing home resident develops sudden onset high fever, myalgias, headache, and dry cough during influenza season. Rapid influenza test is positive. Which antiviral is most appropriate if started within 48 hours?

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

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

Pleural fluid to serum protein ratio >0.5
Pleural fluid protein >3 g/dL
Pleural fluid LDH to serum LDH ratio >0.6 (Correct answer)
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 48: A 40-year-old male with gout has his second attack in 6 months. Serum uric acid is 9.2 mg/dL. He tolerates NSAIDs well. What is the most appropriate long-term management?

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

Correct answer: Allopurinol therapy

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

Question 49: A 16-year-old obese male presents with left hip and knee pain and a limp. The hip is held in external rotation. What is the most likely diagnosis?

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

Correct answer: Slipped capital femoral epiphysis

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

Question 50: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hypernatremia
Hypercalcemia
Hypokalemia
Hyperphosphatemia (Correct answer)

Correct answer: Hyperphosphatemia

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

Question 51: 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?

Testosterone supplementation
Estrogen-only therapy (Correct answer)
Combined estrogen-progestin therapy
Progestin-only 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 52: A 55-year-old woman with COPD and a 60-pack-year history presents with hemoptysis and a 3 cm spiculated pulmonary nodule on CXR. What is the most appropriate next step?

Repeat CXR in 6 months
CT-guided biopsy immediately
CT scan of the chest with contrast (Correct answer)
PET scan

Correct answer: CT scan of the chest with contrast

A CT scan of the chest is the next step to characterize the nodule's features (size, density, borders) and guide further management including biopsy or PET scan.

Question 53: What is the value of continuing education in eent for PANCE professionals?

It is primarily a social activity
It is only needed for recertification
It 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 54: A 55-year-old woman presents with bilateral knee pain worsened by climbing stairs and improved with rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Rheumatoid arthritis
Pseudogout
Gout
Osteoarthritis (Correct answer)

Correct answer: Osteoarthritis

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

Question 55: A 28-year-old presents with bloody diarrhea, tenesmus, and proctitis. Colonoscopy shows continuous mucosal inflammation starting from the rectum. Which diagnosis is most consistent?

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

Correct answer: Ulcerative colitis

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

Question 56: What is the best practice for maintaining endocrine system performance over time?

Wait for failures before acting
Implement scheduled preventive maintenance (Correct answer)
Outsource all maintenance
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 57: Which of the following features best differentiates essential tremor from Parkinson tremor?

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

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

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

Question 58: What is the primary consideration when implementing changes to endocrine system?

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

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

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

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 60: 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?

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

Correct answer: Primary hyperparathyroidism

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

Question 61: A 50-year-old man is found to have a serum calcium of 9.0 mg/dL and PTH of 12 pg/mL (low). He complains of muscle cramps and perioral tingling. Which condition is most likely?

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

Correct answer: Hypoparathyroidism

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

Question 62: A 44-year-old woman is newly diagnosed with stage II cervical cancer. HPV genotyping shows HPV-18. Which treatment modality is most appropriate?

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

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 63: 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?

Prophylactic tamoxifen
Risk-reducing bilateral salpingo-oophorectomy (Correct answer)
Oral contraceptive use for 5 years
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 64: 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?

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

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

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

Correct answer: Vancomycin 125 mg PO QID × 10 days

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

Question 66: What is the best practice for maintaining reproductive system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 67: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?

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

Correct answer: Liver function tests

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

Question 68: A 55-year-old presents with a painless neck mass. Fine-needle aspiration shows squamous cell carcinoma. He has a 40 pack-year smoking history and drinks alcohol daily. Nasopharyngoscopy reveals an asymmetric, ulcerated lesion in the pyriform sinus. What is the most likely primary site?

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

Correct answer: Hypopharynx (pyriform sinus)

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

Question 69: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

Take with a full glass of water and remain upright for 30 minutes (Correct answer)
Take at bedtime to reduce GI side effects
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 70: What is the best practice for maintaining cardiovascular system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 71: A 10-year-old develops cola-colored urine and periorbital edema 2 weeks after a strep throat infection. What is the diagnosis?

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

Correct answer: Poststreptococcal glomerulonephritis

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

Question 72: 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
Homocystinuria (Correct answer)
Multiple endocrine neoplasia type 1
Acromegaly

Correct answer: Homocystinuria

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

Question 73: 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
Microsporum canis
Trichophyton rubrum
Malassezia furfur (Correct answer)

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

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

Correct answer: Zollinger-Ellison syndrome

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

Question 75: A 70-year-old man with history of MI 10 years ago presents with a pulsatile abdominal mass. Ultrasound shows infrarenal aortic diameter of 6 cm. What is the recommended management?

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

Correct answer: Elective surgical or endovascular repair

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

Question 76: 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?

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

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

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

Correct answer: Nocturnal diarrhea awakening the patient

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

Question 78: 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?

S1
L3
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 79: 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?

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

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

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

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

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

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

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

Question 82: Which of the following is the most appropriate first-line treatment for Helicobacter pylori eradication in the US?

