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

Question 1: A 22-year-old female with hypermobile joints presents with recurrent shoulder dislocations. Anterior apprehension test is positive. What is the most common direction of glenohumeral instability?

Posterior
Anterior (Correct answer)
Inferior
Multidirectional

Correct answer: Anterior

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

Question 2: What is the value of continuing education in eent for PANCE professionals?

It keeps professionals current with evolving standards and practices (Correct answer)
It replaces workplace experience
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 3: 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)
Oral hairy leukoplakia (Correct answer)
Lichen planus
Aphthous ulcers

Correct answer: Oral hairy leukoplakia

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

Question 4: 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?

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

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

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

Correct answer: Patellar tendinopathy

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

Question 6: 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
Musculocutaneous nerve
Radial nerve (Correct answer)

Correct answer: Radial nerve

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

Question 7: A 10-year-old with recurrent otitis media now has a white pearly mass visible through the tympanic membrane with a foul-smelling discharge. CT shows erosion of the ossicles. What is the diagnosis?

Adenoid hypertrophy
Cholesteatoma (Correct answer)
Glomus tympanicum
Tympanosclerosis

Correct answer: Cholesteatoma

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

Question 8: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

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

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 9: A 60-year-old man with newly diagnosed heart failure has an ejection fraction of 30%. He is already on an ACE inhibitor and a beta-blocker. Which additional agent has been shown to reduce mortality in this patient?

Hydralazine
Spironolactone (Correct answer)
Amlodipine
Digoxin

Correct answer: Spironolactone

Aldosterone antagonists (spironolactone/eplerenone) reduce mortality in HFrEF when added to ACE inhibitor and beta-blocker therapy in appropriately selected patients.

Question 10: 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 antihistamines alone
Intranasal corticosteroids (Correct answer)
Oral decongestants

Correct answer: Intranasal corticosteroids

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

Question 11: 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)
Streptococcus viridans
Staphylococcus epidermidis
Enterococcus faecalis

Correct answer: Staphylococcus aureus

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

Question 12: 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 13: 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?

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

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 14: 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?

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

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

Fallopian tube (Correct answer)
Cervix
Pelvic cavity
Uterine cornu

Correct answer: Fallopian tube

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

Question 16: A 40-year-old presents with unilateral progressive sensorineural hearing loss, high-frequency tinnitus, and unsteadiness. MRI with gadolinium shows an enhancing cerebellopontine angle mass. What is the most likely diagnosis?

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

Correct answer: Vestibular schwannoma (acoustic neuroma)

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

Question 17: A 62-year-old has fatigue, back pain, hypercalcemia, anemia, and a serum M-protein spike on SPEP. What is the most likely diagnosis?

Metastatic prostate cancer
Chronic lymphocytic leukemia
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 18: A 5-year-old child presents with fever, malaise, and diffuse flaccid bullae with superficial skin sloughing that resembles scalded skin. Nikolsky sign is positive. What is the causative organism?

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

Correct answer: Staphylococcus aureus exfoliative toxin

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

Question 19: A 22-year-old college student presents with fever, pharyngitis, cervical lymphadenopathy, and marked fatigue. A peripheral blood smear shows atypical lymphocytes. Heterophile antibody test is positive. Which complication should be avoided during recovery?

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

Correct answer: Contact sports

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

Question 20: 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
Osgood-Schlatter disease (Correct answer)
Legg-Calvé-Perthes disease

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

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

Correct answer: Decreased erythropoietin production

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

Question 22: What is the best practice for maintaining pulmonary system performance over time?

Implement scheduled preventive maintenance (Correct answer)
Upgrade all equipment annually
Wait for failures before acting
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 23: A 60-year-old male smoker presents with a persistent cough, hemoptysis, and a 4 cm hilar mass on CXR. Biopsy shows small dark cells with nuclear molding and necrosis. What is the cell type?

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

Correct answer: Small cell lung cancer

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

Question 24: 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
Immediate insulin titration only
Prescribe corrective lenses
Urgent ophthalmology referral for laser photocoagulation (Correct answer)

Correct answer: Urgent ophthalmology referral for laser photocoagulation

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

Question 25: A patient with acromegaly would most commonly present with which cardiovascular complication?

Mitral valve prolapse
Pericardial effusion
Aortic stenosis
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 26: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?

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

Correct answer: Liver function tests

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

Question 27: A 50-year-old returns from a trip to sub-Saharan Africa with fever, chills, and rigors occurring every 48 hours. Blood smear reveals ring-form trophozoites with appliqué (accolé) positioning and no Schüffner's dots. Which Plasmodium species is most likely responsible?

Plasmodium vivax
Plasmodium falciparum (Correct answer)
Plasmodium ovale
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 28: 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?

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

Correct answer: Slipped capital femoral epiphysis

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

Question 29: A 25-year-old woman has recurrent episodes of unilateral throbbing headache with photophobia, phonophobia, and nausea lasting 12–24 hours. What is the acute treatment of choice?

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

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

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

Question 30: A 70-year-old male smoker presents with a 3-cm solitary pulmonary nodule found incidentally on chest X-ray. What characteristic would MOST suggest a benign lesion?

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

Correct answer: Popcorn calcification pattern

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

Question 31: On his fingertips, a 26-year-old male has 3 to 4 cm depigmented irregular patches that have been there for the past two months and appear to be becoming bigger. What is probably taking place with this patient?

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

Correct answer: Loss of skin melanocytes with unclear cause

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

Question 32: 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?

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

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 33: 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?

Sulfasalazine
Methotrexate (Correct answer)
Hydroxychloroquine
Leflunomide

Correct answer: Methotrexate

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

Question 34: 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?

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

Correct answer: Hypoparathyroidism

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

Question 35: A patient with chronic alcohol use presents with hematemesis. Upper endoscopy reveals tortuous, dilated veins at the gastroesophageal junction. What is the mechanism of this finding?

