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

Question 1: A 55-year-old man with small cell lung cancer develops ascending weakness and areflexia two weeks after chemotherapy. Anti-Hu antibodies are detected. This is an example of:

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

Correct answer: Paraneoplastic encephalomyelitis/sensory neuronopathy

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

Question 2: The typical symptoms of this illness, such as a severe state of disorientation or difficulty focusing or maintaining attention, are present in this patient. Delirium is also characterized by difficulties with orientation and a sharp decline in short-term memory and recall.

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

Correct answer: Delirium

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

Question 3: A 55-year-old man with a history of alcohol use disorder presents with painless jaundice, clay-colored stools, and dark urine. Ultrasound shows dilation of the common bile duct. What is the most likely cause?

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

Correct answer: Pancreatic head carcinoma

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

Question 4: A patient with community-acquired pneumonia has a parapneumonic effusion. Thoracentesis reveals pH 7.15, glucose 45 mg/dL, and LDH 1,200 U/L. What is the next best step?

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

Correct answer: Chest tube drainage

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

Question 5: A 35-year-old presents with chronic nasal congestion, facial pressure, anosmia, and nasal polyps visible on anterior rhinoscopy. He has a history of aspirin sensitivity and asthma. What triad does this represent?

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

Correct answer: Samter's triad (AERD)

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

Question 6: A 55-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows grade 1 endometrioid adenocarcinoma. Which is the most significant risk factor she likely has?

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

Correct answer: Unopposed estrogen exposure

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

Question 7: A 48-year-old woman presents with hot flashes, vaginal dryness, and irregular menses for 8 months. FSH is 62 mIU/mL. She has no uterus. Which hormone replacement is appropriate?

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

Correct answer: Estrogen-only therapy

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

Question 8: A 70-year-old farmer presents with a pearly, rolled-edge nodule with telangiectasias on his nose that occasionally bleeds. What is the first-line treatment?

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

Correct answer: Mohs micrographic surgery

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

Question 9: A 30-year-old IV drug user presents with fever, new holosystolic murmur at the right sternal border, and multiple septic pulmonary emboli on CT scan. Which organism is most commonly responsible for right-sided endocarditis in IV drug users?

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

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 10: 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?

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

Correct answer: Hypopharynx (pyriform sinus)

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

Question 11: A 40-year-old man presents with recurrent painful oral aphthous ulcers, genital ulcerations, and uveitis. Which additional finding would confirm the diagnosis of Behçet disease?

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

Correct answer: Positive pathergy test

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

Question 12: A 60-year-old diabetic male presents with severe left-sided otalgia, purulent otorrhea, and granulation tissue visible in the external auditory canal. He has facial nerve palsy. CT shows cortical bone erosion at the skull base. What is the most likely organism?

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

Correct answer: Pseudomonas aeruginosa

Malignant (necrotizing) external otitis in diabetics is almost exclusively caused by Pseudomonas aeruginosa; facial nerve palsy indicates skull base osteomyelitis requiring prolonged IV antipseudomonal therapy.

Question 13: A 50-year-old male presents with gradually worsening low back pain and bilateral lower extremity pain that is relieved by leaning forward or sitting. MRI shows narrowing of the spinal canal. What is the most likely diagnosis?

Cauda equina syndrome
Herniated nucleus pulposus
Ankylosing spondylitis
Lumbar spinal stenosis (Correct answer)

Correct answer: Lumbar spinal stenosis

Lumbar spinal stenosis causes neurogenic claudication with bilateral leg pain relieved by flexion (sitting or leaning forward), which opens the canal.

Question 14: A patient with known primary pulmonary hypertension develops worsening dyspnea. Echocardiogram shows RV systolic pressure of 80 mmHg. Which medication class acts by increasing cyclic GMP to cause pulmonary vasodilation?

Prostacyclin analogs (epoprostenol)
Phosphodiesterase-5 inhibitors (sildenafil) (Correct answer)
Calcium channel blockers (nifedipine)
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 15: A 26-year-old woman with no prenatal care delivers a term infant. The neonate develops purulent conjunctivitis at 5 days of life. Gram stain shows intracellular gram-negative diplococci. What is the treatment?

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

Correct answer: IV ceftriaxone

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

Question 16: A patient presents with sudden painless monocular vision loss lasting 10 minutes, described as a 'curtain coming down.' Fundoscopy during the episode shows a pale retina. What is the most likely diagnosis?

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

Correct answer: Amaurosis fugax due to carotid artery stenosis

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

Question 17: A 70-year-old male presents with insidious onset dyspnea and a dry cough over 18 months. HRCT shows honeycombing with basal predominance. Pulmonary function tests reveal a restrictive pattern. Which diagnosis is most likely?

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

Correct answer: Idiopathic pulmonary fibrosis (IPF)

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

Question 18: Which of the following is the most common cause of Cushing syndrome in clinical practice?

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

Correct answer: Exogenous corticosteroid use

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

Question 19: A patient with recurrent DVT has a prolonged aPTT that does not correct with a 1:1 mixing study. What is the most likely diagnosis?

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

Correct answer: Antiphospholipid syndrome

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

Question 20: 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?

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

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

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 22: 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?

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

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

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

Question 23: 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?

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

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 24: 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?

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

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

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

Correct answer: Accumulation of ammonia causing cerebral edema

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

Question 26: A 67-year-old man with BPH presents with inability to void, suprapubic distension, and a post-void residual of 800 mL on ultrasound. What is the most immediate intervention?

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

Correct answer: Urethral catheterization

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

Question 27: A patient presents with a painless penile ulcer with clean base and raised indurated edges. Dark-field microscopy of the lesion reveals spirochetes. Which antibiotic is first-line treatment?

Ceftriaxone 500 mg IM single dose
Doxycycline 100 mg PO BID × 14 days
Azithromycin 1 g PO 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 28: A 40-year-old lady is undergoing in vitro fertilization procedures with her husband's sperm and eggs that were removed from her body. 15% of attempts at conception will be successful for the patient. The physician assistant learns from reading the patient's records that the patient was unintentionally implanted with a fertilized egg from another couple 24 hours prior. Which of the following is the physician assistant's best line of action?