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

Correct answer: Omeprazole + amoxicillin + clarithromycin for 14 days

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

Question 83: A 6-year-old child presents with a single circular patch of hair loss on the scalp with broken-off hairs at the scalp surface ('black dots') and mild scaling. Wood's lamp examination is negative. What is the treatment of choice?

Topical selenium sulfide shampoo alone
Intralesional triamcinolone
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 84: 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?

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

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 85: 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 86: 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
Topical clotrimazole cream
Oral terbinafine for 12 weeks (Correct answer)
Nail avulsion only

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

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

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

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

Correct answer: Catheter-related bloodstream infection

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

Question 89: 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?

IV antibiotics and urgent surgical drainage (Correct answer)
Oral amoxicillin-clavulanate and close follow-up
Topical nasal decongestants and systemic steroids
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 90: 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 esophageal adenocarcinoma (Correct answer)
Increased risk of aspiration pneumonia
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 91: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?

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

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

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

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 93: A 70-year-old woman develops diplopia and dysphagia after recovering from a respiratory infection 3 weeks ago. Tensilon (edrophonium) test is positive. What is the underlying mechanism?

Antibodies against voltage-gated calcium channels
Antibodies against acetylcholine receptors at the neuromuscular junction (Correct answer)
Autoimmune destruction of motor neuron cell bodies
Demyelination of cranial nerve axons

Correct answer: Antibodies against acetylcholine receptors at the neuromuscular junction

Myasthenia gravis results from anti-AChR antibodies blocking neuromuscular transmission, and symptoms improve with edrophonium (acetylcholinesterase inhibitor).

Question 94: A 66-year-old woman has a blood pressure of 158/96 mmHg at two separate visits. She has a history of type 2 diabetes and microalbuminuria. Which antihypertensive is most appropriate as first-line therapy?

Amlodipine
Hydrochlorothiazide
Metoprolol
Lisinopril (Correct answer)

Correct answer: Lisinopril

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

Question 95: A 68-year-old male presents with inability to urinate and a distended, palpable bladder. What is the most common cause in this population?

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

Correct answer: Benign prostatic hyperplasia

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

Question 96: A 25-year-old male has recurrent hemarthroses, a prolonged aPTT, and normal PT. Factor VIII activity is 2%. What is the diagnosis?

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

Correct answer: Hemophilia A

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

Question 97: A 50-year-old man presents with multiple velvety, brown-black warty plaques on his trunk that appear 'stuck on.' They have a cerebriform surface and vary in size. What is the diagnosis?

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

Correct answer: Seborrheic keratosis

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

Question 98: A 32-year-old woman develops gestational diabetes at 28 weeks. Her fasting glucose is 105 mg/dL. After failing medical nutrition therapy, what is the preferred pharmacologic treatment during pregnancy?

Empagliflozin
Metformin
Insulin (Correct answer)
Glipizide

Correct answer: Insulin

Insulin is the preferred medication for gestational diabetes when dietary modification fails, as it does not cross the placenta in significant amounts.

Question 99: A patient exposed to a bat in their bedroom is brought to the ED. The bat was not captured for testing. The patient has no visible bite marks but was asleep. What is the appropriate management?

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

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

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

Correct answer: Pulmonary regurgitation

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

Question 101: A patient on heparin for 7 days develops a platelet count drop from 240,000 to 55,000 and a new lower extremity DVT. What is the diagnosis?

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

Correct answer: Heparin-induced thrombocytopenia

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

Question 102: A 50-year-old presents with symmetric ascending weakness starting in the legs 2 weeks after a GI illness. Deep tendon reflexes are absent. CSF shows elevated protein with normal cell count (albuminocytologic dissociation). What is the diagnosis?

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

Correct answer: Guillain-Barré syndrome

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

Question 103: A 35-year-old female presents with diffuse musculoskeletal pain for 6 months, fatigue, non-restorative sleep, and 14 tender points. Labs including ANA and ESR are normal. What is the diagnosis?

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

Correct answer: Fibromyalgia

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

Question 104: A 22-year-old presents with sudden onset unilateral chest pain and dyspnea. He is tall and thin with no prior medical history. CXR shows a 25% pneumothorax. What is the appropriate management?

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

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 105: 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
Rigid bronchoscopy for foreign body removal (Correct answer)
Bronchodilator treatment and observation

Correct answer: Rigid bronchoscopy for foreign body removal

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

Question 106: 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?

Blastomycosis
Aspergillosis
Histoplasmosis (Correct answer)
Coccidioidomycosis

Correct answer: Histoplasmosis

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

Question 107: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

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

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 108: 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?

Squamous cell carcinoma
Carcinoid tumor
Lymphoma
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 109: 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?

Tuberculosis
Histoplasmosis
Sarcoidosis (Correct answer)
Lymphoma

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

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

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

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

Question 111: A patient has microcytic anemia, low serum ferritin, low serum iron, and elevated TIBC. What is the diagnosis?

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

Correct answer: Iron deficiency anemia

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

Question 112: Which laboratory finding is most characteristic of acute pancreatitis?

