Physician Assistant National Recertifying Examination (PANRE) — Questions and Answers

Question 1: A 45-year-old female presents with morning stiffness lasting more than 1 hour, symmetric joint swelling, and a positive rheumatoid factor. Which joint pattern is most characteristic of rheumatoid arthritis?

PIP and MCP joints of the hands (Correct answer)
DIP joints of the hands
First MTP joint
Lumbar facet joints

Correct answer: PIP and MCP joints of the hands

Rheumatoid arthritis characteristically involves the PIP and MCP joints symmetrically, sparing the DIP joints (which are more typical of osteoarthritis or psoriatic arthritis).

Question 2: A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

Lorazepam IV
Thiamine 100 mg IV (Correct answer)
Naloxone IV
Glucose infusion

Correct answer: Thiamine 100 mg IV

The classic triad of confusion, ataxia, and ophthalmoplegia is Wernicke encephalopathy; thiamine must be given before glucose to prevent worsening.

Question 3: Which medication class is first-line for reducing proteinuria and slowing progression of diabetic nephropathy?

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

Correct answer: ACE inhibitors or ARBs

ACE inhibitors and ARBs reduce intraglomerular pressure and proteinuria, providing renoprotection in diabetic nephropathy.

Question 4: Which approach best demonstrates mastery of orthopedics in PANRE practice?

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

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 5: A patient reports that her neighbor has been poisoning her food for the past year. She is otherwise functional, with no hallucinations or disorganized speech. What is the most likely diagnosis?

Schizophreniform disorder
Delusional disorder, persecutory type (Correct answer)
Brief psychotic disorder
Paranoid schizophrenia

Correct answer: Delusional disorder, persecutory type

Delusional disorder features a fixed non-bizarre or bizarre delusion for ≥1 month without prominent hallucinations or disorganization.

Question 6: A 28-year-old woman with polycystic ovary syndrome (PCOS) and insulin resistance would most benefit from which medication to improve metabolic parameters?

Clomiphene
Metformin (Correct answer)
Spironolactone
Oral contraceptive pills alone

Correct answer: Metformin

Metformin improves insulin sensitivity in PCOS, which can restore menstrual regularity, reduce androgen levels, and lower cardiovascular metabolic risk.

Question 7: A patient on warfarin for atrial fibrillation has an INR of 9.2 with active major bleeding. Which intervention is most appropriate?

Administer 4-factor prothrombin complex concentrate (PCC) and IV vitamin K (Correct answer)
Fresh frozen plasma alone
Administer vitamin K 10 mg orally
Hold warfarin and recheck INR in 24 hours

Correct answer: Administer 4-factor prothrombin complex concentrate (PCC) and IV vitamin K

Life-threatening warfarin-associated bleeding requires 4-factor PCC for rapid reversal combined with IV vitamin K for sustained effect; PCC works faster than FFP alone.

Question 8: Which finding is most consistent with primary hyperaldosteronism (Conn syndrome)?

Hyperkalemia with hypertension
Hyperkalemia with hypotension
Hyponatremia with hypertension
Hypokalemia with hypertension (Correct answer)

Correct answer: Hypokalemia with hypertension

Primary hyperaldosteronism causes sodium retention and potassium wasting, resulting in hypokalemia and hypertension.

Question 9: A patient reports recurrent intrusive thoughts about harming her infant, accompanied by significant distress and avoidance. She does not want to act on these thoughts. What is the most likely diagnosis?

Postpartum psychosis
Obsessive-compulsive disorder, postpartum onset (Correct answer)
Infanticide risk requiring hospitalization
Postpartum depression with psychotic features

Correct answer: Obsessive-compulsive disorder, postpartum onset

Ego-dystonic, intrusive, and distressing thoughts with avoidance and no intent are characteristic of OCD, not psychosis.

Question 10: A breastfeeding mother 6 weeks postpartum desires contraception. Which method is contraindicated?

Progestin-only pill
Copper IUD
Combined oral contraceptive pill (Correct answer)
Levonorgestrel IUD

Correct answer: Combined oral contraceptive pill

Combined oral contraceptives (estrogen + progestin) are contraindicated in the first 6 weeks postpartum in breastfeeding women due to estrogen's suppression of milk production.

Question 11: A 30-year-old athlete collapses during a basketball game and is found to be in ventricular fibrillation. After resuscitation, which condition is most likely?

Hypertrophic cardiomyopathy (Correct answer)
Dilated cardiomyopathy
Wolff-Parkinson-White syndrome
Long QT syndrome type 1

Correct answer: Hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young athletes in the United States.

Question 12: A 25-year-old woman has episodes of muscle weakness triggered by rest after exercise and is improved by eating. Potassium level is low during attacks. Diagnosis?

Myotonic dystrophy
Paramyotonia congenita
Lambert-Eaton myasthenic syndrome
Hypokalemic periodic paralysis (Correct answer)

Correct answer: Hypokalemic periodic paralysis

Hypokalemic periodic paralysis is characterized by episodic weakness with low serum potassium, often triggered by rest after exercise or carbohydrate-rich meals.

Question 13: In PANRE practice, what is the best approach to quality improvement in endocrinology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 14: A patient receiving unfractionated heparin for 8 days develops a platelet count drop from 230,000 to 65,000/μL and a new arterial thrombosis. What is the most appropriate next step?

Switch to low-molecular-weight heparin
Discontinue heparin and start a direct thrombin inhibitor such as argatroban (Correct answer)
Increase the heparin dose to achieve therapeutic anticoagulation
Administer platelet transfusion

Correct answer: Discontinue heparin and start a direct thrombin inhibitor such as argatroban

Heparin-induced thrombocytopenia (HIT) with thrombosis requires immediate cessation of all heparin and initiation of a non-heparin anticoagulant like argatroban; platelet transfusion is contraindicated.

Question 15: What role does collaboration play in dermatology for PANRE professionals?

It is only needed in emergencies
It slows down work unnecessarily
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 16: A 50-year-old man has acromegaly confirmed by elevated IGF-1. What is the primary treatment?

Radiation therapy
Transsphenoidal surgery (Correct answer)
Octreotide (somatostatin analog)
Bromocriptine

Correct answer: Transsphenoidal surgery

Transsphenoidal surgery is the primary treatment for acromegaly, achieving biochemical cure in the majority of microadenomas and many macroadenomas.

Question 17: A patient with celiac disease continues to have diarrhea and weight loss despite strict gluten avoidance. What should be the next step in management?

Start systemic corticosteroids immediately
Start azathioprine empirically
Perform colonoscopy to rule out colitis
Reassess dietary compliance and consider refractory celiac disease workup (Correct answer)

Correct answer: Reassess dietary compliance and consider refractory celiac disease workup

Persistent symptoms despite gluten-free diet require reassessment of dietary adherence and consideration of refractory celiac disease, which may require biopsy and further evaluation.

Question 18: Which of the following features distinguishes Crohn's disease from ulcerative colitis?

Pseudopolyps on colonoscopy
Transmural inflammation with skip lesions (Correct answer)
Rectal involvement
Continuous mucosal inflammation

Correct answer: Transmural inflammation with skip lesions

Crohn's disease is characterized by transmural inflammation that can affect any part of the GI tract in a discontinuous (skip lesion) pattern, unlike the continuous mucosal inflammation of UC.

Question 19: A 35-year-old woman with PCOS is anovulatory and desires conception. After lifestyle modification fails, what is the first-line pharmacologic ovulation induction agent?

Clomiphene citrate
Letrozole (Correct answer)
Metformin
Gonadotropins

Correct answer: Letrozole

Letrozole (an aromatase inhibitor) is now preferred over clomiphene as first-line ovulation induction in PCOS due to higher live birth rates.

Question 20: A 58-year-old man is diagnosed with a proximal DVT after knee replacement surgery. He has normal renal function and no active cancer. What is the preferred anticoagulation therapy?

Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily (Correct answer)
Aspirin 81 mg daily
Unfractionated heparin infusion for 3 months
Warfarin with a target INR of 2-3

Correct answer: Rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily

Direct oral anticoagulants such as rivaroxaban are preferred over warfarin for DVT treatment in patients without cancer or severe renal impairment due to their predictable dosing and no need for monitoring.

Question 21: A 58-year-old man presents with new-onset ascites. Paracentesis shows SAAG of 1.5 g/dL. Which condition is most consistent with this result?

Peritoneal carcinomatosis
Nephrotic syndrome
Tuberculous peritonitis
Portal hypertension (Correct answer)

Correct answer: Portal hypertension

A SAAG ≥1.1 g/dL indicates portal hypertension as the cause of ascites, including cirrhosis, heart failure, or Budd-Chiari syndrome.

Question 22: A patient presents with sudden-onset urticaria and angioedema 20 minutes after eating shellfish. Blood pressure is 80/50 mmHg and heart rate is 120 bpm. What is the immediate treatment?

Epinephrine 1:1000 IM 0.3mg (Correct answer)
Cetirizine PO 10mg
Diphenhydramine IM 50mg
Methylprednisolone IV 125mg

Correct answer: Epinephrine 1:1000 IM 0.3mg

Epinephrine 1:1000 IM (0.3–0.5 mg in the anterolateral thigh) is the first-line treatment for anaphylaxis due to its rapid vasopressor and bronchodilator effects.

Question 23: What is the most common cause of community-acquired bacterial meningitis in adults in the United States?

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

Correct answer: Streptococcus pneumoniae

Streptococcus pneumoniae is the leading cause of bacterial meningitis in adults and elderly patients in the United States.

Question 24: What is the preferred first-line agent for uncomplicated urinary tract infections in otherwise healthy adult women in the United States?

Trimethoprim-sulfamethoxazole
Ciprofloxacin
Nitrofurantoin (Correct answer)
Amoxicillin

Correct answer: Nitrofurantoin

Nitrofurantoin is a preferred first-line agent for uncomplicated UTIs due to low resistance rates and minimal impact on systemic flora.

Question 25: What role does collaboration play in orthopedics for PANRE professionals?