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

Correct answer: Immediately inform the patient of the error

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

Question 29: 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)
Cauda equina syndrome
Lumbar spinal stenosis

Correct answer: L4-L5 disc herniation

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

Question 30: What role does collaboration play in dermatology for PANCE professionals?

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

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

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

Question 31: 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?

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

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 32: 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)
Leydig cell tumor
Seminoma
Embryonal carcinoma

Correct answer: Yolk sac tumor

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

Question 33: Which of the following is the most appropriate first-line treatment for Helicobacter pylori eradication in the US?

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

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

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

Correct answer: Hypokalemia and hypertension

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

Question 35: A 72-year-old man has a PSA of 18 ng/mL. Prostate biopsy shows Gleason score 4+4=8 in 8 of 12 cores. Bone scan shows no metastases. Which treatment is most appropriate?

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

Correct answer: Radical prostatectomy or radiation with androgen deprivation therapy

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

Question 36: A 55-year-old diabetic patient presents with severe right ear pain, purulent otorrhea, and facial nerve palsy. CT scan shows bony erosion at the skull base. Which organism is responsible for this condition?

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

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 37: 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:

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

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

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 39: 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)
Blumer shelf
Irish node
Sister Mary Joseph node

Correct answer: Virchow node

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

Question 40: What is the fundamental principle behind pulmonary system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

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

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

Correct answer: Impact assessment and change management

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

Question 42: A 29-year-old pregnant woman at 28 weeks is found to have Rh-negative blood type. Her partner is Rh-positive. What is the correct management?

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

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

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

Question 43: A 28-year-old sexually active woman presents with dysuria, mucopurulent cervical discharge, and cervical motion tenderness. Nucleic acid amplification test is positive for Chlamydia trachomatis. Which additional organism must empirically be treated simultaneously?

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

Correct answer: Neisseria gonorrhoeae

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

Question 44: What is the primary consideration when implementing changes to endocrine 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 45: An 8-year-old child develops facial edema and frothy urine. Urinalysis shows 4+ protein. Serum albumin is 1.8 g/dL. No hematuria or hypertension. What is the most likely diagnosis?

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

Correct answer: Nephrotic syndrome — minimal change disease

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

Question 46: 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
Nephroblastoma
Renal cell carcinoma (Correct answer)

Correct answer: Renal cell carcinoma

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

Question 47: A 40-year-old African American woman presents with bilateral hilar lymphadenopathy, uveitis, and erythema nodosum. Serum ACE level is elevated. What is the most likely diagnosis?

Histoplasmosis
Sarcoidosis (Correct answer)
Tuberculosis
Lymphoma

Correct answer: Sarcoidosis

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

Question 48: 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 49: What is the best practice for maintaining reproductive system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 50: Which of the following drugs would not be recommended for a glaucoma patient to take?

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

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

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

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

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

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

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

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

Question 53: Which physical exam finding is pathognomonic for constrictive pericarditis?

Kussmaul sign (Correct answer)
S3 gallop
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 54: 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)
Streptococcus pneumoniae
Haemophilus influenzae
Listeria monocytogenes

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

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

Correct answer: Primary hyperparathyroidism

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

Question 56: A 3-year-old presents with vesicles on an erythematous base in a dermatomal distribution on the trunk. The child's mother has active chickenpox. What is the most likely diagnosis?

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

Correct answer: Primary varicella (chickenpox)

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

Question 57: A 30-year-old woman at 10 weeks gestation is found to have a complete hydatidiform mole on ultrasound with a 'snowstorm' appearance. After suction curettage, what is the most important follow-up?

Chest CT to rule out metastases
Immediate chemotherapy with methotrexate
Repeat ultrasound in 4 weeks
Serial serum hCG monitoring until undetectable (Correct answer)

Correct answer: Serial serum hCG monitoring until undetectable

Serial serum hCG monitoring is mandatory after molar evacuation to detect persistent gestational trophoblastic neoplasia, which occurs in ~15-20% of complete moles.

Question 58: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

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

Correct answer: Oval fat bodies

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

Question 59: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

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

Correct answer: ACE inhibitors

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

Question 60: 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?

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

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

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

Correct answer: Sumatriptan 50 mg orally

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

Question 62: A 48-year-old woman with a history of breast cancer presents with severe back pain and new bilateral leg weakness with bowel/bladder incontinence. What is the most urgent next step?

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

Correct answer: Emergency MRI of the spine and neurosurgical consult

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

Question 63: A 50-year-old male smoker presents with weight loss, hemoptysis, and hyponatremia (Na 122 mEq/L). Chest CT shows a central hilar mass. Which cell type is most likely responsible for his electrolyte abnormality?

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

Correct answer: Small cell carcinoma

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

Question 64: A 38-year-old woman at 20 weeks gestation undergoes amniocentesis. Which complication should be discussed as the most significant risk?

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

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

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

Question 65: In PANCE practice, what is the best approach to quality improvement in eent?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 66: A patient with multiple myeloma develops worsening renal function. Which renal complication is most directly caused by light chain deposition in tubules?

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

Correct answer: Cast nephropathy

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

Question 67: A 35-year-old G2P1 at 36 weeks gestation presents with painless bright red vaginal bleeding. Fetal heart tones are reassuring. What is the most likely diagnosis?

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

Correct answer: Placenta previa

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

Question 68: 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 69: A patient taking phenytoin for seizures presents with nystagmus, ataxia, and diplopia. Serum phenytoin level is 28 mcg/mL (therapeutic 10–20). What is the best management?

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

Correct answer: Reduce phenytoin dose

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

Question 70: A 25-year-old male presents with painless enlargement of the right testis. Ultrasound shows a solid intratesticular mass. AFP is elevated. What is the most likely tumor type?

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

Correct answer: Yolk sac tumor

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

Question 71: A 70-year-old has macrocytic anemia, glossitis, and neurologic symptoms. Labs show elevated methylmalonic acid and homocysteine. What is the deficiency?

Folate
Thiamine
Pyridoxine
Vitamin B12 (Correct answer)

Correct answer: Vitamin B12

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

Question 72: A 55-year-old man undergoes thyroidectomy. Postoperatively he develops perioral numbness and carpopedal spasm. Which sign would you elicit?

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

Correct answer: Chvostek sign

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

Question 73: A 25-year-old man presents with bilateral cryptorchidism corrected at age 4 and now seeks fertility counseling. What is the most appropriate initial test?