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

Correct answer: Increased portal venous pressure causing portosystemic shunting

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

Question 36: Which finding is MOST specific for exudative pleural effusion using Light's criteria?

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

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

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

Question 37: A patient with type 1 diabetes develops sudden confusion, diaphoresis, and tremors. Blood glucose is 42 mg/dL. What is the most appropriate immediate intervention?

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

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

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

Question 38: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

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

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

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

Question 39: A neonate born at 28 weeks gestation develops respiratory distress within 2 hours of birth. CXR shows bilateral ground-glass opacities and air bronchograms. What is the underlying pathophysiology?

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

Correct answer: Surfactant deficiency

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

Question 40: 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?

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

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

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

Correct answer: L4-L5 disc herniation

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

Question 42: What is the most important professional competency for PANCE certification in musculoskeletal?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 43: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

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

Correct answer: Vitamin C

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

Question 44: 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:

Ménière disease (Correct answer)
Vestibular neuritis
Acoustic neuroma
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 45: 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 terbinafine cream
Intralesional triamcinolone
Topical selenium sulfide shampoo alone
Oral griseofulvin (Correct answer)

Correct answer: Oral griseofulvin

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

Question 46: What is the first-line treatment for newly diagnosed warm autoimmune hemolytic anemia?

Corticosteroids (Correct answer)
Intravenous immunoglobulin
Rituximab
Splenectomy

Correct answer: Corticosteroids

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

Question 47: A 45-year-old patient who received a renal transplant 6 months ago presents with fever, dyspnea, and non-productive cough. CT chest shows bilateral ground-glass opacities. BAL with Gomori methenamine silver stain reveals cysts. What is the treatment?

Fluconazole
Trimethoprim-sulfamethoxazole (Correct answer)
Amphotericin B
Caspofungin

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

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

Correct answer: Impact assessment and change management

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

Question 49: 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 ciprofloxacin oral solution
Inhaled amphotericin B
Inhaled azithromycin
Inhaled tobramycin (Correct answer)

Correct answer: Inhaled tobramycin

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

Question 50: 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:

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

Correct answer: Bromocriptine or cabergoline

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

Question 51: A 70-year-old male presents with insidious onset dyspnea and a dry cough over 18 months. HRCT shows honeycombing with basal predominance. Pulmonary function tests reveal a restrictive pattern. Which diagnosis is most likely?

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

Correct answer: Idiopathic pulmonary fibrosis (IPF)

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

Question 52: 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)
Human papillomavirus
Cytomegalovirus
Epstein-Barr virus

Correct answer: Human herpesvirus 8 (HHV-8)

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

Question 53: 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?

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

Correct answer: Heparin-induced thrombocytopenia

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

Question 54: A 35-year-old presents with episodic positional vertigo triggered when lying down or rolling over in bed. Episodes last less than 1 minute. Dix-Hallpike test elicits upbeat-torsional nystagmus with a latency of 5 seconds. What is the first-line treatment?

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

Correct answer: Epley canalith repositioning maneuver

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

Question 55: A patient is found to have a Horner syndrome (ptosis, miosis, anhidrosis) on the right side. Which of the following is the most concerning etiology?

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

Correct answer: Carotid artery dissection

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

Question 56: 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?

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

Correct answer: Primary hyperparathyroidism

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

Question 57: A 22-year-old female presents with joint pain, a butterfly rash, and oral ulcers. Labs show positive ANA, anti-dsDNA, and low complement levels. What is the most likely diagnosis?

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

Correct answer: Systemic lupus erythematosus

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

Question 58: In PANCE practice, what is the best approach to quality improvement in dermatology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 59: What role does collaboration play in gastrointestinal for PANCE professionals?

It reduces individual accountability
It enhances outcomes through diverse perspectives and shared expertise (Correct answer)
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 60: A 28-year-old African American male develops hemolytic anemia after starting primaquine for malaria prophylaxis. What is the underlying enzyme deficiency?

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

Correct answer: G6PD deficiency

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

Question 61: A 35-year-old woman develops sudden-onset severe headache and is found to have markedly elevated blood pressure (240/130 mmHg) with papilledema. Which agent should be avoided?

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

Correct answer: Nitroprusside IV

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

Question 62: In PANCE certification, what does redundancy in system design primarily provide?

Simplified maintenance
Increased complexity
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 63: 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?

Lupus nephritis (Correct answer)
Serositis
Dermatitis
Photosensitivity

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

Wait for failures before acting
Outsource all maintenance
Implement scheduled preventive maintenance (Correct answer)
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 65: Which murmur is best heard at the left sternal border and increases with inspiration?

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

Correct answer: Tricuspid regurgitation

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

Question 66: A 5-year-old child presents with periorbital edema, frothy urine, and hypoalbuminemia. Urinalysis shows 4+ protein but no blood. What is the most common histologic finding on renal biopsy in this age group?

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

Correct answer: Minimal change disease

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

Question 67: A 60-year-old presents with recurrent hemoptysis, and CT shows a central endobronchial lesion. Biopsy reveals squamous cell carcinoma. Which paraneoplastic syndrome is most associated with this tumor type?

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

Correct answer: Hypercalcemia due to PTHrP secretion

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

Question 68: A patient exposed to a bat in their bedroom is brought to the ED. The bat was not captured for testing. The patient has no visible bite marks but was asleep. What is the appropriate management?

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

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

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

Question 69: A patient develops oliguria and elevated creatinine after aminoglycoside therapy. Urinalysis shows muddy brown granular casts. What is the diagnosis?

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

Correct answer: Acute tubular necrosis

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

Question 70: A 40-year-old woman with butterfly-shaped erythema across her cheeks and nose presents after sun exposure. Her ANA is positive with anti-dsDNA antibodies. Which skin finding would be considered discoid lupus?