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

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

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

Question 26: A patient develops fever, chills, hypotension, and back pain shortly after beginning a blood transfusion. The patient's plasma appears pink-red (hemoglobinemia). What is the most likely type of transfusion reaction?

Allergic/anaphylactic transfusion reaction
Acute hemolytic transfusion reaction (ABO incompatibility) (Correct answer)
Febrile non-hemolytic transfusion reaction
Transfusion-related acute lung injury (TRALI)

Correct answer: Acute hemolytic transfusion reaction (ABO incompatibility)

Acute hemolytic transfusion reactions due to ABO incompatibility cause complement-mediated intravascular hemolysis, presenting with fever, hypotension, hemoglobinemia, and flank pain within minutes of transfusion.

Question 27: A patient with Graves disease is treated with methimazole. Which serious adverse effect requires immediate discontinuation?

Agranulocytosis (Correct answer)
Arthralgia
Mild rash
Elevated liver enzymes (mild)

Correct answer: Agranulocytosis

Agranulocytosis is a rare but life-threatening complication of thionamides; patients with fever or sore throat should stop the drug and get an immediate CBC.

Question 28: A 55-year-old presents with fatigue, petechiae, and gingival hyperplasia. CBC shows WBC 40,000 with blasts, Hgb 7.8, platelets 18,000. Bone marrow biopsy shows >20% blasts with Auer rods. What is the most likely diagnosis?

Myelodysplastic syndrome
Acute myeloid leukemia (AML) (Correct answer)
Acute lymphoblastic leukemia (ALL)
Chronic myelomonocytic leukemia

Correct answer: Acute myeloid leukemia (AML)

AML presents with Auer rods on marrow biopsy (pathognomonic), gingival hyperplasia, and rapidly progressive pancytopenia; >20% myeloid blasts confirms the diagnosis.

Question 29: Which vaccine is contraindicated in a 30-year-old pregnant woman?

Tetanus, diphtheria, pertussis (Tdap)
MMR (measles, mumps, rubella) (Correct answer)
Inactivated influenza
Pneumococcal polysaccharide

Correct answer: MMR (measles, mumps, rubella)

MMR is a live attenuated vaccine and is absolutely contraindicated in pregnancy due to theoretical risk of fetal infection.

Question 30: A 55-year-old male with a history of prostate cancer presents with severe low back pain. Plain radiograph shows mixed lytic and blastic lesions of the lumbar vertebrae. What is the most likely etiology?

Primary osteosarcoma
Multiple myeloma
Metastatic prostate cancer (Correct answer)
Paget disease

Correct answer: Metastatic prostate cancer

Prostate cancer metastases classically produce mixed lytic and blastic lesions (predominantly blastic) in the axial skeleton.

Question 31: A 52-year-old farmer presents with acute onset fever, myalgia, and bilateral pulmonary infiltrates 4-6 hours after working in a dusty barn. Symptoms resolve within 24 hours without treatment. What is the most likely diagnosis?

Organic dust toxic syndrome (Correct answer)
Community-acquired pneumonia
Acute eosinophilic pneumonia
Hypersensitivity pneumonitis (acute)

Correct answer: Organic dust toxic syndrome

Organic dust toxic syndrome (ODTS) occurs after heavy organic dust exposure causing flu-like illness and bilateral infiltrates that resolve spontaneously within 24-48 hours without sensitization.

Question 32: An adult patient presents with erythema migrans (bull's-eye rash) after hiking in Connecticut. What is the most appropriate treatment?

Amoxicillin 500 mg three times daily for 7 days
Azithromycin 500 mg daily for 5 days
Ceftriaxone 2g IV daily for 14 days
Doxycycline 100 mg twice daily for 14-21 days (Correct answer)

Correct answer: Doxycycline 100 mg twice daily for 14-21 days

Doxycycline for 14-21 days is the preferred oral treatment for early localized Lyme disease in non-pregnant adults.

Question 33: A 22-year-old Black male with sickle cell disease presents with severe bone pain in his legs and back for 12 hours. Temperature is 37.2°C, SpO2 is 97%. What is the most appropriate immediate management?

Hydroxyurea administration
IV morphine and IV fluids (Correct answer)
Emergent bone marrow biopsy
Urgent exchange transfusion

Correct answer: IV morphine and IV fluids

A vaso-occlusive pain crisis is managed with adequate analgesia (IV opioids) and IV hydration to reduce sickling and improve microvascular flow.

Question 34: A 58-year-old male with type 2 diabetes presents with a painless, punched-out ulcer on the plantar surface of his foot. Pedal pulses are intact and monofilament testing shows loss of sensation. What is the primary pathophysiology?

Peripheral arterial disease
Venous insufficiency
Peripheral neuropathy (Correct answer)
Charcot arthropathy

Correct answer: Peripheral neuropathy

Peripheral neuropathy is the primary driver of neuropathic (diabetic) foot ulcers, causing loss of protective sensation and pressure-induced tissue breakdown.

Question 35: A 16-year-old male presents with knee pain after playing basketball. Examination reveals tenderness at the tibial tuberosity. X-ray shows soft tissue swelling with irregular ossification. What is the diagnosis?

Prepatellar bursitis
Sinding-Larsen-Johansson syndrome
Patellar tendinopathy
Osgood-Schlatter disease (Correct answer)

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is a traction apophysitis at the tibial tuberosity common in adolescent athletes, caused by repetitive quadriceps contraction.

Question 36: A 65-year-old man presents with a non-healing, indurated ulcer on his lower lip with raised, everted edges. He has a 40 pack-year smoking history and dentures. Biopsy shows invasive squamous cell carcinoma. What is the most important prognostic factor?

Perineural invasion
Patient age
Tumor diameter
Regional lymph node involvement (Correct answer)

Correct answer: Regional lymph node involvement

Regional lymph node metastasis is the single most important prognostic factor for cutaneous and lip squamous cell carcinoma, significantly worsening 5-year survival.

Question 37: A 72-year-old man has a murmur that decreases with standing and increases with squatting. Which diagnosis is most consistent?

Tricuspid regurgitation
Hypertrophic obstructive cardiomyopathy (Correct answer)
Aortic stenosis
Mitral valve prolapse

Correct answer: Hypertrophic obstructive cardiomyopathy

HOCM murmur increases with maneuvers that decrease preload (standing, Valsalva) and decreases with increased preload (squatting).

Question 38: What role does collaboration play in emergency medicine for PANRE professionals?

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

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 39: An 8-year-old child presents with inspiratory stridor, drooling, and prefers to sit in a tripod position. Temperature is 39.5°C. What is the most likely diagnosis?

Croup
Epiglottitis (Correct answer)
Foreign body aspiration
Anaphylaxis

Correct answer: Epiglottitis

Epiglottitis presents with the classic triad of drooling, dysphagia, and distress along with high fever and a tripod posture to maintain airway patency.

Question 40: Which finding on nerve conduction studies best distinguishes demyelinating neuropathy from axonal neuropathy?

Increased insertional activity on EMG
Slowed conduction velocity with conduction block (Correct answer)
Reduced amplitude of CMAP
Absent F-waves only

Correct answer: Slowed conduction velocity with conduction block

Demyelinating neuropathies are characterized by markedly slowed conduction velocities and conduction block, reflecting impaired myelin function rather than axon loss.

Question 41: A 70-year-old with a 45-pack-year history has a 1.2 cm spiculated pulmonary nodule on CT chest. PET scan shows increased FDG uptake. Which is the next best step?

PET-CT alone is sufficient for diagnosis
Surgical resection or tissue sampling (Correct answer)
Follow-up CT in 3 months
Observation for 2 years

Correct answer: Surgical resection or tissue sampling

A spiculated nodule >1 cm with high FDG avidity on PET in a high-risk patient warrants tissue diagnosis or surgical resection.

Question 42: A 52-year-old smoker presents with hemoptysis, weight loss, and a right hilar mass on chest X-ray. Biopsy shows small, dark cells with scant cytoplasm. Which treatment is most appropriate?

Chemotherapy and radiation (Correct answer)
Surgical lobectomy
Bronchial artery embolization
Targeted therapy with erlotinib

Correct answer: Chemotherapy and radiation

Small cell lung cancer is exquisitely sensitive to chemotherapy and radiation, making chemoradiation the primary treatment even in limited-stage disease.

Question 43: What is the value of continuing education in emergency medicine for PANRE professionals?

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

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 44: A traveler returning from Central America presents with bloody diarrhea, fever, and a liver abscess on ultrasound. Which organism is most likely responsible?

Cryptosporidium parvum
Giardia lamblia
Cyclospora cayetanensis
Entamoeba histolytica (Correct answer)

Correct answer: Entamoeba histolytica

Entamoeba histolytica causes amoebic dysentery and can disseminate hematogenously to cause amoebic liver abscess.

Question 45: A patient sustains a proximal humerus fracture. Which nerve is at greatest risk of injury?

Radial nerve
Axillary nerve (Correct answer)
Median nerve
Musculocutaneous nerve

Correct answer: Axillary nerve

The axillary nerve passes inferior to the glenohumeral joint and around the surgical neck of the humerus, making it vulnerable in proximal humerus fractures.

Question 46: Which of the following is the most appropriate initial treatment for a non-displaced clavicle fracture?

Open reduction and internal fixation
Figure-of-eight brace for 8 weeks
Sling immobilization for 4–6 weeks (Correct answer)
Closed reduction and casting

Correct answer: Sling immobilization for 4–6 weeks

Non-displaced clavicle fractures are managed non-operatively with a simple sling for 4–6 weeks; figure-of-eight braces offer no advantage and are less comfortable.

Question 47: Which special test is used to evaluate for rotator cuff impingement?

Speed test
O'Brien active compression test
Sulcus sign
Neer impingement sign (Correct answer)

Correct answer: Neer impingement sign

The Neer impingement sign is performed by passively forward-flexing the arm with the forearm pronated; pain indicates subacromial impingement.

Question 48: Which of the following drugs increased insulin release from pancreatic beta cells, hence lowering plasma glucose levels?