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

Correct answer: Semen analysis

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

Question 74: A 9-year-old presents with a painless, firm, non-tender nodule on the upper eyelid that has been present for 3 weeks. There is no erythema or purulent discharge. What is the most likely diagnosis?

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

Correct answer: Chalazion

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

Question 75: A 55-year-old man with type 2 diabetes and a history of heart failure with reduced ejection fraction (HFrEF) needs better glycemic control. Which agent provides the most cardiovascular benefit?

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

Correct answer: Empagliflozin (SGLT-2 inhibitor)

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

Question 76: 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
Hypokalemic periodic paralysis
Multiple sclerosis

Correct answer: Narcolepsy with cataplexy

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

Question 77: A patient with end-stage renal disease on dialysis develops hypotension with distended neck veins and muffled heart sounds. CXR shows enlarged cardiac silhouette. Immediate management is:

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

Correct answer: Pericardiocentesis

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

Question 78: A 3-year-old presents with high fever, drooling, muffled voice, and refusal to open the mouth. Examination shows medial displacement of the tonsil and uvular deviation. What is the most appropriate next step?

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

Correct answer: Immediate needle aspiration or incision and drainage

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

Question 79: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hypercalcemia
Hyperphosphatemia (Correct answer)
Hypernatremia
Hypokalemia

Correct answer: Hyperphosphatemia

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

Question 80: A 28-year-old male presents with a painless scrotal swelling. Urethral culture is positive for an intracellular gram-negative diplococci. He also complains of urethral discharge. Which is the recommended dual therapy per current CDC guidelines?

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

Correct answer: Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days

Current CDC guidelines recommend ceftriaxone 500 mg IM (single dose) plus doxycycline 100 mg BID × 7 days for uncomplicated gonorrhea to cover co-infection with chlamydia.

Question 81: Which approach is recommended for troubleshooting reproductive system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 82: A 65-year-old woman presents with bilateral shoulder and hip girdle aching, morning stiffness over 1 hour, and ESR of 85 mm/hr. Muscle strength is normal. What is the first-line treatment?

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

Correct answer: Low-dose prednisone

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

Question 83: 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 84: 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)
Foreign body aspiration
Epiglottitis
Bacterial tracheitis

Correct answer: Croup (laryngotracheobronchitis)

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

Question 85: A child develops oliguria, microangiopathic hemolytic anemia, and thrombocytopenia after a bloody diarrheal illness. What is the diagnosis?

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

Correct answer: Hemolytic uremic syndrome

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

Question 86: Which approach is recommended for troubleshooting cardiovascular system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 87: A 25-year-old male has recurrent hemarthroses, a prolonged aPTT, and normal PT. Factor VIII activity is 2%. What is the diagnosis?

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

Correct answer: Hemophilia A

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

Question 88: On his fingertips, a 26-year-old male has 3 to 4 cm depigmented irregular patches that have been there for the past two months and appear to be becoming bigger. What is probably taking place with this patient?

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

Correct answer: Loss of skin melanocytes with unclear cause

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

Question 89: A patient with known Addison disease presents with severe hypotension and vomiting after a flu illness. Which is the most critical immediate treatment?

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

Correct answer: IV hydrocortisone and saline

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

Question 90: A 40-year-old immunocompromised patient presents with painful vesicular lesions along a unilateral dermatomal distribution on the chest. Which antiviral, started within 72 hours of rash onset, is the treatment of choice?

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

Correct answer: Valacyclovir 1000 mg PO TID × 7 days

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

Question 91: A 35-year-old runner presents with pain at the inferior pole of the patella that worsens with jumping. No effusion is present. What is the most likely diagnosis?

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

Correct answer: Patellar tendinopathy

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

Question 92: A 60-year-old man on lithium for 15 years presents with polyuria and polydipsia. Urine osmolality remains low after water deprivation but increases after desmopressin. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

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

Question 93: 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?

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

Correct answer: Referral to ophthalmology for evaluation

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

Question 94: Which of the following statements about end-of-life concerns for cystic fibrosis patients is accurate?

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

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

Testicular cancer (Correct answer)
Spermatocele
Hydrocele
Epididymitis

Correct answer: Testicular cancer

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

Question 96: A right-handed patient has an infarct of the left middle cerebral artery territory. Which deficit is most expected?

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

Correct answer: Right hemiplegia with expressive aphasia

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

Question 97: A 45-year-old woman presents with acute onset of right upper quadrant pain, fever, and jaundice. Her labs show elevated total bilirubin, alkaline phosphatase, and WBC of 18,000. What is the most likely diagnosis?

Pancreatitis
Ascending cholangitis (Correct answer)
Acute cholecystitis
Acute hepatitis

Correct answer: Ascending cholangitis

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

Question 98: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

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

Correct answer: Vitamin C

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

Question 99: A neonate is diagnosed with transposition of the great arteries. Which immediate intervention maintains cardiac output prior to surgical correction?

Atropine
IV furosemide
Digoxin
Prostaglandin E1 infusion (Correct answer)

Correct answer: Prostaglandin E1 infusion

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

Question 100: A 32-year-old woman develops gestational diabetes at 28 weeks. Her fasting glucose is 105 mg/dL. After failing medical nutrition therapy, what is the preferred pharmacologic treatment during pregnancy?

Empagliflozin
Glipizide
Insulin (Correct answer)
Metformin

Correct answer: Insulin

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

Question 101: 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?

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

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 102: A 4-year-old boy presents with a 3-day history of fever, bilateral conjunctivitis, strawberry tongue, cracked lips, a polymorphous rash, and cervical lymphadenopathy. What is the most important complication to prevent?

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

Correct answer: Coronary artery aneurysms

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

Question 103: 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?

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

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

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

Correct answer: Lower LDL with high-intensity statin

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

Question 105: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

Serum sodium 130 mEq/L, urine osmolality 80 mOsm/kg, urine sodium 10 mEq/L
Serum sodium 125 mEq/L, urine osmolality 60 mOsm/kg, urine sodium 5 mEq/L
Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L (Correct answer)
Serum sodium 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 106: A 16-year-old girl presents with severe dysmenorrhea since menarche. Pelvic exam is normal. NSAIDs provide minimal relief. What is the most appropriate next treatment?