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

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

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

Correct answer: Accountability and commitment to standards

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

Question 114: 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)
Seborrheic keratosis
Actinic 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 115: Which approach is recommended for troubleshooting cardiovascular system issues?

Wait for the problem to resolve itself
Use systematic isolation and testing methods (Correct answer)
Rely solely on past experience
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 116: Which of the following best differentiates central from obstructive sleep apnea on polysomnography?

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

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

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

Correct answer: Dyshidrotic eczema (pompholyx)

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

Question 118: A 45-year-old man has prolonged QT on EKG (QTc 510 ms) and is prescribed an antibiotic. Which is SAFEST to use?

Moxifloxacin
Azithromycin
Amoxicillin (Correct answer)
Erythromycin

Correct answer: Amoxicillin

Amoxicillin does not prolong the QT interval, making it safe in patients with prolonged QTc, unlike macrolides and fluoroquinolones.

Question 119: When examining a patient who has known benign prostatic hyperplasia, what would you anticipate finding?

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

Correct answer: Rubbery prostate with digital rectal exam

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

Question 120: A 55-year-old presents with flank pain, gross hematuria, and a palpable mass. CT reveals a solid renal mass. What is the most likely diagnosis?

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

Correct answer: Renal cell carcinoma

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

Question 121: 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?

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

Correct answer: Valacyclovir 1000 mg PO TID × 7 days

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

Question 122: A patient with a pulmonary embolism develops hypotension (BP 80/50) and RV dilation on echo. She has no contraindications to thrombolytics. Which statement best describes the appropriate management?

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

Correct answer: Systemic thrombolysis with alteplase

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

Question 123: 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 124: Which EKG pattern is associated with right ventricular strain in pulmonary embolism?

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

Correct answer: S1Q3T3 pattern

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

Question 125: A patient with type 2 diabetes and CKD stage 3 requires glucose-lowering therapy. Which agent is contraindicated due to risk of lactic acidosis?

Metformin (Correct answer)
Glipizide
Empagliflozin
Sitagliptin

Correct answer: Metformin

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

Question 126: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 127: What is the first-line noninvasive screening test for suspected renal artery stenosis?

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

Correct answer: Renal artery duplex ultrasound

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

Question 128: 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 aureus (Correct answer)
Enterococcus faecalis
Streptococcus viridans
Staphylococcus epidermidis

Correct answer: Staphylococcus aureus

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

Question 129: A 35-year-old with HIV (CD4 count 60 cells/μL) presents with fever, dry cough, and bilateral interstitial infiltrates. LDH is markedly elevated. Methenamine silver stain of BAL fluid shows cysts. What is the first-line treatment?

Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
Fluconazole
Caspofungin
Voriconazole

Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)

TMP-SMX is the first-line treatment for Pneumocystis jirovecii pneumonia (PCP), which presents with interstitial infiltrates and elevated LDH in severely immunocompromised patients.

Question 130: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

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

Correct answer: Prepare for emergent cesarean delivery

A sinusoidal fetal heart rate pattern is a Category III (abnormal) tracing indicating severe fetal compromise requiring emergent cesarean delivery.

Question 131: 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
Vestibular neuritis
Ménière's disease (Correct answer)
Benign paroxysmal positional vertigo

Correct answer: Ménière's disease

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

Question 132: How does donepezil function when used to treat Alzheimer's disease?

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

Correct answer: Acetylcholinesterase inhibitor

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

Question 133: A 25-year-old presents with recurrent abdominal pain, diarrhea, and mouth sores. Labs show elevated ESR and CRP. Colonoscopy shows ileitis with skip lesions. What extraintestinal manifestation is most commonly associated with this condition?

Ankylosing spondylitis
Primary sclerosing cholangitis
Pyoderma gangrenosum
Erythema nodosum (Correct answer)

Correct answer: Erythema nodosum

Erythema nodosum (tender red nodules on the shins) is the most common extraintestinal skin manifestation of both Crohn disease and ulcerative colitis.

Question 134: A 70-year-old man on warfarin for atrial fibrillation presents with an INR of 8.5 and active GI bleeding. What is the most appropriate reversal strategy?

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

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

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

Question 135: 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
Insulin with dextrose
IV calcium gluconate (Correct answer)
Sodium bicarbonate

Correct answer: IV calcium gluconate

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

Question 136: 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 137: Which approach best demonstrates mastery of eent in PANCE practice?

Relying entirely on technology
Avoiding complex scenarios
Applying principles to novel situations with sound judgment (Correct answer)
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 138: 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?

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

Correct answer: Complete androgen insensitivity syndrome

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

Question 139: A patient with sickle cell disease presents with acute bone pain, fever, and dactylitis. What is the most appropriate initial management?

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

Correct answer: IV fluids, oxygen, and analgesics

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

Question 140: A 25-year-old presents with sudden severe headache, photophobia, and vision loss in the right eye. Slit-lamp exam shows cells and flare in the anterior chamber. Fundoscopic exam is limited by haze but shows disc hyperemia. What condition should be suspected?