Acarbose
Glyburide (Correct answer)
Metformin
Pioglitazone

Correct answer: Glyburide

Glyburide is a sulfonylurea medication that works by increasing insulin release from pancreatic beta cells. It binds to specific receptors on these cells, leading to the closure of ATP-sensitive potassium channels, which depolarizes the cell and triggers calcium influx. This calcium influx then stimulates the secretion of insulin, thereby lowering plasma glucose levels in patients with type 2 diabetes.

Question 49: A neonate presents with seizures, lethargy, and bulging fontanelle within 24 hours of birth. CSF shows gram-positive cocci in pairs. Causative organism?

Neisseria meningitidis
Listeria monocytogenes
Escherichia coli
Group B Streptococcus (Correct answer)

Correct answer: Group B Streptococcus

Group B Streptococcus (Streptococcus agalactiae) is the most common cause of early-onset neonatal meningitis and appears as gram-positive cocci in pairs or chains.

Question 50: A 35-year-old G0 woman is found to have a 6 cm simple ovarian cyst on transvaginal ultrasound performed for pelvic pain. CA-125 is normal. What is the most appropriate management?

CT scan of abdomen and pelvis
Repeat ultrasound in 6-12 weeks (Correct answer)
Oral contraceptive suppression for 3 months
Immediate surgical removal

Correct answer: Repeat ultrasound in 6-12 weeks

Simple ovarian cysts ≤10 cm in premenopausal women with normal CA-125 can be followed with repeat ultrasound in 6-12 weeks.

Question 51: A patient with type 1 diabetes presents with blood glucose of 650 mg/dL, pH 7.20, bicarbonate 12 mEq/L, and large ketones. What is the hallmark of diabetic ketoacidosis that distinguishes it from hyperglycemic hyperosmolar state?

Altered mental status
High serum osmolality
Significant ketonemia and anion gap metabolic acidosis (Correct answer)
Severe hyperglycemia

Correct answer: Significant ketonemia and anion gap metabolic acidosis

DKA is defined by the triad of hyperglycemia, ketonemia/ketonuria, and anion gap metabolic acidosis, which distinguishes it from HHS where ketosis and acidosis are absent or minimal.

Question 52: Which medication is first-line for absence seizures in a 10-year-old child?

Ethosuximide (Correct answer)
Carbamazepine
Phenytoin
Levetiracetam

Correct answer: Ethosuximide

Ethosuximide is first-line for childhood absence epilepsy because it targets thalamic T-type calcium channels responsible for spike-and-wave discharges.

Question 53: A 45-year-old presents with acute scrotal pain of 2 hours duration. The testicle is tender, elevated, and the cremasteric reflex is absent. What is the priority action?

Apply ice and re-examine in 4 hours
Order a scrotal ultrasound and wait for results before acting
Arrange immediate surgical exploration (Correct answer)
Administer antibiotics for epididymitis

Correct answer: Arrange immediate surgical exploration

Absent cremasteric reflex with acute scrotal pain is testicular torsion until proven otherwise; surgical detorsion within 6 hours is critical to salvage the testicle.

Question 54: A 55-year-old male presents with dysphagia to solids only that has progressively worsened over 6 months along with a 15-pound weight loss. Which diagnosis is most concerning?

Schatzki ring
Diffuse esophageal spasm
Achalasia
Esophageal carcinoma (Correct answer)

Correct answer: Esophageal carcinoma

Progressive dysphagia to solids with significant weight loss in an older male raises high concern for esophageal carcinoma.

Question 55: Which ventilator parameter should be prioritized when managing ARDS to prevent ventilator-induced lung injury (VILI)?

Tidal volume 4-6 mL/kg ideal body weight (Correct answer)
PEEP <5 cm H2O to avoid barotrauma
FiO2 100% to maximize oxygenation
RR <12 breaths/min to minimize auto-PEEP

Correct answer: Tidal volume 4-6 mL/kg ideal body weight

The ARDSNet protocol demonstrated reduced mortality using lung-protective ventilation with low tidal volumes of 4-6 mL/kg IBW to minimize VILI.

Question 56: A patient with suspected pulmonary embolism has a Wells score of 6. D-dimer is elevated. What is the best next diagnostic step?

Start anticoagulation empirically without further workup
Obtain lower extremity Doppler ultrasound only
Perform V/Q scan as first-line imaging
Obtain CT pulmonary angiography (CTPA) (Correct answer)

Correct answer: Obtain CT pulmonary angiography (CTPA)

A Wells score ≥5 indicates high pre-test probability for PE, and CTPA is the preferred confirmatory imaging modality.

Question 57: In PANRE practice, what is the best approach to quality improvement in emergency medicine?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 58: Which medication is contraindicated in patients with spontaneous bacterial peritonitis (SBP) who have acute kidney injury?

Cefotaxime
Albumin infusion
Albumin plus antibiotics
NSAIDs (Correct answer)

Correct answer: NSAIDs

NSAIDs are contraindicated in SBP with AKI as they further reduce renal perfusion in already hemodynamically compromised cirrhotic patients.

Question 59: A patient with rheumatoid arthritis develops atlantoaxial instability. Which X-ray view best demonstrates this?

AP view of the cervical spine
Lateral flexion-extension views of the cervical spine (Correct answer)
Open-mouth odontoid view
Oblique view of the cervical spine

Correct answer: Lateral flexion-extension views of the cervical spine

Lateral flexion-extension views demonstrate atlantoaxial instability by showing abnormal anterior displacement of C1 on C2 with the atlantodental interval exceeding 3 mm.

Question 60: A neonate develops a desquamating rash starting around the mouth and spreading to form large flaccid bullae that rupture to leave a scalded appearance. Nikolsky sign is positive. Which toxin is responsible?

Staphylococcal exfoliative toxin A/B (Correct answer)
Streptococcal pyrogenic exotoxin A
Clostridium perfringens alpha toxin
Staphylococcal toxic shock toxin-1

Correct answer: Staphylococcal exfoliative toxin A/B

Staphylococcal scalded skin syndrome is caused by exfoliative toxins A and B from S. aureus, which cleave desmoglein-1 in the superficial epidermis.

Question 61: Which finding on endoscopy is most indicative of Barrett's esophagus?

Esophageal rings at 20 cm from the incisors
White plaques on the esophageal mucosa
Salmon-colored tongues of mucosa extending above the GEJ (Correct answer)
Linear ulcerations in the distal esophagus

Correct answer: Salmon-colored tongues of mucosa extending above the GEJ

Barrett's esophagus is characterized by salmon-colored columnar metaplasia extending proximal to the gastroesophageal junction, confirmed by intestinal metaplasia on biopsy.

Question 62: A 25-year-old presents with fever, headache, and a rash that began on the wrists and ankles and spread centrally after a tick exposure. What is the most likely diagnosis?

Rocky Mountain Spotted Fever (Correct answer)
Tularemia
Lyme Disease
Ehrlichiosis

Correct answer: Rocky Mountain Spotted Fever

Rocky Mountain Spotted Fever (RMSF) classically presents with fever, headache, and a centripetal rash beginning on the wrists and ankles caused by Rickettsia rickettsii.

Question 63: A 40-year-old woman presents with fatigue, constipation, weight gain, and cold intolerance. TSH is 12 mIU/L and free T4 is low. Which treatment is indicated?

Levothyroxine (Correct answer)
Propylthiouracil
Methimazole
Radioactive iodine ablation

Correct answer: Levothyroxine

Primary hypothyroidism (elevated TSH, low free T4) is treated with levothyroxine replacement therapy.

Question 64: A 60-year-old woman on bisphosphonate therapy for osteoporosis has a 'drug holiday' recommended after 5 years. Which bisphosphonate characteristic makes this most appropriate?

Risk of rebound hypercalcemia
Prolonged skeletal retention and residual effect after discontinuation (Correct answer)
Short half-life in bone
High renal excretion requiring drug holiday

Correct answer: Prolonged skeletal retention and residual effect after discontinuation

Bisphosphonates have a prolonged half-life in bone (years), providing continued fracture protection after discontinuation, which supports a drug holiday to minimize risks like atypical femur fractures.

Question 65: A 24-year-old African American male develops hemolytic anemia and hemoglobinuria after being prescribed dapsone for dermatitis herpetiformis. Peripheral smear shows Heinz bodies. What is the underlying defect?

Hereditary spherocytosis
Sickle cell trait
Glucose-6-phosphate dehydrogenase (G6PD) deficiency (Correct answer)
Pyruvate kinase deficiency

Correct answer: Glucose-6-phosphate dehydrogenase (G6PD) deficiency

G6PD deficiency causes oxidative hemolysis when triggered by oxidant drugs (dapsone, primaquine), infections, or fava beans, resulting in Heinz body formation and intravascular hemolysis.

Question 66: At what GFR level is hemodialysis typically initiated in symptomatic CKD patients?

5 mL/min/1.73m²
10-15 mL/min/1.73m² (Correct answer)
20 mL/min/1.73m²
30 mL/min/1.73m²

Correct answer: 10-15 mL/min/1.73m²

Dialysis is generally initiated when GFR falls to 10-15 mL/min/1.73m² in patients with uremic symptoms or complications.

Question 67: A patient with recurrent genital herpes wants suppressive therapy to reduce outbreaks. Which regimen is appropriate?

Famciclovir 500 mg twice daily during outbreaks only
Ganciclovir 5 mg/kg IV twice daily
Foscarnet 40 mg/kg IV three times daily
Valacyclovir 500 mg daily (Correct answer)

Correct answer: Valacyclovir 500 mg daily

Valacyclovir 500 mg daily is a standard suppressive therapy regimen for recurrent genital herpes that reduces outbreak frequency and viral shedding.

Question 68: A child presents with cola-colored urine, periorbital edema, and hypertension 2 weeks after strep throat. What is the most likely diagnosis?

Nephrotic syndrome
Lupus nephritis
IgA nephropathy
Post-streptococcal glomerulonephritis (Correct answer)

Correct answer: Post-streptococcal glomerulonephritis

Post-streptococcal glomerulonephritis classically presents 1-3 weeks after Group A Strep pharyngitis with hematuria, edema, and hypertension.