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

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

Kinked endotracheal tube (Correct answer)
Pulmonary fibrosis
Auto-PEEP
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 108: An 8-year-old boy presents with pubic hair and testicular enlargement. Bone age is advanced. LH and FSH are elevated. What is the most likely diagnosis?

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

Correct answer: Central (gonadotropin-dependent) precocious puberty

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

Question 109: A 55-year-old man has a 3-month history of progressive distal lower extremity weakness, areflexia, and glove-and-stocking sensory loss. Nerve conduction studies show reduced amplitudes and slow velocities. What is the most likely diagnosis?

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

Correct answer: Chronic inflammatory demyelinating polyneuropathy (CIDP)

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

Question 110: For the past four weeks, a 35-year-old African American lady has been experiencing increased malaise, dyspnea, and low-grade fever. Her iritis was just treated. Physical examination reveals modest hepatomegaly and red nodules over the anterior lower legs. An x-ray of the chest reveals bilateral hilar adenopathy. Which of the subsequent diagnoses is most likely?

Mesothelioma
Lymphoma
Tuberculosis
Sarcoidosis (Correct answer)

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

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

Correct answer: IV magnesium sulfate

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

Question 112: A 70-year-old hypertensive patient presents with sudden unilateral vision loss that lasted 10 minutes and resolved completely. Fundoscopic exam is normal. What is this episode called and what is the first-line imaging study?

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

Correct answer: Amaurosis fugax; carotid duplex ultrasound

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

Question 113: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 114: In PANCE certification, what does redundancy in system design primarily provide?

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

Correct answer: Fault tolerance and high availability

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

Question 115: A 75-year-old man has a rough, scaly, erythematous papule on a sun-damaged area of his face. Biopsy shows atypical keratinocytes confined to the epidermis. What is the diagnosis?

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

Correct answer: Bowen disease

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

Question 116: A 65-year-old man with hypertension and diabetes presents with exertional dyspnea and preserved ejection fraction (60%). BNP is elevated. What is the most likely diagnosis?

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

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

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

Question 117: 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 118: 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?

Legg-Calvé-Perthes disease (Correct answer)
Septic arthritis
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 119: Which professional attribute is most valued in eent 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 120: On lumbar puncture in bacterial meningitis, which CSF finding best distinguishes it from viral meningitis?

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

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

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

Question 121: Which documentation is essential when working with neurologic system in PANCE?

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 122: A patient develops worsening hypoxemia 48 hours after an aspiration event. CXR shows bilateral infiltrates with no evidence of cardiogenic edema. PaO2/FiO2 ratio is 150. How is this classified?

Acute lung injury (ALI)
Moderate ARDS
Severe ARDS (Correct answer)
Mild 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 123: 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?

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

Correct answer: Nonseminomatous germ cell tumor

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

Question 124: A 70-year-old presents with sudden onset severe abdominal pain out of proportion to exam, with a history of atrial fibrillation. Lactate is elevated. What is the most likely diagnosis?

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

Correct answer: Acute mesenteric ischemia

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

Question 125: A 55-year-old woman with COPD and a 60-pack-year history presents with hemoptysis and a 3 cm spiculated pulmonary nodule on CXR. What is the most appropriate next step?

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

Correct answer: CT scan of the chest with contrast

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

Question 126: 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?

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

Correct answer: Test for HIV and other STIs

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

Question 127: A 30-year-old presents with recurrent episodes of severe unilateral eye pain, redness, and halos around lights. Each episode lasts 2-3 hours and resolves spontaneously. IOP during an attack is 45 mmHg. What is the treatment of choice for long-term prevention?

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

Correct answer: Laser peripheral iridotomy

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

Question 128: A 45-year-old woman presents with menorrhagia and pelvic pressure. Uterus is 14-week size on exam. Ultrasound shows multiple intramural masses. What is the most appropriate first-line pharmacologic treatment?

Danazol
Levonorgestrel IUD (Correct answer)
GnRH agonist indefinitely
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 129: A 19-year-old female presents with amenorrhea for 4 months, fatigue, and cold intolerance. She has a BMI of 16.5 and excessive exercise. Labs: low LH, low FSH, low estradiol, normal TSH. Which diagnosis explains these findings?

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

Correct answer: Hypothalamic amenorrhea

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

Question 130: A patient on long-term PPI therapy is most at risk for deficiency in which micronutrient?

Iron
All of the above (Correct answer)
Magnesium
Vitamin B12

Correct answer: All of the above

Long-term PPI use impairs absorption of magnesium, vitamin B12 (requires acid for release from food), and iron, making all three deficiencies relevant.

Question 131: A 25-year-old basketball player twists his knee and feels a pop. He develops a knee effusion within 2 hours and has a positive Lachman test. What structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

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

Question 132: A patient presents with fever, new-onset aortic regurgitation murmur, and splinter hemorrhages. Blood cultures grow viridans streptococci. Which is the most likely portal of entry?

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

Correct answer: Dental procedure

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

Question 133: A 55-year-old with long-standing GERD undergoes endoscopy showing replacement of squamous epithelium with columnar epithelium in the distal esophagus. What is the most serious concern with this finding?

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

Correct answer: Increased risk of esophageal adenocarcinoma

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

Question 134: A 72-year-old man with heart failure has a BNP of 1,200 pg/mL. His ejection fraction is 30%. Which diuretic combination is preferred for decongestion?

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

Correct answer: Furosemide plus metolazone

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

Question 135: A 60-year-old patient who recently completed a 10-day course of antibiotics for a respiratory infection develops profuse watery diarrhea. Stool testing reveals the causative toxin. Which antibiotic is the preferred first-line treatment for mild-to-moderate disease?

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

Correct answer: Vancomycin 125 mg PO QID × 10 days

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

Question 136: Which documentation is essential when working with endocrine system in PANCE?

Marketing materials
Detailed technical specifications and as-built diagrams (Correct answer)
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 137: A 28-year-old presents with bloody diarrhea, tenesmus, and proctitis. Colonoscopy shows continuous mucosal inflammation starting from the rectum. Which diagnosis is most consistent?

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

Correct answer: Ulcerative colitis

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

Question 138: 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?