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

Correct answer: Uveitis (anterior and posterior)

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

Question 141: Which approach best demonstrates mastery of gastrointestinal in PANCE practice?

Applying principles to novel situations with sound judgment (Correct answer)
Relying entirely on technology
Avoiding complex scenarios
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 142: 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)
Glenohumeral instability
Bicipital tendinopathy
AC joint separation

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

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

Correct answer: Morpheaform (sclerosing) basal cell carcinoma

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

Question 144: What is the best practice for maintaining pulmonary system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 145: 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?

Fibromyalgia
Polymyalgia rheumatica
Myasthenia gravis
Polymyositis (Correct answer)

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

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

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

Correct answer: Aortic dissection

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

Question 148: What is the best practice for maintaining neurologic system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 149: A patient with CKD has normocytic anemia and a reticulocyte count of 0.5%. What is the most likely pathophysiologic cause?

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

Correct answer: Decreased erythropoietin production

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

Question 150: 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
Memorization of all reference materials
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 151: A 45-year-old male with ankylosing spondylitis has back pain unresponsive to two NSAIDs after 3 months. What is the next appropriate treatment?

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

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

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

Correct answer: Accountability and commitment to standards

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

Question 153: A 45-year-old man with HIV (CD4 count 80 cells/μL) presents with painless, papular, violaceous lesions on his lower extremities and oral mucosa. What is the causative organism?

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

Correct answer: Human herpesvirus 8 (HHV-8)

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

Question 154: 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
Clindamycin 900 mg IV
Ampicillin-sulbactam 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 155: A patient with COPD has a resting PaO2 of 54 mmHg and cor pulmonale. What is the minimum daily duration of supplemental oxygen required to improve mortality?

15 hours (Correct answer)
24 hours
12 hours
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 156: 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?

Staphylococcus aureus
Pseudomonas aeruginosa (Correct answer)
Aspergillus fumigatus
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 157: 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?

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

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

Lower initial cost
Simplified maintenance
Fault tolerance and high availability (Correct answer)
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 159: Which acid-base disorder is most commonly seen in end-stage renal disease?

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

Correct answer: High anion gap metabolic acidosis

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

Question 160: A patient with known Addison disease presents with severe hypotension and vomiting after a flu illness. Which is the most critical immediate treatment?

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

Correct answer: IV hydrocortisone and saline

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

Question 161: A patient with a distal radius fracture develops loss of thumb opposition and thenar atrophy 3 months after casting. Which nerve is involved?

Ulnar nerve
Median nerve (Correct answer)
Anterior interosseous nerve
Radial 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 162: Which electrolyte abnormality is most characteristic of primary hyperaldosteronism (Conn syndrome)?

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

Correct answer: Hypokalemia and hypertension

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

Question 163: 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
Reassure and discharge
Splint and follow-up in 4 weeks
MRI or CT scan of the wrist (Correct answer)

Correct answer: MRI or CT scan of the wrist

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

Question 164: A 22-year-old sexually active woman has a positive urine hCG. Transvaginal ultrasound shows no intrauterine gestational sac, and serum hCG is 2,400 mIU/mL. What is the most appropriate next step?

Perform dilation and curettage
Diagnostic laparoscopy
Repeat hCG in 48 hours (Correct answer)
Administer methotrexate immediately

Correct answer: Repeat hCG in 48 hours

With hCG below the discriminatory zone (~3,000 mIU/mL), no intrauterine sac is expected; repeat hCG in 48 hours assesses rise pattern to distinguish ectopic from early intrauterine pregnancy.

Question 165: 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)
Cryptogenic organizing pneumonia (COP)
Hypersensitivity pneumonitis
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 166: 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?

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

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

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

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

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

Question 168: A patient with a humeral shaft fracture develops wrist drop and inability to extend the fingers. Which nerve is most likely injured?

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

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 169: 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?

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

Correct answer: Low-dose prednisone

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

Question 170: In PANCE practice, what is the best approach to quality improvement in dermatology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 171: What is the primary consideration when implementing changes to reproductive system?

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

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

Methotrexate
Allopurinol
Indomethacin or colchicine (Correct answer)
Probenecid

Correct answer: Indomethacin or colchicine

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

Question 173: A patient with community-acquired pneumonia has a parapneumonic effusion. Thoracentesis reveals pH 7.15, glucose 45 mg/dL, and LDH 1,200 U/L. What is the next best step?

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

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 174: 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
Cholesteatoma
Otosclerosis (Correct answer)
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 175: A 78-year-old man has an ECG showing a delta wave and short PR interval. He presents with palpitations and rapid irregular rhythm. Which drug is CONTRAINDICATED?

DC cardioversion
Amiodarone IV (cautiously)
Adenosine (Correct answer)
Procainamide

Correct answer: Adenosine

Adenosine blocks the AV node in Wolff-Parkinson-White with atrial fibrillation, forcing conduction through the accessory pathway and potentially causing ventricular fibrillation.