Question 69: A 40-year-old male construction worker presents with pain in the first metatarsophalangeal joint after 3 days of high-purine diet and alcohol use. Joint aspiration reveals negatively birefringent, needle-shaped crystals. What is the treatment?

Allopurinol
Probenecid
Indomethacin
Colchicine or NSAIDs (Correct answer)

Correct answer: Colchicine or NSAIDs

Acute gout is treated with colchicine, NSAIDs, or corticosteroids; urate-lowering therapy like allopurinol is initiated after the acute attack resolves.

Question 70: What is the most important professional competency for PANRE certification in orthopedics?

Speed of task completion
Memorization of all reference materials
Ability to work alone exclusively
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 71: Which lab finding is most characteristic of primary biliary cholangitis (PBC)?

Elevated AST/ALT with low alkaline phosphatase
Elevated alkaline phosphatase with positive anti-mitochondrial antibody (Correct answer)
Elevated GGT with positive ANA
Positive anti-smooth muscle antibody

Correct answer: Elevated alkaline phosphatase with positive anti-mitochondrial antibody

PBC is characterized by elevated alkaline phosphatase (cholestatic pattern) and the presence of anti-mitochondrial antibodies (AMA) in >90% of cases.

Question 72: A 35-year-old with bipolar I disorder is stable on lithium but develops polyuria and polydipsia. What is the most appropriate next step?

Add desmopressin without further workup
Switch to valproate immediately
Discontinue lithium and start lamotrigine
Check serum lithium level and renal function (Correct answer)

Correct answer: Check serum lithium level and renal function

Nephrogenic diabetes insipidus is a common lithium side effect; checking levels and renal function guides management.

Question 73: A 45-year-old woman undergoes LEEP for CIN 2. Pathology returns with CIN 2 and negative margins. What is the recommended follow-up?

Return to routine screening in 3 years
Hysterectomy
Co-testing (HPV + cytology) at 1 and 2 years post-treatment (Correct answer)
Repeat colposcopy in 6 months

Correct answer: Co-testing (HPV + cytology) at 1 and 2 years post-treatment

After excisional treatment of CIN 2-3 with negative margins, co-testing at 1 and 2 years is recommended before returning to routine screening.

Question 74: Which finding best distinguishes dermatophyte tinea capitis from alopecia areata in a child?

Exclamation point hairs
Nail pitting
Positive KOH preparation (Correct answer)
Boggy scalp tenderness

Correct answer: Positive KOH preparation

A positive KOH preparation demonstrating hyphae or spores confirms a dermatophyte infection, definitively distinguishing tinea capitis from alopecia areata.

Question 75: A 38-year-old man presents with severe epigastric pain radiating to the back, nausea, and vomiting. He denies alcohol use. Lipase is 4× normal and triglycerides are 1,800 mg/dL. What is the cause of his pancreatitis?

Hypertriglyceridemia-induced pancreatitis (Correct answer)
Idiopathic pancreatitis
Gallstone pancreatitis
Medication-induced pancreatitis

Correct answer: Hypertriglyceridemia-induced pancreatitis

Triglyceride levels above 1,000 mg/dL can cause acute pancreatitis, and this patient's markedly elevated triglycerides with no other identified cause confirms hypertriglyceridemia-induced pancreatitis.

Question 76: Which thyroid cancer subtype has the worst prognosis?

Papillary
Follicular
Medullary
Anaplastic (Correct answer)

Correct answer: Anaplastic

Anaplastic (undifferentiated) thyroid carcinoma is extremely aggressive with median survival of only 3-5 months after diagnosis.

Question 77: Which class of antihypertensive is preferred as first-line therapy in a Black patient without diabetes or heart failure?

Beta-blockers
ACE inhibitors
ARBs alone
Thiazide diuretics or calcium channel blockers (Correct answer)

Correct answer: Thiazide diuretics or calcium channel blockers

JNC and ACC/AHA guidelines recommend thiazide diuretics or calcium channel blockers as first-line therapy in Black patients due to superior efficacy.

Question 78: Which antifungal is first-line for treating oropharyngeal candidiasis in an immunocompromised patient?

Amphotericin B
Caspofungin
Voriconazole
Fluconazole (Correct answer)

Correct answer: Fluconazole

Fluconazole is the preferred agent for oropharyngeal candidiasis due to high efficacy and a favorable side effect profile.

Question 79: Which vaccine is routinely recommended for all healthcare workers due to occupational exposure risk?

Hepatitis B (Correct answer)
HPV
Hepatitis A
Pneumococcal

Correct answer: Hepatitis B

Hepatitis B vaccination is mandatory for healthcare workers because of significant occupational risk from blood-borne pathogen exposure.

Question 80: Which of the following is the safest antidepressant choice during pregnancy when treatment is necessary?

Sertraline (Correct answer)
Nortriptyline
Phenelzine
Paroxetine

Correct answer: Sertraline

Sertraline has the most pregnancy safety data among SSRIs; paroxetine carries cardiac malformation risk.

Question 81: Which lipid abnormality pattern is most associated with metabolic syndrome?

Elevated LDL with normal triglycerides
Isolated elevated HDL
Elevated LDL with low triglycerides
Low HDL with elevated triglycerides (Correct answer)

Correct answer: Low HDL with elevated triglycerides

Metabolic syndrome characteristically presents with hypertriglyceridemia and low HDL cholesterol, along with insulin resistance.

Question 82: A 45-year-old with HIV presents with focal seizures and a ring-enhancing lesion on MRI. The most likely diagnosis is:

Progressive multifocal leukoencephalopathy
Cryptococcal meningitis
Toxoplasma encephalitis (Correct answer)
Primary CNS lymphoma

Correct answer: Toxoplasma encephalitis

In HIV-positive patients, a ring-enhancing brain lesion most commonly represents Toxoplasma gondii encephalitis, especially when CD4 count is below 100 cells/µL.

Question 83: In PANRE practice, what is the best approach to quality improvement in cardiology?

Make changes without measuring results
Use data-driven methods with measurable outcomes (Correct answer)
Copy what other organizations do without analysis
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 84: A 62-year-old man with cirrhosis develops confusion, asterixis, and an elevated ammonia level. Which is the most appropriate initial treatment?

Metronidazole
Lactulose (Correct answer)
Rifaximin
Neomycin

Correct answer: Lactulose

Lactulose is first-line therapy for hepatic encephalopathy as it reduces ammonia absorption by acidifying colonic contents.

Question 85: A patient has a positive Lachman test but negative McMurray test. Which structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

The Lachman test specifically assesses ACL integrity by checking anterior tibial translation with the knee at 20–30 degrees flexion.

Question 86: Which hemodynamic profile is characteristic of cardiogenic shock?

High PCWP, low CO, high SVR (Correct answer)
Low PCWP, high CO, low SVR
Low CVP, low PCWP, high CO, low SVR
High CVP, high CO, low SVR

Correct answer: High PCWP, low CO, high SVR

Cardiogenic shock is characterized by elevated filling pressures (high PCWP), reduced cardiac output, and compensatory increased systemic vascular resistance.

Question 87: A 45-year-old woman is found to have a serum LDL of 210 mg/dL with no cardiovascular risk factors. Initial management should include:

Lifestyle modification for 3 months, then reassess (Correct answer)
Immediate coronary calcium scoring
High-intensity statin and aspirin
Ezetimibe monotherapy

Correct answer: Lifestyle modification for 3 months, then reassess

In primary prevention with elevated LDL but no other risk factors, lifestyle modification is the initial step before pharmacotherapy.

Question 88: What is the most important professional competency for PANRE certification in pulmonology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 89: Which medication requires a REMS program due to the risk of QTc prolongation and cardiac arrhythmia?

Haloperidol
Clozapine (Correct answer)
Ziprasidone
Quetiapine

Correct answer: Clozapine

Clozapine has a REMS program primarily for agranulocytosis, but also requires monitoring for QTc effects.

Question 90: Which of the following is the most common cause of acute pancreatitis in the United States?

Alcohol use
Medications
Hypertriglyceridemia
Gallstones (Correct answer)

Correct answer: Gallstones

Gallstones are the most common cause of acute pancreatitis in the US, followed by alcohol as the second most common cause.

Question 91: Which condition is characterized by at least 2 years of fluctuating hypomanic and depressive symptoms that do not meet criteria for full bipolar episodes?

Cyclothymic disorder (Correct answer)
Persistent depressive disorder
Bipolar II disorder
Borderline personality disorder

Correct answer: Cyclothymic disorder

Cyclothymic disorder requires ≥2 years (1 year in children) of subsyndromal hypomanic and depressive periods.

Question 92: Which diuretic is preferred to manage edema in nephrotic syndrome?

Loop diuretics (furosemide) (Correct answer)
Hydrochlorothiazide
Spironolactone
Acetazolamide

Correct answer: Loop diuretics (furosemide)

Loop diuretics such as furosemide are the primary treatment for edema in nephrotic syndrome due to their potency in patients with low albumin.

Question 93: What is the most important professional competency for PANRE certification in emergency medicine?

Ability to work alone exclusively
Deep knowledge combined with practical application skills (Correct answer)
Speed of task completion
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 94: Which approach best demonstrates mastery of psychiatry in PANRE practice?

Relying entirely on technology
Applying principles to novel situations with sound judgment (Correct answer)
Avoiding complex scenarios
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 95: At the intensive care unit (ICU), a newborn was being treated for cyanotic episodes and stunted growth. Auscultation reveals a systolic murmur, and an x-ray reveals a heart that resembles a boot. Which diagnosis is more likely?

Hypoplastic left heart syndrome
Tetralogy of Fallot (Correct answer)
Persistent truncus arteriosus
Transportation of the great arteries

Correct answer: Tetralogy of Fallot

The combination of cyanotic episodes, stunted growth, a systolic murmur, and a 'boot-shaped heart' on X-ray is classic for Tetralogy of Fallot (TOF). TOF is a congenital heart defect comprising four anomalies: a ventricular septal defect, pulmonary stenosis, an overriding aorta, and right ventricular hypertrophy. The 'boot-shaped heart' appearance is due to right ventricular hypertrophy and pulmonary artery hypoplasia.