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

Correct answer: Systemic thrombolysis with alteplase

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

Question 139: A 30-year-old woman with Hashimoto thyroiditis is euthyroid. She asks about her risk for other autoimmune conditions. Which condition is she at increased risk for?

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

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

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

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

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 142: A 55-year-old male presents with dysphagia to solids that has progressed to liquids over 3 months, with a 15-lb weight loss. Which diagnosis is most likely?

Esophageal spasm
Esophageal adenocarcinoma (Correct answer)
Zenker diverticulum
Achalasia

Correct answer: Esophageal adenocarcinoma

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

Question 143: Which approach is recommended for troubleshooting pulmonary system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 144: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 145: A 28-year-old woman presents with optic neuritis and a prior episode of transverse myelitis. MRI shows periventricular white matter lesions disseminated in time and space. Which treatment reduces long-term disability?

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

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

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

Question 146: A 40-year-old male with chronic kidney disease stage 3 presents with lab values: sodium 138, potassium 5.8, bicarbonate 18, BUN 42, creatinine 2.4. Which acid-base disturbance is present?

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

Correct answer: Anion gap metabolic acidosis

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

Question 147: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?

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

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 148: 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)
High-dose aspirin
Dietary restriction alone
Colchicine indefinitely

Correct answer: Allopurinol therapy

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

Question 149: Which urine finding best differentiates nephritic syndrome from nephrotic syndrome?

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

Correct answer: RBC casts

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

Question 150: A 45-year-old patient presents with sudden painless vision loss in one eye described as a 'curtain coming down.' Fundoscopic exam reveals a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

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

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

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

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

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

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

Correct answer: Accountability and commitment to standards

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

Question 153: 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
Ménière's disease (Correct answer)
Benign paroxysmal positional vertigo
Acoustic neuroma

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

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

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

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

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

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

Question 156: 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 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?

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

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 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

Cystitis
Peritonitis (Correct answer)
Uterine fibroids
Vaginitis

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 159: 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)
Eaton-Lambert syndrome
Cushing syndrome from ectopic ACTH
SIADH causing hyponatremia

Correct answer: Hypercalcemia due to PTHrP secretion

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

Question 160: A patient with a humeral shaft fracture develops wrist drop and inability to extend the fingers. Which nerve is most likely injured?

Median nerve
Ulnar 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 161: 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?

Asbestosis
Berylliosis
Silicosis (Correct answer)
Coal workers' pneumoconiosis

Correct answer: Silicosis

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

Question 162: A 66-year-old woman has a blood pressure of 158/96 mmHg at two separate visits. She has a history of type 2 diabetes and microalbuminuria. Which antihypertensive is most appropriate as first-line therapy?

Hydrochlorothiazide
Metoprolol
Amlodipine
Lisinopril (Correct answer)

Correct answer: Lisinopril

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

Question 163: What is the first-line treatment for newly diagnosed warm autoimmune hemolytic anemia?

Intravenous immunoglobulin
Rituximab
Corticosteroids (Correct answer)
Splenectomy

Correct answer: Corticosteroids

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

Question 164: A 45-year-old guy is being checked because he feels weak and weary and has experienced indications of sexual dysfunction. The reading is 100/60 mmHg for him. Physical examination reveals thinning pubic, axillary, and facial hair. Laboratory tests reveal lower levels of testosterone, thyroxine, and the luteinizing and follicle-stimulating hormones; the thyroid-stimulating hormone level is within acceptable ranges. Which of the subsequent diagnoses is most likely?

Diabetes mellitus
Hypopituitarism (Correct answer)
Hypothyroidism
Hyperprolactinemia

Correct answer: Hypopituitarism

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

Question 165: A 52-year-old has splenomegaly, WBC of 85,000 with basophilia, and a Philadelphia chromosome on cytogenetics. What is the diagnosis?

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

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

Applying principles to novel situations with sound judgment (Correct answer)
Following procedures without understanding
Relying entirely on technology
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 167: Which of the following helps the reader of the study determine whether the outcomes in a randomized, double-blind, placebo-controlled clinical trial are statistically significant?

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

Correct answer: P value

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

Question 168: A 50-year-old man with a history of gout presents with acute onset of severe pain and swelling of the first MTP joint. He is on hydrochlorothiazide for hypertension. What is the best initial treatment for the acute attack?

Febuxostat
Allopurinol
Indomethacin (Correct answer)
Probenecid

Correct answer: Indomethacin

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

Question 169: A 3-year-old boy is brought in for evaluation of a painless scrotal mass. Transillumination is positive. What is the most likely diagnosis?

Hydrocele (Correct answer)
Testicular torsion
Inguinal hernia
Epididymitis

Correct answer: Hydrocele

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

Question 170: A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. What is the immediate treatment?

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

Correct answer: Thiamine before glucose

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

Question 171: 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
Long-acting nitrate
Calcium channel blocker
Beta-blocker (Correct answer)

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 172: 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?

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

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

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

Correct answer: Central diabetes insipidus

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

Question 174: What is the best practice for maintaining endocrine system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 175: A patient develops oliguria and elevated creatinine after aminoglycoside therapy. Urinalysis shows muddy brown granular casts. What is the diagnosis?

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

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

Correct answer: Subacromial impingement syndrome

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

Question 177: 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?

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

Correct answer: Prerenal azotemia

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

Question 178: A patient with type 2 diabetes has an HbA1c of 9.2% and CKD stage 3 (eGFR 38 mL/min). Which medication should be avoided or used with caution?

Insulin glargine
Metformin (Correct answer)
Sitagliptin
Empagliflozin

Correct answer: Metformin

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

Question 179: 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?

Glomus tympanicum
Tympanosclerosis
Cholesteatoma (Correct answer)
Adenoid hypertrophy

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

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

Correct answer: Slipped capital femoral epiphysis

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

Question 181: 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 182: Which finding on osmotic fragility testing is most characteristic of hereditary spherocytosis?

Normal fragility with normal MCHC
Increased osmotic fragility (Correct answer)
Decreased osmotic fragility
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 183: 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)
DIC
Drug-induced aplasia

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 184: A 30-year-old man develops a targetoid lesion with a central blister after starting sulfonamide antibiotics. The lesion is localized to the palms. What is the most likely diagnosis?