Question 176: Which approach is recommended for troubleshooting pulmonary system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 177: 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)
Pyridoxine
Folate
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 178: 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
Ceftriaxone plus vancomycin
Liposomal amphotericin B plus flucytosine (Correct answer)
Fluconazole monotherapy

Correct answer: Liposomal amphotericin B plus flucytosine

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

Question 179: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

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

Correct answer: ACE inhibitors

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

Question 180: A 30-year-old woman presents with a butterfly rash, joint pain, oral ulcers, and a positive ANA with anti-dsDNA antibodies. Which complication is most likely to determine her long-term prognosis?

Photosensitivity
Dermatitis
Serositis
Lupus nephritis (Correct answer)

Correct answer: Lupus nephritis

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

Question 181: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

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

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

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

Question 182: What is the fundamental principle behind reproductive system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 183: A 22-year-old woman presents with salt craving, hyperpigmentation, hypotension, and hyponatremia with hyperkalemia. Morning cortisol is 3 mcg/dL. What is the diagnosis?

Primary adrenal insufficiency (Addison disease) (Correct answer)
Hyperaldosteronism
Secondary adrenal insufficiency
Cushing syndrome

Correct answer: Primary adrenal insufficiency (Addison disease)

Primary adrenal insufficiency causes hyperpigmentation (elevated ACTH) and both glucocorticoid and mineralocorticoid deficiency, causing hyperkalemia and hyponatremia.

Question 184: 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?

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

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 185: A 68-year-old man presents with exertional chest pain relieved by rest. EKG shows ST depression during a stress test. Which medication is first-line for symptom management?

Calcium channel blocker
Sublingual nitroglycerin
Beta-blocker (Correct answer)
Long-acting nitrate

Correct answer: Beta-blocker

Beta-blockers are first-line for stable angina as they reduce myocardial oxygen demand by decreasing heart rate and contractility.

Question 186: A 25-year-old lady arrives at the hospital with 2 days' worth of fever and abdominal ache. When the cervix is manipulated during the digital pelvic examination, she feels excruciating agony. According to this, a diagnosis of

Uterine fibroids
Cystitis
Vaginitis
Peritonitis (Correct answer)

Correct answer: Peritonitis

The patient's symptoms of fever, abdominal ache, and excruciating pain upon cervical manipulation (known as the 'chandelier sign') are classic indicators of pelvic inflammatory disease (PID). PID often involves inflammation of the pelvic peritoneum, leading to peritonitis. This condition causes severe abdominal pain and exquisite tenderness during a digital pelvic examination, making peritonitis the most fitting diagnosis among the choices.

Question 187: 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?

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

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 188: A 68-year-old woman presents with tense bullae on an erythematous base on her trunk and proximal extremities. Direct immunofluorescence shows linear IgG and C3 at the dermal-epidermal junction. What is the diagnosis?

Linear IgA bullous dermatosis
Dermatitis herpetiformis
Bullous pemphigoid (Correct answer)
Pemphigus vulgaris

Correct answer: Bullous pemphigoid

Bullous pemphigoid features tense bullae (not flaccid), linear IgG/C3 at the BMZ on DIF, and anti-BP180/BP230 antibodies targeting hemidesmosomes.

Question 189: 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?

Phenytoin
Magnesium sulfate (Correct answer)
Lorazepam
Labetalol

Correct answer: Magnesium sulfate

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

Question 190: A 26-year-old woman with no prenatal care delivers a term infant. The neonate develops purulent conjunctivitis at 5 days of life. Gram stain shows intracellular gram-negative diplococci. What is the treatment?

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

Correct answer: IV ceftriaxone

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

Question 191: A 60-year-old with poorly controlled diabetes presents with right-sided facial pain, purulent nasal discharge, and black necrotic tissue visible in the nasal cavity. CT shows bony erosion of the turbinates. What organism is most likely responsible?

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

Correct answer: Mucor species

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

Question 192: 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)
Ceftriaxone 500 mg IM single dose
Azithromycin 1 g PO single dose
Doxycycline 100 mg PO BID × 14 days

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

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

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

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

Correct answer: Small cell carcinoma

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

Question 195: A newborn develops erythematous macules and papules with surrounding flares on the trunk and extremities within 24–48 hours of birth. Wright stain of pustule contents shows eosinophils. What is the diagnosis?

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

Correct answer: Erythema toxicum neonatorum

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

Question 196: 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?

Leflunomide
Methotrexate (Correct answer)
Sulfasalazine
Hydroxychloroquine

Correct answer: Methotrexate

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

Question 197: A 22-year-old college student presents with fever, severe headache, nuchal rigidity, and a petechial rash. Which organism is the most likely cause?

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

Correct answer: Neisseria meningitidis

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

Question 198: 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?

Alveolar wall thickening reducing diffusion capacity
Bronchial smooth muscle hypertrophy
Mucus gland hyperplasia obstructing large airways
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 199: 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?

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

Correct answer: Severe ARDS

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

Question 200: A 55-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows grade 1 endometrioid adenocarcinoma. Which is the most significant risk factor she likely has?

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

Correct answer: Unopposed estrogen exposure

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

Question 201: Which approach is recommended for troubleshooting reproductive system issues?