Question 96: A 65-year-old male presents with peripheral neuropathy, glossitis, and megaloblastic anemia. Serum B12 is 98 pg/mL. Anti-intrinsic factor antibodies are positive. What is the most likely diagnosis?

Alcoholic liver disease
Celiac disease
Pernicious anemia (Correct answer)
Folate deficiency anemia

Correct answer: Pernicious anemia

Pernicious anemia is caused by autoimmune destruction of gastric parietal cells leading to intrinsic factor deficiency and B12 malabsorption, confirmed by positive anti-intrinsic factor antibodies.

Question 97: Which approach best demonstrates mastery of cardiology in PANRE practice?

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

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 98: During a routine prenatal visit at 28 weeks, a patient's fundal height measures 24 cm. Ultrasound confirms fetal growth restriction with estimated fetal weight at the 8th percentile. What is the most important next step?

Schedule repeat ultrasound in 4 weeks
Immediate delivery
Amniocentesis
Umbilical artery Doppler velocimetry (Correct answer)

Correct answer: Umbilical artery Doppler velocimetry

Umbilical artery Doppler velocimetry is the primary surveillance tool for fetal growth restriction, assessing placental resistance and guiding delivery timing.

Question 99: Which test is most sensitive for detecting early Alzheimer disease when clinical diagnosis is uncertain?

MRI showing hippocampal atrophy
FDG-PET showing temporal-parietal hypometabolism
EEG
CSF tau/amyloid ratio (Correct answer)

Correct answer: CSF tau/amyloid ratio

CSF analysis showing elevated phosphorylated tau and reduced amyloid-beta 42 (or the tau/Aβ42 ratio) is the most sensitive and specific biomarker for early Alzheimer disease.

Question 100: A 25-year-old woman presents with 7 weeks of amenorrhea, left lower quadrant pain, and vaginal spotting. Serum hCG is 2,200 mIU/mL and transvaginal ultrasound shows no intrauterine gestational sac. She is hemodynamically stable. What is the most appropriate management?

Dilation and curettage
Methotrexate 50 mg/m² IM (Correct answer)
Expectant management
Laparoscopic salpingectomy

Correct answer: Methotrexate 50 mg/m² IM

A hemodynamically stable patient with a presumed unruptured ectopic pregnancy, hCG <5,000, and no contraindications is a candidate for medical management with methotrexate.

Question 101: A patient presents with vesicular rash on the forehead, tip of the nose, and periorbital swelling. What is the most urgent complication to rule out?

Herpes zoster ophthalmicus (Correct answer)
Contact dermatitis
Trigeminal neuralgia
Facial cellulitis

Correct answer: Herpes zoster ophthalmicus

Zoster involving the ophthalmic branch of CN V (especially Hutchinson's sign — rash on tip of nose) requires urgent ophthalmologic evaluation for sight-threatening keratitis.

Question 102: A 40-year-old non-smoker presents with hemoptysis and bilateral pulmonary infiltrates. Urinalysis shows hematuria and red cell casts. Anti-GBM antibodies are positive. Which diagnosis is most likely?

Idiopathic pulmonary hemosiderosis
Goodpasture syndrome (Correct answer)
Microscopic polyangiitis
Granulomatosis with polyangiitis (GPA)

Correct answer: Goodpasture syndrome

Goodpasture syndrome presents with pulmonary-renal syndrome (hemoptysis + glomerulonephritis) and is confirmed by positive anti-GBM antibodies.

Question 103: A 33-year-old woman at 16 weeks gestation has a serum alpha-fetoprotein (AFP) of 3.2 MOM. What is the most appropriate next step?

Amniocentesis for karyotype
Targeted ultrasound to evaluate for neural tube defects and other causes (Correct answer)
Reassure the patient; this is normal
Repeat AFP in 4 weeks

Correct answer: Targeted ultrasound to evaluate for neural tube defects and other causes

Elevated maternal serum AFP (≥2.5 MOM) warrants targeted ultrasound to evaluate for open neural tube defects, abdominal wall defects, or dating error.

Question 104: A 55-year-old male presents with progressive exertional dyspnea, loud P2, and right heart failure. Echocardiogram shows RVSP of 58 mmHg. Right heart catheterization confirms mean PAP of 32 mmHg with PCWP of 10 mmHg. Which initial treatment is recommended for WHO Group 1 pulmonary arterial hypertension?

Anticoagulation alone
Calcium channel blockers in all patients
Supplemental oxygen only
Endothelin receptor antagonist or PDE-5 inhibitor (Correct answer)

Correct answer: Endothelin receptor antagonist or PDE-5 inhibitor

WHO Group 1 PAH is treated with PAH-specific therapy including endothelin receptor antagonists (ambrisentan, bosentan) or PDE-5 inhibitors (sildenafil, tadalafil).

Question 105: A patient with ESRD develops pruritis, pericarditis, and encephalopathy. These findings are best explained by which condition?

Uremic syndrome (Correct answer)
Hypervolemia
Hyponatremia
Hyperphosphatemia

Correct answer: Uremic syndrome

Uremic syndrome encompasses pruritis, pericardial inflammation, neurologic changes, and bleeding tendency due to accumulated uremic toxins in ESRD.

Question 106: A 32-year-old woman presents with alternating constipation and diarrhea, bloating, and abdominal cramping relieved by defecation. No alarm features are present. What is the most likely diagnosis?

Irritable bowel syndrome (Correct answer)
Microscopic colitis
Crohn's disease
Ulcerative colitis

Correct answer: Irritable bowel syndrome

The pattern of alternating bowel habits, bloating, and pain relieved by defecation without alarm features fits the Rome IV criteria for irritable bowel syndrome.

Question 107: Per current CDC guidelines, uncomplicated gonorrhea in an adult weighing less than 150 kg is treated with which single-dose regimen?

Azithromycin 1g PO once
Penicillin G 2.4 million units IM once
Ceftriaxone 500 mg IM once (Correct answer)
Doxycycline 100 mg PO twice daily for 7 days

Correct answer: Ceftriaxone 500 mg IM once

Current CDC guidelines recommend ceftriaxone 500 mg IM as a single dose for uncomplicated gonorrhea in patients weighing less than 150 kg.

Question 108: A 24-year-old presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. CA-125 is mildly elevated. What is the gold standard for diagnosis?

Pelvic MRI
Endometrial biopsy
Transvaginal ultrasound
Diagnostic laparoscopy (Correct answer)

Correct answer: Diagnostic laparoscopy

Diagnostic laparoscopy with biopsy is the gold standard for diagnosing endometriosis, as imaging modalities cannot detect peritoneal implants reliably.

Question 109: Oseltamivir for influenza is most effective when started within how many hours of symptom onset?

12 hours
24 hours
72 hours
48 hours (Correct answer)

Correct answer: 48 hours

Oseltamivir (Tamiflu) significantly reduces illness duration and severity when initiated within 48 hours of influenza symptom onset.

Question 110: Which formula is currently recommended for estimating GFR in clinical practice?

Henderson-Hasselbalch equation
MDRD equation
CKD-EPI equation (Correct answer)
Cockcroft-Gault equation

Correct answer: CKD-EPI equation

The CKD-EPI equation is the currently recommended formula for estimating GFR in adults and has replaced MDRD as the standard.

Question 111: Which HbA1c threshold is used to diagnose diabetes mellitus?

≥ 7.0%
≥ 6.5% (Correct answer)
≥ 5.7%
≥ 6.0%

Correct answer: ≥ 6.5%

An HbA1c ≥ 6.5% on two separate occasions (or once with confirmatory testing) meets the diagnostic criteria for diabetes mellitus per ADA guidelines.

Question 112: Which antibiotic class is the treatment of choice for community-acquired pneumonia in a healthy outpatient adult with no comorbidities?

Macrolides (Correct answer)
Tetracyclines
Beta-lactams
Fluoroquinolones

Correct answer: Macrolides

Current IDSA/ATS guidelines recommend macrolides (e.g., azithromycin) as first-line monotherapy for otherwise healthy adults with CAP who have no comorbidities.

Question 113: Which approach best demonstrates mastery of gastroenterology in PANRE practice?

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

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 114: A 30-year-old male presents with bilateral ankle swelling, eye redness, and dysuria following an episode of Chlamydia trachomatis infection. What is the classic triad of his condition?

Arthritis, conjunctivitis, urethritis (Correct answer)
Arthritis, oral ulcers, uveitis
Arthritis, uveitis, urethritis
Arthritis, skin rash, urethritis

Correct answer: Arthritis, conjunctivitis, urethritis

Reactive arthritis (formerly Reiter syndrome) classically presents with the triad of arthritis, conjunctivitis, and urethritis following a triggering infection.

Question 115: A 68-year-old man presents with sudden onset of the worst headache of his life. CT head is negative. What is the next best step?

Start empiric antibiotics
Discharge with analgesics
MRI brain with contrast
Lumbar puncture (Correct answer)

Correct answer: Lumbar puncture

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture is required to detect xanthochromia or RBCs that persist after centrifugation.

Question 116: A patient with schizophrenia on olanzapine gains 20 lbs over 6 months and develops fasting glucose of 126 mg/dL. What is the most appropriate next step?

Discontinue antipsychotic therapy
Switch to aripiprazole or ziprasidone (Correct answer)
Continue olanzapine and start metformin
Add orlistat

Correct answer: Switch to aripiprazole or ziprasidone

Switching to a metabolically neutral antipsychotic (aripiprazole or ziprasidone) is preferred over adding medications for metabolic side effects.

Question 117: A 25-year-old presents with grouped vesicles on an erythematous base in a dermatomal distribution on the right thorax with pain preceding the rash by 3 days. Which antiviral should be initiated?

Oseltamivir 75mg BID x 5 days
Acyclovir 400mg TID x 5 days
Famciclovir 250mg BID x 5 days
Valacyclovir 1000mg TID x 7 days (Correct answer)

Correct answer: Valacyclovir 1000mg TID x 7 days

Valacyclovir 1000mg TID for 7 days is preferred for herpes zoster due to better bioavailability and simplified dosing compared to acyclovir.