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

Correct answer: Erythema multiforme

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

Question 185: A 28-year-old African American male develops hemolytic anemia after starting primaquine for malaria prophylaxis. What is the underlying enzyme deficiency?

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

Correct answer: G6PD deficiency

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

Question 186: Which of the following is the gold standard for diagnosing esophageal motility disorders such as achalasia?

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

Correct answer: Esophageal manometry

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

Question 187: A patient with cirrhosis develops confusion, asterixis, and elevated ammonia. Which intervention is most appropriate?

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

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

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

Question 188: 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)
Systemic lupus erythematosus
Psoriatic arthritis
Seronegative rheumatoid 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 189: A patient with CKD has normocytic anemia and a reticulocyte count of 0.5%. What is the most likely pathophysiologic cause?

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

Correct answer: Decreased erythropoietin production

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

Question 190: A patient with autosomal dominant polycystic kidney disease asks about the most life-threatening extrarenal complication. What is it?

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

Correct answer: Intracranial berry aneurysm

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

Question 191: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

Histamine release from basophils and mast cells triggered by water (Correct answer)
Uremic pruritus from secondary erythrocytosis
Iron deficiency secondary to venesection
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 192: What is the fundamental principle behind endocrine system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 193: 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?

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

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

Glomus jugulare tumor (Correct answer)
Acoustic neuroma
Meningioma
Cholesteatoma

Correct answer: Glomus jugulare tumor

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

Question 195: A patient with CKD has a serum potassium of 6.4 mEq/L and peaked T-waves on ECG. What is the first intervention?

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

Correct answer: IV calcium gluconate

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

Question 196: A 40-year-old woman presents with heat intolerance, weight loss, tremor, and TSH <0.01 mIU/L with elevated free T4. Radioiodine uptake is diffusely increased. What is the preferred long-term treatment option in a non-pregnant patient?

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

Correct answer: Radioactive iodine (RAI) ablation

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

Question 197: 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)
BUN:Cr ratio <10:1 with urine sodium >40 mEq/L
WBC casts with low urine osmolality

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

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

Correct answer: Median nerve

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

Question 199: What is the best practice for maintaining neurologic system performance over time?

Upgrade all equipment annually
Implement scheduled preventive maintenance (Correct answer)
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 200: Which documentation is essential when working with pulmonary system in PANCE?

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 201: A 22-year-old woman presents with salt craving, hyperpigmentation, hypotension, and hyponatremia with hyperkalemia. Morning cortisol is 3 mcg/dL. What is the diagnosis?

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

Correct answer: Primary adrenal insufficiency (Addison disease)

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

Question 202: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

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

Correct answer: Prepare for emergent cesarean delivery

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

Question 203: A 44-year-old woman is newly diagnosed with stage II cervical cancer. HPV genotyping shows HPV-18. Which treatment modality is most appropriate?

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

Correct answer: Concurrent cisplatin-based chemotherapy and radiation

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

Question 204: What constitutes a risk factor for endometriosis development?

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

Correct answer: Delayed childbearing

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

Question 205: What is the fundamental principle behind neurologic system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 206: A 28-year-old woman at 32 weeks gestation develops blood pressure of 156/104 mmHg, 3+ proteinuria, and a severe headache. Which medication is the first-line treatment for seizure prophylaxis?

Labetalol
Phenytoin
Lorazepam
Magnesium sulfate (Correct answer)

Correct answer: Magnesium sulfate

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

Question 207: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Spherocytes
Target cells
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 208: 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?

Indomethacin or colchicine (Correct answer)
Probenecid
Methotrexate
Allopurinol

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 209: 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
Folic acid 1 mg IV
Naloxone 0.4 mg IV
Thiamine 100 mg IV before glucose (Correct answer)

Correct answer: Thiamine 100 mg IV before glucose

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

Question 210: 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?

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

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 211: 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
Multiple myeloma (Correct answer)
Waldenstrom macroglobulinemia

Correct answer: Multiple myeloma

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

Question 212: On auscultation, a patient has a harsh systolic murmur that increases in intensity with the Valsalva maneuver. Which condition is most likely?

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

Correct answer: Hypertrophic obstructive cardiomyopathy (HOCM)

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

Question 213: 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?

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

Correct answer: 15 hours

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

Question 214: A 22-year-old college student presents with fever, pharyngitis, cervical lymphadenopathy, and marked fatigue. A peripheral blood smear shows atypical lymphocytes. Heterophile antibody test is positive. Which complication should be avoided during recovery?

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

Correct answer: Contact sports

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

Question 215: A 35-year-old presents with episodic peptic ulcers refractory to PPI therapy and diarrhea. Fasting serum gastrin is 1,200 pg/mL. What is the most likely diagnosis?

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

Correct answer: Zollinger-Ellison syndrome

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

Question 216: A 30-year-old woman presents with bilateral proptosis, lid retraction, and a stare. Thyroid-stimulating hormone is suppressed and free T4 is elevated. What finding on extraocular muscle testing is most characteristic of her orbital condition?

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

Correct answer: Limitation of elevation (inferior rectus restriction)

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

Question 217: What is the best practice for maintaining cardiovascular system performance over time?

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

Correct answer: Implement scheduled preventive maintenance

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

Question 218: A 15-year-old presents with bilateral nasal polyps. No history of asthma or aspirin sensitivity. A sweat chloride test is ordered. What underlying condition is being screened for?

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

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

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 220: A 35-year-old woman presents with an 8 mm pigmented lesion on her foot showing amelanotic areas and nail involvement (melanonychia). What is the most important next diagnostic step?

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

Correct answer: Dermoscopy and punch biopsy

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

Question 221: 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)
Lewy body dementia
Alzheimer disease
Vascular 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 222: A 22-year-old college student presents with fever, severe headache, photophobia, and a non-blanching petechial rash. What is the most immediate treatment?

Start oral doxycycline empirically
Obtain blood cultures, then administer IV ceftriaxone
Perform lumbar puncture before starting antibiotics
Administer IV ceftriaxone immediately without delay (Correct answer)

Correct answer: Administer IV ceftriaxone immediately without delay

In suspected bacterial meningitis with a petechial rash (suggesting meningococcemia), IV antibiotics must be given immediately without waiting for lumbar puncture to prevent death.