Wait for the problem to resolve itself
Use systematic isolation and testing methods (Correct answer)
Rely solely on past experience
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 202: What role does collaboration play in gastrointestinal for PANCE professionals?

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

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

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

Question 203: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?

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

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

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

Question 204: A 35-year-old woman has had a rash on her legs for the previous three weeks. No known infectious contacts exist. Her bladder infection was treated with trimethoprim-sulfamethoxazole a month ago. A generalized rash is visible on the shins, left medial ankle, and right medial calf during physical examination. Tender, diffuse, and returning to the same spots, the rash is. A couple of the lesions show bruise-like characteristics. Which of the subsequent diagnoses is most likely?

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

Correct answer: Erythema nodosum

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

Question 205: A patient on mechanical ventilation has high peak airway pressures but normal plateau pressures. Which condition best explains this finding?

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

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

Iron deficiency secondary to venesection
Uremic pruritus from secondary erythrocytosis
Dry skin from hyperviscosity
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 207: 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?

1 cm margin (Correct answer)
0.5 cm margin
3 cm margin
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 208: 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?

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

Correct answer: Haemophilus influenzae type b

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

Question 209: 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:

Beta-blocker (Correct answer)
Catheter ablation
Flecainide
Amiodarone

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 210: 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?

Hypothyroidism
Hypopituitarism (Correct answer)
Diabetes mellitus
Hyperprolactinemia

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

Increase phenytoin to achieve higher levels
Add valproate for better seizure control
Switch to levetiracetam immediately
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 212: 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
Otitis externa
Otitis media
Barotrauma (ear squeeze) (Correct answer)

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 213: 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?

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

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

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

Question 214: A 29-year-old pregnant woman at 28 weeks is found to have Rh-negative blood type. Her partner is Rh-positive. What is the correct management?

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

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 215: 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?

Inferior
Multidirectional
Posterior
Anterior (Correct answer)

Correct answer: Anterior

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

Question 216: A 19-year-old sexually active woman is diagnosed with her second episode of chlamydial cervicitis within 6 months. Her partner was treated after the first episode. What additional step is most critical now?

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

Correct answer: Test for HIV and other STIs

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

Question 217: 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?

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

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 218: What is the fundamental principle behind endocrine system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 219: A miner presents with progressive dyspnea and bilateral upper lobe fibrosis on chest X-ray. Biopsy shows collagen nodules with birefringent crystals. What is the diagnosis?

Silicosis (Correct answer)
Coal workers' pneumoconiosis
Asbestosis
Berylliosis

Correct answer: Silicosis

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

Question 220: A 30-year-old woman with known asthma presents to the ED with severe bronchospasm unresponsive to two doses of albuterol. Which medication is most appropriate next?

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

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 221: A patient with alcoholic cirrhosis develops tense ascites and acute kidney injury with urine sodium <10 mEq/L and no response to diuretics or albumin. What is the most likely diagnosis?

Acute tubular necrosis
Hepatorenal syndrome (Correct answer)
Prerenal azotemia
Glomerulonephritis

Correct answer: Hepatorenal syndrome

Hepatorenal syndrome is a functional renal failure in cirrhosis with ascites, characterized by very low urine sodium, no response to volume expansion, and exclusion of other causes.

Question 222: A 65-year-old male with a history of NSAID use presents with a duodenal ulcer. Which of the following locations is most common for duodenal ulcers?

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

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

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

Question 223: A 28-year-old woman has amenorrhea, galactorrhea, and a serum prolactin of 120 ng/mL. MRI shows a 7 mm pituitary lesion. First-line treatment is:

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

Correct answer: Bromocriptine or cabergoline

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

Question 224: A patient with Parkinson disease develops visual hallucinations after starting a new medication. Which drug is the most likely culprit?

Trihexyphenidyl
Pramipexole (Correct answer)
Carbidopa-levodopa
Amantadine

Correct answer: Pramipexole

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

Question 225: 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
Lumbar puncture
HIV
Magnetic resonance imaging (MRI) (Correct answer)

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 226: 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
Neisseria meningitidis (Correct answer)
Streptococcus pneumoniae

Correct answer: Neisseria meningitidis

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

Question 227: A 9-year-old presents with a painless, firm, non-tender nodule on the upper eyelid that has been present for 3 weeks. There is no erythema or purulent discharge. What is the most likely diagnosis?

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

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 228: 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?

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

Correct answer: Radioactive iodine (RAI) ablation

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

Question 229: 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?

Empagliflozin
Metformin (Correct answer)
Insulin glargine
Sitagliptin

Correct answer: Metformin

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

Question 230: A 19-year-old male athlete collapses during a basketball game. He is resuscitated from ventricular fibrillation. ECG shows ST elevation in V1-V2 with a right bundle branch block pattern. What is the most likely diagnosis?

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

Correct answer: Brugada syndrome

Brugada syndrome presents with the characteristic coved-type ST elevation in V1-V2 with RBBB pattern and is a cause of sudden cardiac death in young individuals.

Question 231: A newborn has ambiguous genitalia, hyponatremia, hyperkalemia, and low cortisol. 17-hydroxyprogesterone is markedly elevated. What is the most likely diagnosis?