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

Correct answer: Scarring plaques with follicular plugging and dyspigmentation

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

Question 71: 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?

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

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

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

Correct answer: Herpes zoster oticus (Ramsay Hunt syndrome)

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

Question 73: 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?

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

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

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

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 75: 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?

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

Correct answer: Neisseria gonorrhoeae

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

Question 76: 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?

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

Correct answer: Complete hydatidiform mole

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

Question 77: 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?

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

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

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

Correct answer: 15 hours

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

Question 79: A patient with known primary pulmonary hypertension develops worsening dyspnea. Echocardiogram shows RV systolic pressure of 80 mmHg. Which medication class acts by increasing cyclic GMP to cause pulmonary vasodilation?

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

Correct answer: Phosphodiesterase-5 inhibitors (sildenafil)

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

Question 80: A 50-year-old man with a history of gout presents with acute onset of severe pain and swelling of the first MTP joint. He is on hydrochlorothiazide for hypertension. What is the best initial treatment for the acute attack?

Febuxostat
Indomethacin (Correct answer)
Allopurinol
Probenecid

Correct answer: Indomethacin

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

Question 81: 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
Adenocarcinoma
Small cell carcinoma (Correct answer)
Large cell carcinoma

Correct answer: Small cell carcinoma

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

Question 82: A 19-year-old male presents with multiple firm, flesh-colored, umbilicated papules in the groin and inner thighs after sexual contact. What is the causative agent?

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

Correct answer: Molluscum contagiosum virus (poxvirus)

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

Question 83: Which of the following best differentiates central from obstructive sleep apnea on polysomnography?

More than 5 events per hour of sleep
Absence of respiratory effort during apneic episodes (Correct answer)
Apnea duration longer than 10 seconds
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 84: A patient has microcytic anemia, low serum ferritin, low serum iron, and elevated TIBC. What is the diagnosis?

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

Correct answer: Iron deficiency anemia

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

Question 85: 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?

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

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

Travoprost
Levothyroxine
Amitriptyline (Correct answer)
Montelukast

Correct answer: Amitriptyline

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

Question 87: 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 88: 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)
Uterine rupture
Placental abruption
Vasa previa

Correct answer: Placenta previa

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

Question 89: A 45-year-old male with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?

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

Correct answer: Thiamine 100 mg IV before glucose

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

Question 90: 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?

Pendred syndrome
Alport syndrome (Correct answer)
Usher syndrome
Waardenburg 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 91: Which of the following best distinguishes Crohn disease from ulcerative colitis on endoscopy?

Skip lesions with cobblestone appearance (Correct answer)
Presence of pseudopolyps
Involvement limited to the colon
Continuous mucosal involvement from the rectum

Correct answer: Skip lesions with cobblestone appearance

Crohn disease classically shows discontinuous skip lesions, transmural inflammation, and cobblestone mucosa due to deep fissuring ulcers, unlike UC's continuous mucosal disease.

Question 92: A 55-year-old diabetic patient presents with severe right ear pain, purulent otorrhea, and facial nerve palsy. CT scan shows bony erosion at the skull base. Which organism is responsible for this condition?

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

Correct answer: Pseudomonas aeruginosa

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

Question 93: 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?

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

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

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

Correct answer: Hashimoto thyroiditis

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

Question 95: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Target cells
Spherocytes
Schistocytes (Correct answer)
Bite cells

Correct answer: Schistocytes

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

Question 96: A 40-year-old immunocompromised patient presents with painful vesicular lesions along a unilateral dermatomal distribution on the chest. Which antiviral, started within 72 hours of rash onset, is the treatment of choice?

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

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 97: 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
Arrhythmogenic right ventricular cardiomyopathy
Brugada syndrome (Correct answer)
Long QT syndrome

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

It reduces individual accountability
It slows down work unnecessarily
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 99: 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?

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

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 100: 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?

Combined oral contraceptive pills (Correct answer)
Laparoscopy to rule out endometriosis
Opioid analgesics
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 101: A dialysis patient develops fever, chills, and hypotension during a hemodialysis session. What is the most likely cause?

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

Correct answer: Catheter-related bloodstream infection

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

Question 102: 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 103: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?

Bisphosphonate plus calcium and vitamin D (Correct answer)
Raloxifene
Teriparatide alone
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 104: 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?

Discharge with sumatriptan for migraine
Order ESR and CRP for temporal arteritis
Perform lumbar puncture to detect xanthochromia (Correct answer)
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 105: Which finding on osmotic fragility testing is most characteristic of hereditary spherocytosis?

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

Correct answer: Increased osmotic fragility

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

Question 106: A 65-year-old woman presents with bilateral shoulder and hip girdle aching, morning stiffness over 1 hour, and ESR of 85 mm/hr. Muscle strength is normal. What is the first-line treatment?

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

Correct answer: Low-dose prednisone

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

Question 107: Which dermatome corresponds to the umbilicus?

L1
T4
T10 (Correct answer)
T6

Correct answer: T10

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

Question 108: 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?

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

Correct answer: Normal pressure hydrocephalus

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

Question 109: 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?

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

Correct answer: Narcolepsy with cataplexy

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

Question 110: 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
Esophageal stricture formation
Increased risk of esophageal squamous cell carcinoma

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 111: 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)
Patent ductus arteriosus
Ventricular septal defect
Tetralogy of Fallot

Correct answer: Bicuspid aortic valve and coarctation of the aorta

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

Question 112: 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?

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

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

Correct answer: Varicocele

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

Question 114: 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?

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

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

Adrenal adenoma
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (Correct answer)
Congenital hypothyroidism
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 116: Which laboratory finding is most characteristic of acute pancreatitis?

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

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

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

Correct answer: Insulin therapy plus metformin

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

Question 118: 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 119: A 70-year-old man on warfarin for atrial fibrillation presents with an INR of 8.5 and active GI bleeding. What is the most appropriate reversal strategy?