Question 118: Which professional attribute is most valued in orthopedics within the PANRE field?

Avoiding challenging situations
Accountability and commitment to standards (Correct answer)
Prioritizing personal convenience
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 119: A patient presents with altered mental status, fever of 40°C, muscle rigidity, and autonomic instability after starting a new antipsychotic. What is the diagnosis?

Heat stroke
Serotonin syndrome
Neuroleptic malignant syndrome (Correct answer)
Malignant hyperthermia

Correct answer: Neuroleptic malignant syndrome

Neuroleptic malignant syndrome is characterized by hyperthermia, lead-pipe rigidity, autonomic instability, and altered consciousness following antipsychotic use.

Question 120: In PANRE practice, what is the best approach to quality improvement in dermatology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 121: Which professional attribute is most valued in psychiatry within the PANRE field?

Prioritizing personal convenience
Accountability and commitment to standards (Correct answer)
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 122: Which statement about transudative pleural effusions is correct?

Pleural LDH >200 U/L
Pleural protein >3.0 g/dL
Pleural LDH/serum LDH ratio >0.6
Pleural protein/serum protein ratio <0.5 (Correct answer)

Correct answer: Pleural protein/serum protein ratio <0.5

By Light's criteria, a transudate has pleural/serum protein ratio <0.5, pleural/serum LDH ratio <0.6, and pleural LDH <2/3 upper limit of normal.

Question 123: A 30-year-old woman develops a butterfly-shaped rash across her cheeks and nasal bridge that spares the nasolabial folds. Which test is most specific for confirming systemic lupus erythematosus?

ANA
Anti-dsDNA (Correct answer)
Anti-histone
Complement C3/C4

Correct answer: Anti-dsDNA

Anti-dsDNA antibodies are highly specific for SLE (>95%) and correlate with disease activity, particularly lupus nephritis.

Question 124: A 6-year-old boy has recurrent hemarthroses and prolonged bleeding after minor trauma. PTT is 68 seconds (normal <35), PT is normal, platelet count is normal, bleeding time is normal. Factor VIII activity is 2%. What is the diagnosis?

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

Correct answer: Hemophilia A

Hemophilia A is caused by factor VIII deficiency, presenting with hemarthroses and deep muscle bleeds, prolonged PTT with normal PT, and very low factor VIII activity levels.

Question 125: A 70-year-old man presents with a scaly, erythematous plaque on his lower lip that has been present for 8 months. Biopsy reveals full-thickness dysplasia. What is this condition?

Actinic cheilitis (Correct answer)
Leukoplakia
Erythroplakia
Lichen planus

Correct answer: Actinic cheilitis

Actinic cheilitis is a premalignant condition caused by chronic UV exposure, presenting as scaly, atrophic changes on the lower lip with risk of SCC transformation.

Question 126: A 45-year-old patient with immune thrombocytopenic purpura (ITP) has a platelet count of 8,000/μL and is actively bleeding from the gums. Which is the most appropriate initial management?

IV immunoglobulin (IVIG) and high-dose corticosteroids (Correct answer)
Splenectomy
Platelet transfusion alone
Rituximab infusion

Correct answer: IV immunoglobulin (IVIG) and high-dose corticosteroids

For acute severe ITP with bleeding, IVIG combined with high-dose corticosteroids provides the fastest platelet count rise and is the preferred initial treatment.

Question 127: A 50-year-old man with long-standing GERD undergoes surveillance endoscopy revealing Barrett's esophagus with high-grade dysplasia. What is the recommended management?

Endoscopic eradication therapy (radiofrequency ablation) (Correct answer)
Continue surveillance every 6 months
Intensify PPI therapy and repeat endoscopy in 3 months
Esophagectomy

Correct answer: Endoscopic eradication therapy (radiofrequency ablation)

Endoscopic eradication therapy, particularly radiofrequency ablation, is the recommended treatment for Barrett's esophagus with high-grade dysplasia as it effectively eliminates dysplastic epithelium.

Question 128: A 28-year-old presents with 2 weeks of depressed mood, insomnia, poor concentration, and passive suicidal ideation after a romantic breakup. She denies psychosis. What is the diagnosis?

Major depressive episode (Correct answer)
Dysthymia
Bereavement
Adjustment disorder with depressed mood

Correct answer: Major depressive episode

Five or more DSM-5 depressive symptoms for ≥2 weeks including depressed mood qualifies as a major depressive episode.

Question 129: A child develops fever, malaise, and a bright red 'slapped cheek' rash followed by a lacy reticular rash on the trunk. What is the causative agent?

Epstein-Barr virus
Rubella virus
Varicella-zoster virus
Parvovirus B19 (Correct answer)

Correct answer: Parvovirus B19

Parvovirus B19 causes erythema infectiosum (fifth disease), characterized by the classic slapped cheek appearance followed by a lacy truncal rash.

Question 130: A patient with suspected pheochromocytoma should be screened using which initial test?

24-hour urine catecholamines and metanephrines (Correct answer)
Adrenal CT scan
ACTH stimulation test
Random serum epinephrine level

Correct answer: 24-hour urine catecholamines and metanephrines

24-hour urine catecholamines and fractionated metanephrines (or plasma metanephrines) are the recommended biochemical screening tests for pheochromocytoma.

Question 131: A 50-year-old obese man with type 2 diabetes has elevated transaminases. Liver biopsy shows steatosis, lobular inflammation, and hepatocyte ballooning. What is the diagnosis?

Alcoholic hepatitis
Nonalcoholic steatohepatitis (NASH) (Correct answer)
Primary sclerosing cholangitis
Autoimmune hepatitis

Correct answer: Nonalcoholic steatohepatitis (NASH)

The triad of steatosis, lobular inflammation, and hepatocyte ballooning in the absence of significant alcohol use defines nonalcoholic steatohepatitis (NASH).

Question 132: A 33-year-old with cystic fibrosis has FEV1 38% predicted and recurrent Pseudomonas exacerbations. Which chronic suppressive antibiotic regimen is most appropriate?

IV piperacillin-tazobactam every 3 months
Inhaled tobramycin alternating monthly (Correct answer)
Inhaled colistin twice daily continuously
Daily oral ciprofloxacin

Correct answer: Inhaled tobramycin alternating monthly

Inhaled tobramycin in alternating monthly cycles is a guideline-recommended chronic suppressive therapy for CF patients with chronic Pseudomonas infection.

Question 133: A patient on lithium for 10 years presents with coarse tremor, ataxia, and confusion. His lithium level is 2.4 mEq/L. What is the priority intervention?

Add propranolol for tremor
Hold next dose and recheck level in 12 hours
Hemodialysis (Correct answer)
IV sodium bicarbonate

Correct answer: Hemodialysis

Lithium levels above 2.0 mEq/L with neurological symptoms warrant hemodialysis for rapid elimination.

Question 134: CSF analysis shows neutrophilic pleocytosis, elevated protein, and markedly decreased glucose. What is the most likely diagnosis?

Subarachnoid hemorrhage
Bacterial meningitis (Correct answer)
Fungal meningitis
Viral meningitis

Correct answer: Bacterial meningitis

Bacterial meningitis is characterized by CSF with neutrophilic pleocytosis, elevated protein, and low glucose due to bacterial metabolism.

Question 135: A 45-year-old woman presents with episodic hypertension, headache, diaphoresis, and palpitations. Which initial test is most appropriate?

Urine cortisol
Thyroid-stimulating hormone
24-hour urine catecholamines and metanephrines (Correct answer)
Plasma aldosterone-to-renin ratio

Correct answer: 24-hour urine catecholamines and metanephrines

The classic triad of headache, diaphoresis, and palpitations with episodic hypertension suggests pheochromocytoma, best screened with 24-hour urine metanephrines.

Question 136: A 16-year-old is brought in by parents for refusing to speak at school for 3 months, though he speaks normally at home. His school performance is declining. What is the diagnosis?

Avoidant personality disorder
Autism spectrum disorder
Selective mutism (Correct answer)
Social anxiety disorder

Correct answer: Selective mutism

Selective mutism is defined by consistent failure to speak in specific social situations despite speaking normally elsewhere.

Question 137: In PANRE practice, what is the best approach to quality improvement in obstetrics and gynecology?

Copy what other organizations do without analysis
Use data-driven methods with measurable outcomes (Correct answer)
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 138: Which of the following fractures requires urgent surgical intervention due to risk of compartment syndrome?

Clavicle fracture
Fifth metatarsal fracture
Distal radius fracture
Tibial shaft fracture (Correct answer)

Correct answer: Tibial shaft fracture

Tibial shaft fractures have the highest risk of compartment syndrome due to the tight compartments in the leg and the energy required to fracture this bone.

Question 139: A 19-year-old sexually active woman presents for her first gynecologic visit. According to current USPSTF guidelines, at what age should cervical cancer screening (Pap smear) begin?

Age 25
Age 18
At first sexual intercourse
Age 21 (Correct answer)

Correct answer: Age 21

Current guidelines recommend beginning cervical cancer screening with cytology alone at age 21, regardless of sexual activity onset.

Question 140: What is the value of continuing education in neurology for PANRE professionals?

It is only needed for recertification
It is primarily a social activity
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 141: A 55-year-old man post-CABG develops new-onset fever, pleuritic chest pain, and pericardial rub on day 10. What is the most likely diagnosis?

Pulmonary embolism
Recurrent MI
Sternal wound infection
Post-cardiac injury syndrome (Dressler syndrome) (Correct answer)

Correct answer: Post-cardiac injury syndrome (Dressler syndrome)

Dressler syndrome is an autoimmune pericarditis occurring weeks after cardiac surgery or MI, presenting with fever, pleuritic pain, and friction rub.

Question 142: A 40-year-old woman with known Crohn's disease presents with right lower quadrant pain, fever, and a palpable mass. Which complication should be suspected?