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

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

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

Question 232: A 28-year-old woman at 10 weeks gestation presents with severe nausea, vomiting, and a uterus larger than expected for gestational age. β-hCG is markedly elevated. Ultrasound shows a 'snowstorm' pattern. What is the diagnosis?

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

Correct answer: Complete hydatidiform mole

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

Question 233: A patient has urine sodium of 10 mEq/L, urine osmolality 700 mOsm/kg, and elevated BUN. What is the most likely cause of AKI?

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

Correct answer: Prerenal azotemia

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

Question 234: A patient with hypertrophic obstructive cardiomyopathy (HOCM) experiences syncope. Which intervention would WORSEN outflow obstruction?

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

Correct answer: Amyl nitrite inhalation

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

Question 235: 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?

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

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 236: 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?

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

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 237: 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?

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

Correct answer: Plantar fasciitis

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

Question 238: 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)
Vasa previa
Uterine rupture
Placental abruption

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 239: 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?

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

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 240: 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?

Struvite
Calcium oxalate (Correct answer)
Cystine
Uric acid

Correct answer: Calcium oxalate

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

Question 241: A newborn is noted to have a unilateral nasal obstruction with failure to pass a catheter through the right nostril. The infant becomes cyanotic while feeding but pinks up when crying. What is the diagnosis?

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

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

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

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 243: Which approach is recommended for troubleshooting neurologic system issues?

Use systematic isolation and testing methods (Correct answer)
Replace all components simultaneously
Rely solely on past experience
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 244: 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?

Amphotericin B
Caspofungin
Fluconazole
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 245: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

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

Correct answer: Oval fat bodies

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

Question 246: 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?

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

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

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

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

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 248: 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?

Mycoplasma genitalium
Neisseria gonorrhoeae (Correct answer)
Trichomonas vaginalis
Gardnerella vaginalis

Correct answer: Neisseria gonorrhoeae

Pelvic inflammatory disease (PID) treatment must cover both Chlamydia trachomatis and Neisseria gonorrhoeae empirically due to frequent co-infection.

Question 249: Which approach is recommended for troubleshooting endocrine system issues?

Use systematic isolation and testing methods (Correct answer)
Rely solely on past experience
Replace all components simultaneously
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 250: On lumbar puncture in bacterial meningitis, which CSF finding best distinguishes it from viral meningitis?

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

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

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

Question 251: A patient with known primary pulmonary hypertension develops worsening dyspnea. Echocardiogram shows RV systolic pressure of 80 mmHg. Which medication class acts by increasing cyclic GMP to cause pulmonary vasodilation?

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

Correct answer: Phosphodiesterase-5 inhibitors (sildenafil)

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

Question 252: A 68-year-old presents with gradual bilateral vision loss. Fundoscopic exam reveals drusen deposits and geographic atrophy in the macular region but no hemorrhage or exudate. What type of macular degeneration does this represent?

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

Correct answer: Dry (atrophic) AMD

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

Question 253: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 254: A 28-year-old African American male develops hemolytic anemia after starting primaquine for malaria prophylaxis. What is the underlying enzyme deficiency?

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

Correct answer: G6PD deficiency

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

Question 255: 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?

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

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 256: Which of the following is the first-line treatment for absence seizures?

Valproic acid
Phenytoin
Carbamazepine
Ethosuximide (Correct answer)

Correct answer: Ethosuximide

Ethosuximide is first-line for pure absence seizures; it blocks T-type calcium channels in thalamic neurons.

Question 257: A 50-year-old presents with jaundice, pale stools, dark urine, and a palpable, non-tender gallbladder. Which condition is most likely?

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

Correct answer: Pancreatic head carcinoma

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

Question 258: A neonate is diagnosed with transposition of the great arteries. Which immediate intervention maintains cardiac output prior to surgical correction?

IV furosemide
Digoxin
Atropine
Prostaglandin E1 infusion (Correct answer)

Correct answer: Prostaglandin E1 infusion

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

Question 259: The typical symptoms of this illness, such as a severe state of disorientation or difficulty focusing or maintaining attention, are present in this patient. Delirium is also characterized by difficulties with orientation and a sharp decline in short-term memory and recall.

Delirium (Correct answer)
Paranoid personality disorder
Major neurocognitive disorder
Bipolar disorder

Correct answer: Delirium

The described symptoms—severe disorientation, difficulty focusing and maintaining attention, problems with orientation, and a sharp decline in short-term memory and recall—are the hallmark features of delirium. Delirium is an acute and fluctuating disturbance in attention and cognition, typically caused by an underlying medical condition, medication, or substance.

Question 260: Which professional attribute is most valued in gastrointestinal within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 261: A 55-year-old diabetic presents with fever, crepitus, and rapidly spreading necrosis of the scrotum and perineum. CT shows subcutaneous gas. What is the immediate management priority?

Emergent surgical debridement plus broad-spectrum IV antibiotics (Correct answer)
Hyperbaric oxygen therapy as definitive treatment
Start IV vancomycin and piperacillin-tazobactam and observe for 24 hours
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 262: 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-Mi-2 (Correct answer)
Anti-Jo-1
Anti-MDA5
Anti-SRP

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 263: 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?