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

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

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

Question 120: Which physical exam finding is pathognomonic for constrictive pericarditis?

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

Correct answer: Kussmaul sign

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

Question 121: A 23-year-old woman presents with 3 months of secondary amenorrhea, galactorrhea, and headache. MRI shows a 12 mm pituitary mass. What is first-line treatment?

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

Correct answer: Bromocriptine or cabergoline

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

Question 122: 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?

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

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.

Question 123: Which documentation is essential when working with pulmonary system in PANCE?

Detailed technical specifications and as-built diagrams (Correct answer)
General descriptions without specifics
Only verbal notes
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 124: 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 125: A 35-year-old flight attendant develops sudden-onset pleuritic chest pain and dyspnea after a long flight. CT pulmonary angiography confirms a pulmonary embolism. She has no bleeding risk factors. What is the first-line treatment?

Alteplase thrombolysis
Rivaroxaban (Correct answer)
Unfractionated heparin infusion with warfarin bridge
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 126: What is the most important professional competency for PANCE certification in gastrointestinal?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 127: 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
Anterior interosseous nerve
Radial nerve
Median nerve (Correct answer)

Correct answer: Median nerve

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

Question 128: 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)
Small cell carcinoma
Squamous 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 129: A patient with CKD has a serum potassium of 6.4 mEq/L and peaked T-waves on ECG. What is the first intervention?

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

Correct answer: IV calcium gluconate

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

Question 130: 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?

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

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 131: 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 132: 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?

Posterior cruciate ligament
Anterior cruciate ligament (Correct answer)
Lateral meniscus
Medial collateral 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 133: What is the value of continuing education in dermatology for PANCE professionals?

It keeps professionals current with evolving standards and practices (Correct answer)
It is primarily a social activity
It replaces workplace experience
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 134: A 34-year-old G1P0 at 41 weeks gestation has a Bishop score of 3. Induction of labor is planned. Which agent is most appropriate for cervical ripening?

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

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

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

Correct answer: Homocystinuria

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

Question 136: 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
Hemophilia A (Correct answer)
Factor X deficiency
Von Willebrand disease type 3

Correct answer: Hemophilia A

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

Question 137: 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 138: A patient with recurrent DVT has a prolonged aPTT that does not correct with a 1:1 mixing study. What is the most likely diagnosis?

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

Correct answer: Antiphospholipid syndrome

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

Question 139: 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?

Uveitis (anterior and posterior) (Correct answer)
Optic neuritis
Bacterial conjunctivitis with iritis
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 140: What is the best practice for maintaining reproductive system performance over time?

Outsource all maintenance
Wait for failures before acting
Implement scheduled preventive maintenance (Correct answer)
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 141: A 45-year-old construction worker develops slowly progressive bilateral hand weakness with wasting of thenar and hypothenar muscles, fasciculations, and hyperreflexia. The most likely diagnosis is:

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

Correct answer: Amyotrophic lateral sclerosis

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

Question 142: 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?

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

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

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

Correct answer: Viral croup (laryngotracheobronchitis)

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

Question 144: A 30-year-old female presents with bilateral hand stiffness in the morning lasting 2 hours, fatigue, and symmetric swollen PIPs and MCPs. RF is negative but anti-CCP is positive. What is the diagnosis?

Seropositive rheumatoid arthritis (Correct answer)
Seronegative rheumatoid arthritis
Systemic lupus erythematosus
Psoriatic arthritis

Correct answer: Seropositive rheumatoid arthritis

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

Question 145: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

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

Correct answer: Oval fat bodies

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

Question 146: Which professional attribute is most valued in musculoskeletal within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 147: An 8-year-old boy presents with pubic hair and testicular enlargement. Bone age is advanced. LH and FSH are elevated. What is the most likely diagnosis?

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

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

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

Correct answer: Nonseminomatous germ cell tumor

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

Question 149: Graves disease is caused by which mechanism?

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

Correct answer: Stimulating antibodies against the TSH receptor

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

Question 150: 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 acetylcholine receptors at the neuromuscular junction (Correct answer)
Antibodies against voltage-gated calcium channels
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 151: A patient with sickle cell disease presents with acute bone pain, fever, and dactylitis. What is the most appropriate initial management?

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

Correct answer: IV fluids, oxygen, and analgesics

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

Question 152: A 62-year-old male with a history of gout presents with acute swollen red first MTP joint. Synovial fluid analysis reveals negatively birefringent needle-shaped crystals. What is the treatment of choice for the acute attack?

Methotrexate
Probenecid
Allopurinol
Indomethacin or colchicine (Correct answer)

Correct answer: Indomethacin or colchicine

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

Question 153: 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?

Caspofungin
Amphotericin B plus flucytosine (Correct answer)
Voriconazole
Fluconazole

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

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

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

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

Correct answer: Central retinal artery occlusion

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

Question 156: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 157: A neonate develops seizures at 36 hours of life after a prolonged difficult delivery. Brain MRI shows restricted diffusion in watershed zones. What is the most appropriate intervention?

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

Correct answer: Therapeutic hypothermia (whole-body cooling)

Therapeutic hypothermia (33–34°C for 72 hours) is the standard of care for hypoxic-ischemic encephalopathy in neonates ≥ 36 weeks when initiated within 6 hours of birth.

Question 158: A 15-year-old presents with bilateral nasal polyps. No history of asthma or aspirin sensitivity. A sweat chloride test is ordered. What underlying condition is being screened for?

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

Correct answer: Cystic fibrosis

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

Question 159: A 55-year-old man undergoes thyroidectomy. Postoperatively he develops perioral numbness and carpopedal spasm. Which sign would you elicit?

Kernig sign
Rovsing sign
Chvostek sign (Correct answer)
Cullen sign

Correct answer: Chvostek sign

Chvostek sign (facial twitch on tapping the facial nerve) indicates hypocalcemia from hypoparathyroidism after thyroidectomy.

