PANCE PANCE Evaluation 5 — Questions and Answers
Question 1: 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?
- Acute cholecystitis
- Ascending cholangitis (Correct answer)
- Acute hepatitis
- Pancreatitis
Correct answer: Ascending cholangitis
Charcot's triad (RUQ pain, fever, jaundice) is classic for ascending cholangitis, indicating biliary obstruction with infection.
Question 2: A 55-year-old male with a 40-pack-year smoking history presents with hemoptysis, weight loss, and a hilar mass on CXR. His serum calcium is 11.8 mg/dL. Which lung cancer type is most likely?
- Adenocarcinoma
- Small cell carcinoma
- Squamous cell carcinoma (Correct answer)
- Large cell carcinoma
Correct answer: Squamous cell carcinoma
Squamous cell carcinoma is centrally located, associated with smoking, and classically causes hypercalcemia via PTHrP secretion.
Question 3: 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?
- Primary ovarian insufficiency
- Hypothyroidism
- Hypothalamic amenorrhea (Correct answer)
- Polycystic ovarian syndrome
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 4: 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?
- Metformin monotherapy and lifestyle modification
- Insulin therapy plus metformin (Correct answer)
- Sulfonylurea alone
- 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 5: A 42-year-old woman is found to have a blood pressure of 176/108 mmHg. She reports episodic severe headaches, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. What is the first step in management after diagnosis?
- Start beta-blocker immediately
- Start alpha-blocker (phenoxybenzamine) first, then add beta-blocker if needed (Correct answer)
- Proceed directly to surgical adrenalectomy
- Start calcium channel blocker and schedule surgery
Correct answer: Start alpha-blocker (phenoxybenzamine) first, then add beta-blocker if needed
In pheochromocytoma, alpha-blockade must precede beta-blockade to prevent unopposed alpha-mediated hypertensive crisis.
Question 6: 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?
- Herniated nucleus pulposus
- Lumbar spinal stenosis (Correct answer)
- Cauda equina syndrome
- Ankylosing spondylitis
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 7: 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?
- Focal segmental glomerulosclerosis
- Minimal change disease (Correct answer)
- Membranous nephropathy
- IgA nephropathy
Correct answer: Minimal change disease
Minimal change disease accounts for ~90% of nephrotic syndrome in children aged 1-8 years and shows effacement of podocyte foot processes on electron microscopy.
PANCE PANCE Evaluation 5
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?