Toxic megacolon
Intra-abdominal abscess (Correct answer)
Ischemic colitis
Colorectal cancer

Correct answer: Intra-abdominal abscess

A palpable mass with fever in Crohn's disease strongly suggests an intra-abdominal abscess, a known complication of transmural inflammation.

Question 143: A 35-year-old woman presents with progressive dyspnea, bilateral hilar lymphadenopathy on CXR, and non-caseating granulomas on bronchoscopic biopsy. Serum ACE is elevated. Which treatment is most appropriate for asymptomatic pulmonary sarcoidosis?

Methotrexate
Hydroxychloroquine
Observation without treatment (Correct answer)
Immediate systemic corticosteroids

Correct answer: Observation without treatment

Asymptomatic pulmonary sarcoidosis (stage I or II without significant impairment) often remits spontaneously and warrants watchful waiting rather than immediate treatment.

Question 144: A 72-year-old woman on warfarin presents with painless bright red blood per rectum. Colonoscopy shows bleeding diverticula in the sigmoid colon. What is the most appropriate initial management?

Emergency colectomy
Endoscopic hemostasis (clips or coagulation) (Correct answer)
Angiography with embolization
Reversal of anticoagulation only

Correct answer: Endoscopic hemostasis (clips or coagulation)

Endoscopic hemostasis with clips or coagulation is the first-line treatment for actively bleeding diverticula identified at colonoscopy.

Question 145: A 45-year-old woman presents with right upper quadrant pain after fatty meals, nausea, and a positive Murphy's sign. Ultrasound shows gallstones. What is the definitive treatment?

Extracorporeal shock wave lithotripsy
Low-fat diet and watchful waiting
Laparoscopic cholecystectomy (Correct answer)
Ursodeoxycholic acid therapy

Correct answer: Laparoscopic cholecystectomy

Symptomatic cholelithiasis is best treated with laparoscopic cholecystectomy, which is the definitive and most commonly recommended intervention.

Question 146: In a patient with chronic kidney disease and new-onset atrial fibrillation, which anticoagulant requires dose adjustment and should be used with caution as GFR declines below 30?

Warfarin
Apixaban
Dabigatran (Correct answer)
Rivaroxaban

Correct answer: Dabigatran

Dabigatran is renally cleared (80%) and is contraindicated with GFR <15-30; other DOACs have less renal dependence but still require dose adjustments.

Question 147: A 45-year-old construction worker presents with a nail embedded in the plantar surface of his foot through his boot. He is not up to date on tetanus. What is appropriate tetanus management?

No tetanus prophylaxis needed if last dose was within 10 years
Both tetanus toxoid and tetanus immune globulin (TIG) (Correct answer)
Tetanus toxoid only
Tetanus immune globulin (TIG) only

Correct answer: Both tetanus toxoid and tetanus immune globulin (TIG)

A contaminated, deep puncture wound in an unvaccinated or incompletely vaccinated patient requires both tetanus toxoid and TIG for passive and active immunization.

Question 148: A 29-year-old primigravida at 41+2 weeks is in active labor. She has an epidural and has been completely dilated for 3.5 hours with no fetal descent despite adequate pushing. Fetal station is 0. What is this called?

Arrest of descent (Correct answer)
Latent phase arrest
Active phase arrest
Protracted active phase

Correct answer: Arrest of descent

Arrest of descent is diagnosed when the fetal presenting part fails to descend after a defined period of pushing in the second stage of labor.

Question 149: A 70-year-old man with a history of NSAID use presents with epigastric pain and melena. Endoscopy reveals a duodenal ulcer with a visible vessel. What is the endoscopic treatment of choice?

Hemoclip or thermal coagulation plus epinephrine injection (Correct answer)
Band ligation
Argon plasma coagulation alone
Sclerotherapy alone

Correct answer: Hemoclip or thermal coagulation plus epinephrine injection

Combination therapy with a mechanical method (hemoclip) or thermal coagulation plus epinephrine injection is the standard of care for high-risk ulcers with visible vessels.

Question 150: A 48-year-old woman presents with hot flashes, night sweats, and irregular menses for 14 months. FSH is 58 mIU/mL. She denies a history of VTE or breast cancer. What is the most effective treatment for her vasomotor symptoms?

Clonidine
Venlafaxine
Black cohosh
Menopausal hormone therapy (Correct answer)

Correct answer: Menopausal hormone therapy

Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms in menopausal women without contraindications.

Question 151: A patient with polycystic kidney disease (PKD) develops a sudden severe 'thunderclap' headache and nuchal rigidity. What complication must be immediately considered?

Urinary tract infection
Intracranial berry aneurysm rupture (Correct answer)
Hypertensive urgency
Renal stone passage

Correct answer: Intracranial berry aneurysm rupture

PKD is associated with intracranial berry aneurysms; rupture causing subarachnoid hemorrhage presents with sudden severe headache and meningismus.

Question 152: Which dermoscopic finding is most specific for melanoma?

Atypical pigment network with regression (Correct answer)
Comma-shaped vessels
Milium-like cysts
Arborizing telangiectasias

Correct answer: Atypical pigment network with regression

An atypical pigment network with irregular meshwork combined with regression structures (white scar-like areas, blue-gray peppering) is highly specific for melanoma on dermoscopy.

Question 153: Which test best distinguishes central (secondary) diabetes insipidus from nephrogenic diabetes insipidus?

Response to desmopressin (DDAVP) administration (Correct answer)
24-hour urine volume
Plasma osmolality after water deprivation
Serum sodium level

Correct answer: Response to desmopressin (DDAVP) administration

Administration of desmopressin (ADH analog) will increase urine concentration in central DI but not in nephrogenic DI where the kidney cannot respond.

Question 154: Which approach best demonstrates mastery of emergency medicine in PANRE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 155: A patient with HIV has a CD4 count of 175 cells/µL. Which opportunistic infection prophylaxis must be initiated?

Azithromycin for MAC
Acyclovir for HSV
Fluconazole for Cryptococcus
TMP-SMX for Pneumocystis jirovecii pneumonia (Correct answer)

Correct answer: TMP-SMX for Pneumocystis jirovecii pneumonia

PCP prophylaxis with TMP-SMX is indicated when CD4 count falls below 200 cells/µL to prevent Pneumocystis jirovecii pneumonia.

Question 156: A 26-year-old male presents with painless cervical lymphadenopathy, night sweats, fever, and weight loss. Biopsy of a lymph node reveals Reed-Sternberg cells. CT shows mediastinal involvement. What is the most likely diagnosis?

Hodgkin lymphoma (Correct answer)
Infectious mononucleosis
Non-Hodgkin lymphoma
Sarcoidosis

Correct answer: Hodgkin lymphoma

Hodgkin lymphoma is characterized by Reed-Sternberg cells on biopsy, bimodal age distribution, B symptoms (fever, night sweats, weight loss), and frequent mediastinal involvement.

Question 157: Which medication has been shown to reduce mortality in patients with stable chronic heart failure with reduced ejection fraction (HFrEF)?

Amlodipine
Digoxin
Furosemide
Carvedilol (Correct answer)

Correct answer: Carvedilol

Carvedilol, a non-selective beta-blocker, is one of the three beta-blockers proven to reduce mortality in HFrEF (along with metoprolol succinate and bisoprolol).

Question 158: What role does collaboration play in endocrinology for PANRE professionals?

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

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

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

Question 159: A 45-year-old with HIV (CD4 count 80) presents with verrucous, cauliflower-like plaques on the trunk unresponsive to topical antifungals. Biopsy shows intracytoplasmic inclusion bodies (Henderson-Paterson bodies). What is the diagnosis?

Disseminated histoplasmosis
Condyloma acuminata
Cryptococcosis
Molluscum contagiosum (Correct answer)

Correct answer: Molluscum contagiosum

Molluscum contagiosum in severely immunocompromised patients (CD4 <200) can present atypically as large, widespread plaques; Henderson-Paterson bodies are pathognomonic on biopsy.

Question 160: A 58-year-old male with a 40-pack-year smoking history presents with progressive dyspnea and FEV1/FVC ratio of 0.62 post-bronchodilator. Which GOLD stage classification applies if his FEV1 is 45% predicted?

GOLD 3 (Correct answer)
GOLD 2
GOLD 4
GOLD 1

Correct answer: GOLD 3

GOLD Stage 3 (severe) corresponds to FEV1 30-49% predicted with FEV1/FVC <0.70 post-bronchodilator.

Question 161: Which professional attribute is most valued in gastroenterology within the PANRE field?

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

Correct answer: Accountability and commitment to standards

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

Question 162: A patient on clozapine develops a WBC of 2,800/mm³. What is the correct action?

Reduce dose by 50%
Continue clozapine with increased monitoring
Add G-CSF and continue clozapine
Discontinue clozapine immediately (Correct answer)

Correct answer: Discontinue clozapine immediately

A WBC below 3,000/mm³ requires immediate discontinuation of clozapine due to agranulocytosis risk.

Question 163: A patient presents with flank pain, hematuria, and nausea. CT shows a 4 mm ureteral stone. What is the most appropriate initial management?

Nephrostomy tube placement
Extracorporeal shock wave lithotripsy
Immediate urologic surgical intervention
Hydration, analgesia, and alpha-blocker (tamsulosin) (Correct answer)

Correct answer: Hydration, analgesia, and alpha-blocker (tamsulosin)

Stones ≤5 mm have a high rate of spontaneous passage; conservative management with hydration, analgesia, and medical expulsive therapy is first-line.

Question 164: A 50-year-old woman presents with polyuria and polydipsia. Serum osmolality is 310 mOsm/kg and urine osmolality is 150 mOsm/kg. After water deprivation, urine osmolality remains low. Desmopressin administration increases urine osmolality to 350 mOsm/kg. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

Response to desmopressin with an increase in urine osmolality confirms central (neurogenic) diabetes insipidus, where ADH production is deficient.

Question 165: A 30-year-old woman presents with sudden-onset severe headache described as 'the worst headache of my life.' CT head is negative. What is the next best step?