Question 160: 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 161: An 8-year-old child presents with honey-crusted erosions around the nares and mouth. Gram stain shows gram-positive cocci in clusters. What is the most appropriate treatment?

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

Correct answer: Topical mupirocin or oral cephalexin

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

Question 162: A 25-year-old woman has an intensely pruritic, vesicular rash on the extensor surfaces of her elbows and knees. IgA deposits are found at the dermal-epidermal junction. What is the associated systemic condition?

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

Correct answer: Celiac disease

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

Question 163: Which approach is recommended for troubleshooting pulmonary system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 164: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 165: 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
Acute tubular necrosis
Glomerulonephritis
Prerenal azotemia (Correct answer)

Correct answer: Prerenal azotemia

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

Question 166: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

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

Correct answer: ACE inhibitors

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

Question 167: A 16-year-old girl presents with pruritic vesicles on her fingers, palms, and soles that seem to 'taper' deep into the skin. The condition worsens in summer. What is the diagnosis?

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

Correct answer: Dyshidrotic eczema (pompholyx)

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

Question 168: In PANCE practice, what is the best approach to quality improvement in gastrointestinal?

Make changes without measuring results
Copy what other organizations do without analysis
Wait for problems to occur before acting
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 169: Which approach is recommended for troubleshooting cardiovascular system issues?

Replace all components simultaneously
Use systematic isolation and testing methods (Correct answer)
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 170: A patient has colicky flank pain radiating to the groin, hematuria, and nausea. KUB shows a radiopaque stone at the ureterovesical junction. What is the most common stone type?

Cystine
Calcium oxalate (Correct answer)
Uric acid
Struvite

Correct answer: Calcium oxalate

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

Question 171: A 55-year-old presents with flank pain, gross hematuria, and a palpable mass. CT reveals a solid renal mass. What is the most likely diagnosis?

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

Correct answer: Renal cell carcinoma

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

Question 172: Which test is most appropriate for diagnosing Clostridioides difficile infection?

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

Correct answer: PCR for C. difficile toxin genes

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

Question 173: Which of the following is the most appropriate first-line treatment for Helicobacter pylori eradication in the US?

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

Correct answer: Omeprazole + amoxicillin + clarithromycin for 14 days

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

Question 174: 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)
Culture the wound and start targeted antibiotic monotherapy
Hyperbaric oxygen therapy as definitive treatment
Start IV vancomycin and piperacillin-tazobactam and observe for 24 hours

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

Vitamin B12 (Correct answer)
Folate
Thiamine
Pyridoxine

Correct answer: Vitamin B12

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

Question 176: 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?

Choledocholithiasis
Acute cholecystitis
Hepatitis A
Ascending cholangitis (Correct answer)

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

Detailed technical specifications and as-built diagrams (Correct answer)
General descriptions without specifics
Only verbal notes
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 178: What is the primary consideration when implementing changes to pulmonary system?

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

Zenker diverticulum
Achalasia
Esophageal adenocarcinoma (Correct answer)
Esophageal spasm

Correct answer: Esophageal adenocarcinoma

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

Question 180: Which physical exam finding best differentiates cellulitis from necrotizing fasciitis?

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

Correct answer: Crepitus, wooden-hard texture of tissue, and disproportionate pain

Crepitus (gas in tissues), a wooden-hard texture to palpation, and pain out of proportion to appearance indicate necrotizing fasciitis requiring emergent surgical debridement.

Question 181: Which of the following statements about end-of-life concerns for cystic fibrosis patients is accurate?

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

Correct answer: Palliative care should be discussed

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

Question 182: In PANCE practice, what is the best approach to quality improvement in eent?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 183: A 65-year-old woman on alendronate for 5 years asks about continuing therapy. What is the most serious rare adverse effect associated with long-term bisphosphonate use?

Hypomagnesemia
Hypercalcemia
Atypical femur fracture (Correct answer)
Adrenal suppression

Correct answer: Atypical femur fracture

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

Question 184: 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?

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

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

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

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

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

Question 186: A 35-year-old presents with chronic nasal congestion, facial pressure, anosmia, and nasal polyps visible on anterior rhinoscopy. He has a history of aspirin sensitivity and asthma. What triad does this represent?

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

Correct answer: Samter's triad (AERD)

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

Question 187: Which of the following is the first-line treatment for absence seizures?

Phenytoin
Ethosuximide (Correct answer)
Valproic acid
Carbamazepine

Correct answer: Ethosuximide

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

Question 188: What is the fundamental principle behind neurologic system in the PANCE domain?

Using the newest technology exclusively
Balancing performance, reliability, and efficiency (Correct answer)
Cost minimization at all costs
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 189: A 60-year-old patient who recently completed a 10-day course of antibiotics for a respiratory infection develops profuse watery diarrhea. Stool testing reveals the causative toxin. Which antibiotic is the preferred first-line treatment for mild-to-moderate disease?

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

Correct answer: Vancomycin 125 mg PO QID × 10 days

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

Question 190: What is the primary consideration when implementing changes to reproductive system?

Vendor preference
Speed of implementation
Personal convenience
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 191: A 35-year-old male presents with recurrent episodes of severe unilateral periorbital pain lasting 45-90 minutes, associated with ipsilateral lacrimation and nasal congestion. What is the most likely diagnosis?

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

Correct answer: Cluster headache

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

Question 192: A 50-year-old presents with progressive bilateral conductive hearing loss. Audiometry shows a Carhart notch at 2000 Hz on bone conduction and an absent stapedial reflex. What is the most likely diagnosis?

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

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

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

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 194: 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?

Metformin (Correct answer)
Sitagliptin
Empagliflozin
Insulin glargine

Correct answer: Metformin

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

Question 195: A 32-year-old woman with PCOS desires contraception and treatment of acne and hirsutism. Which combined oral contraceptive ingredient provides the most anti-androgenic benefit?