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

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 264: 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?

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

Correct answer: Antiphospholipid syndrome

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

Question 265: A 70-year-old woman with osteoporosis is found to have a serum calcium of 10.9 mg/dL and PTH-related peptide (PTHrP) elevated. PTH is suppressed. What is the most likely etiology?

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

Correct answer: Humoral hypercalcemia of malignancy

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

Question 266: 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 267: 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?

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

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

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

Correct answer: Acute tubular necrosis

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

Question 269: A patient presents with fever, new-onset aortic regurgitation murmur, and splinter hemorrhages. Blood cultures grow viridans streptococci. Which is the most likely portal of entry?

Urinary tract infection
IV drug use
Dental procedure (Correct answer)
Skin infection

Correct answer: Dental procedure

Viridans streptococci are oral flora and the most common cause of native valve endocarditis following dental procedures.

Question 270: 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?

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

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 271: A 58-year-old man presents with crushing chest pain radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. Which coronary artery is most likely occluded?

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

Correct answer: Right coronary artery

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

Question 272: A 25-year-old presents with painless, progressive bilateral sensorineural hearing loss since age 12. He has no family history of hearing loss. He is found to have hematuria on urinalysis. Renal biopsy shows thinning of the glomerular basement membrane with a split lamina densa. What syndrome is this?

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

Correct answer: Alport syndrome

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

Question 273: A 40-year-old male with chronic kidney disease stage 3 presents with lab values: sodium 138, potassium 5.8, bicarbonate 18, BUN 42, creatinine 2.4. Which acid-base disturbance is present?

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

Correct answer: Anion gap metabolic acidosis

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

Question 274: What is the primary consideration when implementing changes to neurologic system?

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

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 275: 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?

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

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

Testicular cancer (Correct answer)
Hydrocele
Spermatocele
Epididymitis

Correct answer: Testicular cancer

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

Question 277: A 62-year-old has fatigue, back pain, hypercalcemia, anemia, and a serum M-protein spike on SPEP. What is the most likely diagnosis?

Chronic lymphocytic leukemia
Metastatic prostate cancer
Waldenstrom macroglobulinemia
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 278: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

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

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

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

Correct answer: Accumulation of ammonia causing cerebral edema

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

Question 280: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?

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

Correct answer: Bisphosphonate plus calcium and vitamin D

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

Question 281: 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
Vancomycin plus ceftriaxone
Trimethoprim-sulfamethoxazole
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 282: A 52-year-old has splenomegaly, WBC of 85,000 with basophilia, and a Philadelphia chromosome on cytogenetics. What is the diagnosis?

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

Correct answer: Chronic myelogenous leukemia

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

Question 283: 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 284: 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?

Coronary artery aneurysms (Correct answer)
Acute rheumatic fever
Meningitis
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 285: 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 tobramycin (Correct answer)
Inhaled azithromycin
Inhaled ciprofloxacin oral solution

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 286: 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?

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

Correct answer: Bromocriptine or cabergoline

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

Question 287: 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?

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

Correct answer: Emergency MRI of the spine and neurosurgical consult

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

Question 288: 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?

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

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

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 290: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

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

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

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

Question 291: A 50-year-old presents with progressive hearing loss and a mass behind the ear with pulsatile tinnitus. CT shows a destructive lesion at the jugular foramen. What is the most likely diagnosis?

Glomus jugulare tumor (Correct answer)
Cholesteatoma
Meningioma
Acoustic neuroma

Correct answer: Glomus jugulare tumor

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

Question 292: Which lab pattern is most consistent with prerenal azotemia?

Muddy brown casts with urine sodium >40 mEq/L
BUN:Cr ratio >20:1 with urine sodium <20 mEq/L (Correct answer)
WBC casts with low urine osmolality
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 293: A neonate born at 32 weeks develops respiratory distress immediately after birth with grunting, flaring, and retractions. CXR shows diffuse ground-glass opacities. What is the pathophysiology?

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

Correct answer: Surfactant deficiency

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

Question 294: 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?

Patellar tendinopathy
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
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 295: 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?

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

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 296: 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:

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

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

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

Correct answer: Positive pathergy test

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

Question 298: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Spherocytes
Target cells
Bite cells
Schistocytes (Correct answer)

Correct answer: Schistocytes

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

Question 299: 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 ovale
Plasmodium falciparum (Correct answer)
Plasmodium malariae

Correct answer: Plasmodium falciparum

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

Question 300: A 40-year-old woman with rheumatoid arthritis presents with fatigue, pallor, and a hemoglobin of 9.5 g/dL. Iron studies show low serum iron, low TIBC, and elevated ferritin. What is the most likely cause of her anemia?

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

Correct answer: Anemia of chronic disease

Anemia of chronic disease shows low serum iron and TIBC with elevated ferritin, reflecting sequestration of iron by inflammatory cytokines.

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.

Questions

35 min

Time Limit

70%

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