PANCE PANCE Evaluation 3 — Questions and Answers
Question 1: A 55-year-old diabetic patient presents with a painless foot ulcer over the plantar surface of the first metatarsal head. Pulses are intact. What is the primary etiology?
- Peripheral arterial disease
- Venous insufficiency
- Peripheral neuropathy (Correct answer)
- Osteomyelitis
Correct answer: Peripheral neuropathy
Neuropathic ulcers in diabetics occur at pressure points (plantar metatarsal heads) due to loss of protective sensation from peripheral neuropathy.
Question 2: A 28-year-old woman at 10 weeks gestation presents with severe nausea, vomiting, and a uterus larger than expected for gestational age. β-hCG is markedly elevated. Ultrasound shows a 'snowstorm' pattern. What is the diagnosis?
- Ectopic pregnancy
- Threatened abortion
- Complete hydatidiform mole (Correct answer)
- Twin gestation
Correct answer: Complete hydatidiform mole
A complete hydatidiform mole presents with markedly elevated β-hCG, uterine size larger than dates, and a classic snowstorm ultrasound pattern.
Question 3: 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?
- Respiratory acidosis
- Metabolic alkalosis
- Anion gap metabolic acidosis (Correct answer)
- Non-anion gap metabolic acidosis
Correct answer: Anion gap metabolic acidosis
CKD causes accumulation of uremic acids (phosphate, sulfate, urate) creating an elevated anion gap metabolic acidosis.
Question 4: A 16-year-old male presents with unilateral testicular swelling, nausea, and severe pain of 4 hours duration. The testicle is high-riding with a horizontal lie. What is the most appropriate immediate action?
- Order Doppler ultrasound and await results before surgery
- Prescribe antibiotics for epididymo-orchitis
- Emergent urologic consultation for surgical exploration (Correct answer)
- Apply manual detorsion and discharge
Correct answer: Emergent urologic consultation for surgical exploration
Testicular torsion requires emergent surgical exploration within 6 hours; delay leads to irreversible ischemia and testicular loss.
Question 5: Which physical exam finding best differentiates cellulitis from necrotizing fasciitis?
- Presence of fever and elevated WBC
- Skin erythema that does not cross fascial planes
- Crepitus, wooden-hard texture of tissue, and disproportionate pain (Correct answer)
- 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 6: A 66-year-old woman has a blood pressure of 158/96 mmHg at two separate visits. She has a history of type 2 diabetes and microalbuminuria. Which antihypertensive is most appropriate as first-line therapy?
- Amlodipine
- Metoprolol
- Lisinopril (Correct answer)
- Hydrochlorothiazide
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 7: 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 — consistent with heart failure
- Exudate — pleural LDH > 2/3 upper limit of normal serum LDH (Correct answer)
- Transudate — pleural/serum protein ratio < 0.5
- 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.
PANCE PANCE Evaluation 3
A 55-year-old diabetic patient presents with a painless foot ulcer over the plantar surface of the first metatarsal head.
Pulses are intact.
What is the primary etiology?