Levonorgestrel
Drospirenone (Correct answer)
Norgestrel
Norethindrone

Correct answer: Drospirenone

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

Question 196: Which of the following is the recommended screening interval for colonoscopy in an average-risk patient with no findings on initial screening at age 50?

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

Correct answer: 10 years

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

Question 197: 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 198: 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 199: A 60-year-old man presents with a brown-black lesion with asymmetry, irregular border, color variegation, and diameter of 7 mm on his back. Biopsy confirms melanoma with Breslow thickness of 1.2 mm. What is the recommended surgical margin?

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

Correct answer: 1 cm margin

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

Question 200: Which documentation is essential when working with neurologic system in PANCE?

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 201: A newborn develops erythematous macules and papules with surrounding flares on the trunk and extremities within 24–48 hours of birth. Wright stain of pustule contents shows eosinophils. What is the diagnosis?

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

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

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

Correct answer: CT or MRI of the abdomen/pelvis

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

Question 203: A 35-year-old with Crohn disease develops a new fistula between the bowel and the bladder. What is the most specific symptom of this complication?

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

Correct answer: Pneumaturia (air in the urine)

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

Question 204: 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?

Irregular menstrual cycles
History of migraine with aura (Correct answer)
Family history of ovarian cancer
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 205: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?

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

Correct answer: Right coronary artery

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

Question 206: 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?

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

Correct answer: Subacromial impingement syndrome

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

Question 207: A 65-year-old male with BPH and urinary retention is catheterized and drains 1,200 mL of urine. Two hours later he develops gross hematuria and hypotension. What has occurred?

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

Correct answer: Post-obstructive diuresis with hemorrhagic cystitis

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

Question 208: A 34-year-old woman presents with a 2-week history of fatigue, weight gain, cold intolerance, and constipation. Which lab finding would you expect?

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

Correct answer: High TSH, low free T4

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

Question 209: 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?

Esophageal rupture
Acute MI
Pulmonary embolism
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 210: 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?

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

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 211: 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
Physical therapy and NSAIDs for 6-12 weeks (Correct answer)
Sling immobilization for 8 weeks

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

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

Question 212: A 5-year-old child presents with high fever, inspiratory stridor, drooling, and sitting in the 'tripod position.' Lateral neck X-ray shows the 'thumbprint sign.' Which organism is the most likely cause?

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

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

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

Correct answer: Intracranial berry aneurysm

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

Question 214: What is the fundamental principle behind cardiovascular system in the PANCE domain?

Balancing performance, reliability, and efficiency (Correct answer)
Following a single vendor solution
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 215: A 30-year-old woman with known asthma presents to the ED with severe bronchospasm unresponsive to two doses of albuterol. Which medication is most appropriate next?

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

Correct answer: IV magnesium sulfate

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

Question 216: A 60-year-old presents with rectal bleeding, mucus discharge, and tenesmus. Digital rectal exam reveals a rectal mass 4 cm from the anal verge. Which is the most appropriate next step?

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

Correct answer: Flexible sigmoidoscopy with biopsy

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

Question 217: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?

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

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

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

Question 218: 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?

Malignancy-associated hypercalcemia
Sarcoidosis
Primary hyperparathyroidism (Correct answer)
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 219: 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?

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

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 220: 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?

Oseltamivir 75 mg PO BID × 5 days (Correct answer)
Baloxavir 40 mg PO single dose
Zanamivir 10 mg inhaled BID × 5 days
Amantadine 100 mg PO 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 221: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

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

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

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

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

Correct answer: Chronic myelogenous leukemia

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

Question 224: A newborn fails to pass meconium within 48 hours of birth. Abdominal X-ray shows a distended colon with a transition zone. Rectal biopsy confirms absence of ganglion cells. What is the diagnosis?

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

Correct answer: Hirschsprung disease

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

Question 225: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

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

Correct answer: Immune thrombocytopenic purpura

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

Question 226: A 45-year-old woman presents with weight gain, cold intolerance, and constipation. TSH is 12 mIU/L and free T4 is low. Which medication is first-line treatment?

Propylthiouracil
Radioactive iodine
Levothyroxine (Correct answer)
Methimazole

Correct answer: Levothyroxine

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

Question 227: Which approach best demonstrates mastery of dermatology in PANCE practice?

Following procedures without understanding
Relying entirely on technology
Applying principles to novel situations with sound judgment (Correct answer)
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 228: Which acid-base disorder is most commonly seen in end-stage renal disease?

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

Correct answer: High anion gap metabolic acidosis

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

Question 229: A 28-year-old male presents with a painless scrotal swelling. Urethral culture is positive for an intracellular gram-negative diplococci. He also complains of urethral discharge. Which is the recommended dual therapy per current CDC guidelines?

Ceftriaxone 250 mg IM + azithromycin 1 g PO
Penicillin G 4.8 million units IM + probenecid
Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days (Correct answer)
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 230: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 231: 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?

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

Correct answer: Ciprofloxacin 400 mg IV

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

Question 232: 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
Migraine equivalent; MRI of the brain
Optic neuritis; MRI of the brain
Amaurosis fugax; carotid duplex ultrasound (Correct answer)

Correct answer: Amaurosis fugax; carotid duplex ultrasound

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

Question 233: 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?

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

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

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

Correct answer: Allopurinol therapy

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

Question 235: Which finding on DEXA scan defines osteoporosis (not osteopenia)?

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

Correct answer: T-score of -2.5 or below

Osteoporosis is defined by a T-score of -2.5 or lower on DEXA scan.

Question 236: A 7-year-old is brought in for a school screening failure. Exam reveals the left eye deviates outward when the right eye fixates. The child has no diplopia. What is the most appropriate initial management?