Question 223: A 52-year-old man has a serum calcium of 11.8 mg/dL, PTH of 95 pg/mL, and is asymptomatic. What is the most likely diagnosis?

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

Correct answer: Primary hyperparathyroidism

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

Question 224: Which approach is recommended for troubleshooting endocrine system issues?

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

Correct answer: Use systematic isolation and testing methods

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

Question 225: Which of the following is the first-line treatment for absence seizures?

Ethosuximide (Correct answer)
Valproic acid
Phenytoin
Carbamazepine

Correct answer: Ethosuximide

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

Question 226: What is the fundamental principle behind reproductive system in the PANCE domain?

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

Correct answer: Balancing performance, reliability, and efficiency

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

Question 227: 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?

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

Correct answer: Barotrauma (ear squeeze)

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

Question 228: A 50-year-old woman presents with shoulder pain and inability to abduct the arm past 90 degrees. MRI shows a full-thickness supraspinatus tear. What is the most appropriate initial management?

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

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

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

Correct answer: Acetylcholinesterase inhibitor

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

Question 230: Which acid-base disorder is most commonly seen in end-stage renal disease?

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

Correct answer: High anion gap metabolic acidosis

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

Question 231: Which approach best demonstrates mastery of musculoskeletal in PANCE practice?

Following procedures without understanding
Applying principles to novel situations with sound judgment (Correct answer)
Relying entirely on technology
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 232: 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 233: What role does collaboration play in eent for PANCE professionals?

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

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

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

Question 234: A 28-year-old woman presents with cyclic pelvic pain, dyspareunia, and infertility. Laparoscopy reveals powder-burn lesions on the peritoneum. Which mechanism best explains her infertility?

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

Correct answer: Distorted pelvic anatomy and inflammatory cytokines impairing implantation

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

Question 235: Which finding on chest X-ray is most characteristic of a tension pneumothorax?

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

Correct answer: Contralateral tracheal deviation with ipsilateral lung collapse

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

Question 236: 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?

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

Vancomycin 15 mg/kg IV
Ciprofloxacin 400 mg IV (Correct answer)
Clindamycin 900 mg IV
Ampicillin-sulbactam 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 238: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

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

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

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

Correct answer: HELLP syndrome

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

Question 240: 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 241: What is the first-line noninvasive screening test for suspected renal artery stenosis?

MR angiography
CT 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 242: A 68-year-old presents with productive cough, fever, and consolidation in the right lower lobe. Blood cultures are negative. She was hospitalized 3 weeks ago. Which organism is the most likely causative agent?

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

Correct answer: Methicillin-resistant Staphylococcus aureus (MRSA)

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

Question 243: 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?

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

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 244: 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?

Repeat ultrasound in 6-12 weeks (Correct answer)
Laparoscopic biopsy
Immediate surgical resection
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 245: 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)
Direct erosion of the mucosa by alcohol
Aortoenteric fistula
Coagulopathy from liver disease

Correct answer: Increased portal venous pressure causing portosystemic shunting

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

Question 246: 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
CT scan of the abdomen and pelvis (Correct answer)
24-hour urine catecholamines
Adrenal vein sampling

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

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

Correct answer: Iron deficiency anemia

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

Question 248: What is the value of continuing education in musculoskeletal for PANCE professionals?

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

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

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

Question 249: A 50-year-old male with psoriasis presents with sausage digits, asymmetric joint pain, and nail pitting. RF is negative. Which pattern of joint involvement is described?

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

Correct answer: Dactylitis

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

Question 250: What is the most important professional competency for PANCE certification in musculoskeletal?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 251: A 6-year-old child is brought in for evaluation of a 3-day sore throat, fever of 38.9°C, and enlarged anterior cervical lymph nodes. No cough is present. What is the Centor score and recommended management?

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

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

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

Question 252: A 50-year-old presents with progressive bilateral conductive hearing loss. Audiometry shows a Carhart notch at 2000 Hz on bone conduction and an absent stapedial reflex. What is the most likely diagnosis?

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

Correct answer: Otosclerosis

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

Question 253: 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 254: 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?

Norethindrone
Levonorgestrel
Norgestrel
Drospirenone (Correct answer)

Correct answer: Drospirenone

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

Question 255: Which medication must be held when GFR falls below 30 mL/min due to risk of lactic acidosis?

Metformin (Correct answer)
Lisinopril
Amlodipine
Atorvastatin

Correct answer: Metformin

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

Question 256: A 45-year-old farmer in Ohio presents with fever, chills, and a dry cough after cleaning a chicken coop. Chest X-ray shows hilar lymphadenopathy and diffuse small nodular infiltrates. Urine antigen test is positive. What is the diagnosis?

Aspergillosis
Histoplasmosis (Correct answer)
Coccidioidomycosis
Blastomycosis

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

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

Correct answer: Supervised exercise therapy and cilostazol

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

Question 258: A 70-year-old woman with osteoporosis is found to have a serum calcium of 10.9 mg/dL and PTH-related peptide (PTHrP) elevated. PTH is suppressed. What is the most likely etiology?

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

Correct answer: Humoral hypercalcemia of malignancy

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

Question 259: A 30-year-old male presents with unilateral heel pain at the plantar surface, worse with the first steps in the morning, improving after walking. Tenderness at the calcaneal insertion. What is the diagnosis?

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

Correct answer: Plantar fasciitis

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

Question 260: A patient with type 2 diabetes and CKD stage 3 requires glucose-lowering therapy. Which agent is contraindicated due to risk of lactic acidosis?

Empagliflozin
Metformin (Correct answer)
Sitagliptin
Glipizide

Correct answer: Metformin

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

Question 261: A 50-year-old man is found to have a serum calcium of 9.0 mg/dL and PTH of 12 pg/mL (low). He complains of muscle cramps and perioral tingling. Which condition is most likely?

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

Correct answer: Hypoparathyroidism

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

Question 262: Which of the following best differentiates central from obstructive sleep apnea on polysomnography?

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

Correct answer: Absence of respiratory effort during apneic episodes

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

Question 263: 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?

Transient tachypnea of the newborn
Meconium aspiration
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 264: 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?

