PANCE PANCE Analysis 4 — Questions and Answers
Question 1: 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?
- Allopurinol
- Indomethacin (Correct answer)
- Probenecid
- Febuxostat
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 2: 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?
- Acute rheumatic fever
- Coronary artery aneurysms (Correct answer)
- Meningitis
- Glomerulonephritis
Correct answer: Coronary artery aneurysms
Kawasaki disease can cause coronary artery aneurysms, the most serious complication, which is prevented by early treatment with IVIG and aspirin.
Question 3: A 72-year-old woman presents with sudden-onset right-sided weakness and aphasia that resolved completely within 45 minutes. MRI of the brain shows no acute infarct. What is the most appropriate next step?
- Start aspirin and discharge home
- Admit for urgent evaluation and antiplatelet therapy (Correct answer)
- Administer tPA immediately
- Schedule outpatient neurology follow-up in 2 weeks
Correct answer: Admit for urgent evaluation and antiplatelet therapy
A TIA carries a high short-term stroke risk (up to 10% within 2 days), requiring urgent inpatient evaluation including imaging, cardiac monitoring, and antiplatelet therapy.
Question 4: 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
- Nonseminomatous germ cell tumor (Correct answer)
- Testicular lymphoma
- Hydrocele
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 5: A 34-year-old woman presents with weight gain, cold intolerance, constipation, and dry skin. TSH is 18 mIU/L and free T4 is low. Anti-TPO antibodies are positive. What is the most likely diagnosis?
- Subacute thyroiditis
- Hashimoto thyroiditis (Correct answer)
- Graves disease
- Iodine deficiency hypothyroidism
Correct answer: Hashimoto thyroiditis
Hashimoto thyroiditis (autoimmune) is the most common cause of primary hypothyroidism in the US, characterized by elevated TSH, low T4, and positive anti-TPO antibodies.
Question 6: A 55-year-old woman with COPD and a 60-pack-year history presents with hemoptysis and a 3 cm spiculated pulmonary nodule on CXR. What is the most appropriate next step?
- Repeat CXR in 6 months
- CT-guided biopsy immediately
- CT scan of the chest with contrast (Correct answer)
- PET scan
Correct answer: CT scan of the chest with contrast
A CT scan of the chest is the next step to characterize the nodule's features (size, density, borders) and guide further management including biopsy or PET scan.
Question 7: A 16-year-old girl presents with primary amenorrhea. Physical exam shows normal female external genitalia but absence of pubic and axillary hair. Karyotype is 46,XY. What is the most likely diagnosis?
- Turner syndrome
- Complete androgen insensitivity syndrome (Correct answer)
- Mayer-Rokitansky-Küster-Hauser syndrome
- Congenital adrenal hyperplasia
Correct answer: Complete androgen insensitivity syndrome
Complete androgen insensitivity syndrome (46,XY) presents with female phenotype, absent uterus, and absent body hair due to inability of cells to respond to androgens.
PANCE PANCE Analysis 4
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?