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

Correct answer: Referral to ophthalmology for evaluation

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

Question 237: A 60-year-old presents with iron deficiency anemia, weight loss, and a change in bowel habits. Colonoscopy reveals a mass in the ascending colon. Which is the most likely histologic type?

Lymphoma
Adenocarcinoma (Correct answer)
Carcinoid tumor
Squamous cell carcinoma

Correct answer: Adenocarcinoma

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

Question 238: A patient develops worsening hypoxemia 48 hours after an aspiration event. CXR shows bilateral infiltrates with no evidence of cardiogenic edema. PaO2/FiO2 ratio is 150. How is this classified?

Acute lung injury (ALI)
Mild ARDS
Severe ARDS (Correct answer)
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 239: 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)
Stress fracture
Trochanteric bursitis
Septic arthritis

Correct answer: Avascular necrosis

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

Question 240: A 55-year-old male with a 40-pack-year smoking history presents with hemoptysis, weight loss, and a hilar mass on CXR. His serum calcium is 11.8 mg/dL. Which lung cancer type is most likely?

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

Correct answer: Squamous cell carcinoma

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

Question 241: A 58-year-old man with peripheral artery disease has an ankle-brachial index (ABI) of 0.55. He has rest pain. Next best step?

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

Correct answer: Referral for revascularization

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

Question 242: 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?

Chest tube drainage (Correct answer)
Continue antibiotics and repeat thoracentesis in 48 hours
Thoracoscopic debridement
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 243: Which urine finding best differentiates nephritic syndrome from nephrotic syndrome?

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

Correct answer: RBC casts

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

Question 244: 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
Right hemiplegia with expressive aphasia (Correct answer)
Bilateral lower extremity weakness

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

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

Correct answer: Poststreptococcal glomerulonephritis

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

Question 246: A 40-year-old diver presents with right ear pain and conductive hearing loss after a dive to 30 meters. Otoscopy shows a hemotympanum. What is the diagnosis?

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

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 247: 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?

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

Correct answer: Central retinal artery occlusion

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

Question 248: A 30-year-old presents with recurrent episodes of severe unilateral eye pain, redness, and halos around lights. Each episode lasts 2-3 hours and resolves spontaneously. IOP during an attack is 45 mmHg. What is the treatment of choice for long-term prevention?

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

Correct answer: Laser peripheral iridotomy

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

Question 249: A patient on mechanical ventilation has high peak airway pressures but normal plateau pressures. Which condition best explains this finding?

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

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

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

Correct answer: Concurrent cisplatin-based chemotherapy and radiation

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

Question 251: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

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

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

Ceftriaxone 2 g IV daily × 14 days
Doxycycline 100 mg PO BID × 14–21 days (Correct answer)
Amoxicillin 500 mg PO TID × 21 days
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 253: A 45-year-old man has prolonged QT on EKG (QTc 510 ms) and is prescribed an antibiotic. Which is SAFEST to use?

Erythromycin
Moxifloxacin
Amoxicillin (Correct answer)
Azithromycin

Correct answer: Amoxicillin

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

Question 254: A 45-year-old farmer in Ohio presents with fever, chills, and a dry cough after cleaning a chicken coop. Chest X-ray shows hilar lymphadenopathy and diffuse small nodular infiltrates. Urine antigen test is positive. What is the diagnosis?

Histoplasmosis (Correct answer)
Blastomycosis
Aspergillosis
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 255: A 48-year-old on amiodarone for 3 years develops new bilateral pulmonary infiltrates and worsening PFTs. Which mechanism best explains amiodarone pulmonary toxicity?

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

Correct answer: Direct phospholipid accumulation and oxidative injury

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

Question 256: Which finding on chest X-ray is most characteristic of a tension pneumothorax?

Bilateral diffuse infiltrates
Unilateral pleural effusion without mediastinal shift
Ipsilateral tracheal deviation with complete opacification
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 257: When examining a patient who has known benign prostatic hyperplasia, what would you anticipate finding?

Hard, nodular prostate with digital rectal exam
Rubbery prostate with digital rectal exam (Correct answer)
Fever and elevated white blood cell count (WBC)
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 258: A patient presents with a painless, hard, left supraclavicular lymph node and significant weight loss. Upper endoscopy reveals a gastric mass. Which eponymous finding is described?

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

Correct answer: Virchow node

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

Question 259: A 28-year-old woman presents with cyclic pelvic pain, dyspareunia, and infertility. Laparoscopy reveals powder-burn lesions on the peritoneum. Which mechanism best explains her infertility?

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

Correct answer: Distorted pelvic anatomy and inflammatory cytokines impairing implantation

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

Question 260: A 45-year-old woman presents with menorrhagia and pelvic pressure. Uterus is 14-week size on exam. Ultrasound shows multiple intramural masses. What is the most appropriate first-line pharmacologic treatment?

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

Correct answer: Levonorgestrel IUD

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

Question 261: Which electrolyte abnormality is most characteristic of primary hyperaldosteronism (Conn syndrome)?

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

Correct answer: Hypokalemia and hypertension

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

Question 262: Which professional attribute is most valued in eent within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 263: A miner presents with progressive dyspnea and bilateral upper lobe fibrosis on chest X-ray. Biopsy shows collagen nodules with birefringent crystals. What is the diagnosis?

Coal workers' pneumoconiosis
Berylliosis
Silicosis (Correct answer)
Asbestosis

Correct answer: Silicosis

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

Question 264: 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?

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

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

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

Correct answer: Urinary alkalinization with potassium citrate and allopurinol

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

Question 266: A patient with MEN1 syndrome would most likely have which combination of tumors?

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

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

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

Question 267: A 28-year-old female presents with amenorrhea, galactorrhea, and headaches. Labs show elevated prolactin. MRI reveals a pituitary mass. What is the first-line treatment?