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

Correct answer: Bromocriptine or cabergoline

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

Question 265: A 45-year-old presents with chronic bilateral rhinorrhea, nasal congestion, and excessive sneezing, worst in spring. Nasal smear shows eosinophils. Skin-prick testing is positive for grass and tree pollens. What is first-line pharmacotherapy?

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

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

Zanamivir 10 mg inhaled BID × 5 days
Oseltamivir 75 mg PO BID × 5 days (Correct answer)
Baloxavir 40 mg PO single dose
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 267: Which EKG pattern is associated with right ventricular strain in pulmonary embolism?

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

Correct answer: S1Q3T3 pattern

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

Question 268: What is the value of continuing education in eent for PANCE professionals?

It keeps professionals current with evolving standards and practices (Correct answer)
It is only needed for recertification
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 269: 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?

L5 (Correct answer)
L4
S1
L3

Correct answer: L5

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

Question 270: A 28-year-old man presents with scaly, hypopigmented macules on his trunk that become more prominent after sun exposure. KOH preparation shows 'spaghetti and meatballs' hyphae. What organism is responsible?

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

Correct answer: Malassezia furfur

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

Question 271: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?

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

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

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

Question 272: 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?

Multidirectional
Posterior
Anterior (Correct answer)
Inferior

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

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

Correct answer: MRI or CT scan of the wrist

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

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

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

Correct answer: Impact assessment and change management

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

Question 275: A 55-year-old smoker presents with progressive dyspnea and a barrel chest. Spirometry shows FEV1/FVC ratio of 0.60. Which pathophysiologic mechanism best explains his air trapping?

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

Correct answer: Loss of elastic recoil causing dynamic airway collapse

In emphysema, destruction of alveolar walls reduces elastic recoil, causing dynamic small airway collapse during expiration and air trapping.

Question 276: A 48-year-old on amiodarone for 3 years develops new bilateral pulmonary infiltrates and worsening PFTs. Which mechanism best explains amiodarone pulmonary toxicity?

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

Correct answer: Direct phospholipid accumulation and oxidative injury

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

Question 277: Which approach best demonstrates mastery of gastrointestinal in PANCE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 278: A 38-year-old woman is diagnosed with BRCA1 mutation. She has completed childbearing. Which risk-reduction strategy has the greatest absolute reduction in ovarian cancer risk?

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

Correct answer: Risk-reducing bilateral salpingo-oophorectomy

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

Question 279: A patient exposed to a bat in their bedroom is brought to the ED. The bat was not captured for testing. The patient has no visible bite marks but was asleep. What is the appropriate management?

Administer rabies immune globulin at wound site plus initiate rabies PEP vaccine series (Correct answer)
Reassure and discharge — no treatment needed without confirmed bite
Culture wound site and start prophylactic amoxicillin-clavulanate
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 280: A neonate born at 32 weeks develops respiratory distress immediately after birth with grunting, flaring, and retractions. CXR shows diffuse ground-glass opacities. What is the pathophysiology?

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

Correct answer: Surfactant deficiency

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

Question 281: Which physical exam finding best differentiates cellulitis from necrotizing fasciitis?

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

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

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

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

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

Correct answer: Right coronary artery

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

Question 284: A 35-year-old HIV-positive patient with a CD4 count of 50 cells/µL presents with headache, altered mental status, and a positive India ink stain of the CSF. Which medication is first-line induction therapy?

Fluconazole
Voriconazole
Amphotericin B plus flucytosine (Correct answer)
Caspofungin

Correct answer: Amphotericin B plus flucytosine

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

Question 285: Which of the following best distinguishes Crohn disease from ulcerative colitis on endoscopy?

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

Correct answer: Skip lesions with cobblestone appearance

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

Question 286: What is the most important professional competency for PANCE certification in dermatology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 287: A 45-year-old patient who received a renal transplant 6 months ago presents with fever, dyspnea, and non-productive cough. CT chest shows bilateral ground-glass opacities. BAL with Gomori methenamine silver stain reveals cysts. What is the treatment?

Caspofungin
Amphotericin B
Fluconazole
Trimethoprim-sulfamethoxazole (Correct answer)

Correct answer: Trimethoprim-sulfamethoxazole

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

Question 288: A 70-year-old woman presents with a firm, painless, flesh-colored papule on her lower eyelid that has grown slowly over 2 years. The border is irregular and there is perineural invasion on biopsy. What subtype of cutaneous cancer is most aggressive?

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

Correct answer: Morpheaform (sclerosing) basal cell carcinoma

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

Question 289: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?

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

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

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

Question 290: A 50-year-old returns from a trip to sub-Saharan Africa with fever, chills, and rigors occurring every 48 hours. Blood smear reveals ring-form trophozoites with appliqué (accolé) positioning and no Schüffner's dots. Which Plasmodium species is most likely responsible?

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

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

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

Correct answer: Oral hairy leukoplakia

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

Question 292: Which documentation is essential when working with cardiovascular system in PANCE?

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

Correct answer: Detailed technical specifications and as-built diagrams

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

Question 293: Which finding is MOST specific for exudative pleural effusion using Light's criteria?

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

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

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

Question 294: A 60-year-old man presents with symmetric morning stiffness lasting over 1 hour, swelling of MCPs and PIPs, and positive anti-CCP antibodies. What is the first-line DMARD therapy?

Leflunomide
Hydroxychloroquine
Sulfasalazine
Methotrexate (Correct answer)

Correct answer: Methotrexate

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

Question 295: A patient post-MI develops a new harsh holosystolic murmur at the left sternal border with a thrill. Echo shows a step-up in oxygen saturation from right atrium to right ventricle. What is the diagnosis?

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

Correct answer: Ventricular septal defect

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

Question 296: A newborn is found to have bilious vomiting on day 2 of life. X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

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

Correct answer: Duodenal atresia

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

Question 297: 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?

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

Correct answer: Seborrheic keratosis

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

Question 298: Graves disease is caused by which mechanism?

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

Correct answer: Stimulating antibodies against the TSH receptor

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

Question 299: Which test is most appropriate for diagnosing Clostridioides difficile infection?

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

Correct answer: PCR for C. difficile toxin genes

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

Question 300: 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?

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

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

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

Physician Assistant National Certifying Examination (PANCE)

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

300

Questions

300 min

Time Limit

70%

To Pass

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