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

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

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

Correct answer: Elevated FSH and LH, low testosterone

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

Question 269: A 32-year-old woman presents with pleuritic chest pain, malar rash, oral ulcers, and arthralgias. Lab work shows anti-dsDNA antibodies and low complement (C3/C4). What is the most likely diagnosis?

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

Correct answer: Systemic lupus erythematosus (SLE)

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

Question 270: 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
Myasthenia gravis
Polymyalgia rheumatica
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 271: A 50-year-old man with dilated cardiomyopathy and EF of 25% is on optimal medical therapy. Which device therapy reduces mortality most significantly?

Wearable defibrillator vest
Biventricular pacemaker (CRT) alone
Implantable cardioverter-defibrillator (ICD) (Correct answer)
Permanent pacemaker

Correct answer: Implantable cardioverter-defibrillator (ICD)

ICD implantation reduces sudden cardiac death in patients with EF ≤35% and symptomatic heart failure on optimal medical therapy per MADIT-II and SCD-HeFT trials.

Question 272: A 4-year-old child presents with a barky cough, stridor, and low-grade fever. X-ray shows the 'steeple sign.' What is the most likely diagnosis?

Croup (laryngotracheobronchitis) (Correct answer)
Bacterial tracheitis
Epiglottitis
Foreign body aspiration

Correct answer: Croup (laryngotracheobronchitis)

Croup (viral laryngotracheobronchitis) causes subglottic narrowing seen as the steeple sign on AP neck X-ray.

Question 273: A patient with a pulmonary embolism develops hypotension (BP 80/50) and RV dilation on echo. She has no contraindications to thrombolytics. Which statement best describes the appropriate management?

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

Correct answer: Systemic thrombolysis with alteplase

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

Question 274: A 68-year-old male presents with inability to urinate and a distended, palpable bladder. What is the most common cause in this population?

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

Correct answer: Benign prostatic hyperplasia

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

Question 275: Which documentation is essential when working with endocrine system in PANCE?

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 276: A 28-year-old woman presents with optic neuritis and a prior episode of transverse myelitis. MRI shows periventricular white matter lesions disseminated in time and space. Which treatment reduces long-term disability?

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

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

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

Question 277: A patient presents with watery diarrhea, hypokalemia, and achlorhydria. CT shows a pancreatic mass. Which hormone is most likely responsible?

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

Correct answer: Vasoactive intestinal peptide (VIP)

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

Question 278: A 32-year-old woman presents with pink, annular plaques with raised borders on her arms after hiking in the Southwest US. Serology confirms Coccidioides immitis infection. What skin finding is a sign of good immune response?

Erythema multiforme
Diffuse macular rash
Erythema nodosum (Correct answer)
Petechiae

Correct answer: Erythema nodosum

Erythema nodosum (tender, red subcutaneous nodules on the shins) in coccidioidomycosis indicates a strong cell-mediated immune response and a favorable prognosis.

Question 279: 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

Vaginitis
Cystitis
Uterine fibroids
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 280: What is the first-line noninvasive screening test for suspected renal artery stenosis?

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

Correct answer: Renal artery duplex ultrasound

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

Question 281: A 6-year-old child is brought in for evaluation of a 3-day sore throat, fever of 38.9°C, and enlarged anterior cervical lymph nodes. No cough is present. What is the Centor score and recommended management?

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

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

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

Question 282: 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?

Alendronate (Correct answer)
Calcitonin
Raloxifene
Calcium supplementation alone

Correct answer: Alendronate

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

Question 283: 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
Probenecid
Allopurinol
Indomethacin or colchicine (Correct answer)

Correct answer: Indomethacin or colchicine

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

Question 284: 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)
Polymyalgia rheumatica
Systemic lupus erythematosus

Correct answer: Fibromyalgia

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

Question 285: 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?

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

Correct answer: HELLP syndrome

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

Question 286: 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 287: A 25-year-old male presents with fever, headache, photophobia, and nuchal rigidity. CSF analysis shows WBC 1,200 cells/µL (predominantly neutrophils), glucose 30 mg/dL (serum glucose 90 mg/dL), and protein 180 mg/dL. What is the most likely causative organism in this age group?

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

Correct answer: Neisseria meningitidis

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

Question 288: A 45-year-old woman presents with a salmon-colored, well-demarcated plaque with silvery scale on her elbows and knees. Which finding would most likely be seen on biopsy?

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

Correct answer: Acanthosis with parakeratosis and Munro microabscesses

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

Question 289: 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
Progestin-only therapy
Combined estrogen-progestin therapy
Estrogen-only therapy (Correct answer)

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

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

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

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

Correct answer: Esophagogastroduodenoscopy

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

Question 292: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

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

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

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

Question 293: A 55-year-old diabetic patient presents with a painless foot ulcer over the plantar surface of the first metatarsal head. Pulses are intact. What is the primary etiology?

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

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

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

Correct answer: Prepare for emergent cesarean delivery

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

Question 295: A 30-year-old woman with Hashimoto thyroiditis is euthyroid. She asks about her risk for other autoimmune conditions. Which condition is she at increased risk for?

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

Correct answer: Vitiligo and type 1 diabetes

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

Question 296: 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 297: On lumbar puncture in bacterial meningitis, which CSF finding best distinguishes it from viral meningitis?

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

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

Test for HIV and other STIs (Correct answer)
Initiate long-term suppressive azithromycin
Switch to a different antibiotic class for treatment
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 299: 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?

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

Correct answer: Simple aspiration or small-bore chest tube

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

Question 300: A 38-year-old woman at 20 weeks gestation undergoes amniocentesis. Which complication should be discussed as the most significant risk?

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

Physician Assistant National Certifying Examination (PANCE)

The PANCE is the national certification examination administered by the NCCPA for entry-level physician assistants. It tests medical and surgical knowledge across 14 organ systems plus professional practice, and is required for initial PA licensure in the United States.

300

Questions

300 min

Time Limit

70%

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