Perform lumbar puncture to evaluate for xanthochromia (Correct answer)
Order an MRI brain
Start empiric antibiotics for meningitis
Reassure and discharge with analgesics

Correct answer: Perform lumbar puncture to evaluate for xanthochromia

A thunderclap headache with negative CT requires lumbar puncture to detect xanthochromia, which indicates subarachnoid hemorrhage.

Question 166: A patient presents 24 hours after an ankle sprain with significant swelling and inability to bear weight. The Ottawa Ankle Rules indicate X-ray is needed when there is tenderness at which location?

Anterior ankle joint line
Peroneal tendons
Anterior talofibular ligament
Posterior edge of the distal 6 cm of the fibula or tibia (Correct answer)

Correct answer: Posterior edge of the distal 6 cm of the fibula or tibia

Ottawa Ankle Rules require X-ray if there is tenderness over the posterior edge of the distal 6 cm of the fibula or tibia, or at the navicular or base of the fifth metatarsal.

Question 167: A 22-year-old college student has recurrent binge eating followed by self-induced vomiting twice weekly for 4 months. She is normal weight. What is the diagnosis?

Purging disorder
Binge eating disorder
Bulimia nervosa (Correct answer)
Anorexia nervosa, binge-purge subtype

Correct answer: Bulimia nervosa

Bulimia nervosa is defined by recurrent binge-purge cycles at least once weekly for 3 months in a person of normal or above-normal weight.

Question 168: A 28-year-old man presents with sudden severe 'thunderclap' headache reaching maximum intensity within seconds. CT head is negative. What is the next step?

Discharge with neurology follow-up
Obtain MRI with gadolinium
Perform lumbar puncture (Correct answer)
Prescribe sumatriptan and discharge

Correct answer: Perform lumbar puncture

A thunderclap headache with negative CT requires lumbar puncture to rule out subarachnoid hemorrhage, as CT misses 2-5% of SAH.

Question 169: What role does collaboration play in psychiatry for PANRE professionals?

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

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 170: A 60-year-old woman with rheumatoid arthritis on methotrexate develops painless, white, lacy streaks on the buccal mucosa and violaceous, polygonal, flat-topped papules on the wrists. What is the most likely diagnosis?

Secondary syphilis
Pityriasis rosea
Lichen planus (Correct answer)
Psoriasis

Correct answer: Lichen planus

Lichen planus classically presents with the 6 P's: pruritic, polygonal, planar, purple papules and plaques, often with Wickham's striae on mucosal surfaces.

Question 171: A 35-year-old presents after a bee sting with urticaria, hypotension, and stridor. After IM epinephrine, blood pressure improves but stridor persists. What is the next step?

Discharge with an EpiPen prescription
Repeat epinephrine and prepare for definitive airway management (Correct answer)
Administer IV diphenhydramine only
Apply oxygen by mask and observe for 15 minutes

Correct answer: Repeat epinephrine and prepare for definitive airway management

Persistent stridor after epinephrine in anaphylaxis signals imminent airway obstruction; repeat epinephrine and prepare for intubation or surgical airway.

Question 172: A patient with chronic liver disease develops sudden onset abdominal pain, fever, and ascitic fluid PMN count >250 cells/mm³. What is the empiric antibiotic of choice?

Cefotaxime or ceftriaxone (Correct answer)
Ampicillin-sulbactam
Metronidazole
Vancomycin

Correct answer: Cefotaxime or ceftriaxone

Third-generation cephalosporins (cefotaxime or ceftriaxone) are the empiric treatment of choice for spontaneous bacterial peritonitis.

Question 173: Which test is the gold standard for confirming active pulmonary tuberculosis in a patient with a positive PPD and suspicious chest X-ray?

Sputum AFB smear and culture (Correct answer)
Chest X-ray alone
CT scan of the chest
QuantiFERON-TB Gold blood test

Correct answer: Sputum AFB smear and culture

Sputum acid-fast bacilli smear and culture remain the gold standard for confirming active pulmonary TB infection.

Question 174: A 40-year-old woman presents with severe unilateral periorbital pain, lacrimation, rhinorrhea, and ptosis occurring in clusters over weeks. Best acute treatment?

High-flow 100% oxygen (Correct answer)
IV ketorolac
Oral sumatriptan
Prednisone taper

Correct answer: High-flow 100% oxygen

High-flow 100% oxygen via non-rebreather mask is the most effective abortive treatment for acute cluster headache attacks, providing relief within 15–20 minutes.

Question 175: What is the most important professional competency for PANRE certification in dermatology?

Speed of task completion
Deep knowledge combined with practical application skills (Correct answer)
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 176: What is the most common cause of hypercalcemia in the outpatient setting?

Primary hyperparathyroidism (Correct answer)
Malignancy
Sarcoidosis
Vitamin D toxicity

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism is the most common cause of hypercalcemia in outpatients, often discovered incidentally on routine labs.

Question 177: What is the value of continuing education in endocrinology for PANRE professionals?

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

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

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

Question 178: A 44-year-old HIV-positive patient with CD4 count of 90 cells/µL presents with progressive dyspnea, non-productive cough, and fever. CXR shows bilateral interstitial infiltrates. LDH is elevated at 520 U/L. What is the most likely diagnosis?

Cytomegalovirus pneumonitis
Cryptococcal pneumonia
Mycobacterium avium complex (MAC) pulmonary infection
Pneumocystis jirovecii pneumonia (PCP) (Correct answer)

Correct answer: Pneumocystis jirovecii pneumonia (PCP)

PCP classically presents in HIV patients with CD4 <200 with bilateral interstitial infiltrates, elevated LDH, and non-productive cough, and is the leading AIDS-defining pulmonary opportunistic infection.

Question 179: In PANRE practice, what is the best approach to quality improvement in orthopedics?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 180: Which urinalysis finding best distinguishes prerenal AKI from intrinsic renal (ATN) AKI?

Presence of granular casts
Urine osmolality <350 mOsm/kg
Fractional excretion of sodium (FENa) <1% (Correct answer)
Urine sodium >40 mEq/L

Correct answer: Fractional excretion of sodium (FENa) <1%

A FENa <1% indicates intact tubular sodium reabsorption, consistent with prerenal azotemia where tubular function is preserved.

Question 181: Which nerve is most commonly injured in a posterior shoulder dislocation?

Musculocutaneous nerve
Ulnar nerve
Axillary nerve (Correct answer)
Radial nerve

Correct answer: Axillary nerve

The axillary nerve wraps around the surgical neck of the humerus and is most vulnerable in anterior or posterior shoulder dislocations.

Question 182: An ECG that has fallen P waves is being examined by you. Which diagnosis is more probable?

Wolf-Parkinson-White syndrome
None of the above
Sick sinus syndrome (Correct answer)
Wandering atrial pacemaker

Correct answer: Sick sinus syndrome

If an ECG shows 'fallen P waves,' meaning P waves that are not consistently followed by QRS complexes or are irregularly associated with ventricular activity, Sick Sinus Syndrome (SSS) is a probable diagnosis. SSS refers to a group of rhythm disorders caused by a dysfunctional sinus node, the heart's natural pacemaker. This can manifest as sinus bradycardia, sinus arrest, or sinoatrial exit block, leading to abnormal P wave conduction or absence.

Question 183: Which glycated hemoglobin (HbA1c) target is generally recommended for a healthy 45-year-old with type 2 diabetes and no comorbidities?

< 6.0%
< 7.0% (Correct answer)
< 8.0%
< 9.0%

Correct answer: < 7.0%

An HbA1c target of <7.0% is recommended for most non-pregnant adults with type 2 diabetes to reduce microvascular complications without excessive hypoglycemia risk.

Question 184: Which physical exam finding is most characteristic of aortic regurgitation?

Water-hammer pulse (bounding pulse) (Correct answer)
Pulsus paradoxus
Fixed split S2
Opening snap followed by diastolic rumble

Correct answer: Water-hammer pulse (bounding pulse)

The water-hammer (Corrigan's) pulse reflects the wide pulse pressure caused by rapid diastolic runoff in aortic regurgitation.

Question 185: A 60-year-old male presents with progressive low back pain radiating to both legs with walking, relieved by sitting or bending forward. What is the most likely diagnosis?

Spinal stenosis (Correct answer)
Sacroiliac joint dysfunction
Piriformis syndrome
Lumbar disc herniation

Correct answer: Spinal stenosis

Lumbar spinal stenosis causes neurogenic claudication — bilateral leg pain worsened by extension (standing/walking) and relieved by flexion (sitting/leaning forward).

Question 186: Which finding best differentiates delirium from dementia?

Functional decline
Acute fluctuating course (Correct answer)
Memory impairment
Disorientation

Correct answer: Acute fluctuating course

Delirium is distinguished by its acute onset and fluctuating level of consciousness, unlike the gradual decline in dementia.

Question 187: What role does collaboration play in gastroenterology for PANRE professionals?

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

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

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

Question 188: A 68-year-old with lung adenocarcinoma is found to have an EGFR exon 19 deletion mutation. Which first-line therapy is most appropriate?

Osimertinib (third-generation EGFR TKI) (Correct answer)
Erlotinib (first-generation EGFR TKI)
Carboplatin + paclitaxel chemotherapy
Pembrolizumab immunotherapy

Correct answer: Osimertinib (third-generation EGFR TKI)

Osimertinib is the preferred first-line EGFR TKI for NSCLC with EGFR-sensitizing mutations based on superior outcomes in the FLAURA trial.

Question 189: A 70-year-old man is found to have WBC 62,000 on routine labs with small, mature-appearing lymphocytes and smudge cells on peripheral smear. He is asymptomatic with no lymphadenopathy. CD19, CD5, and CD23 are positive on flow cytometry. What is the management for this patient?

Immediate chemotherapy with fludarabine
Allogeneic bone marrow transplant
Radiation therapy to the spleen
Watchful waiting ('watch and wait') (Correct answer)

Correct answer: Watchful waiting ('watch and wait')

Early-stage (Rai 0) chronic lymphocytic leukemia (CLL) in asymptomatic patients is managed with observation, as early treatment does not improve survival.

Question 190: A patient presents with ataxia, nystagmus, and ophthalmoplegia. What is the immediate priority treatment?

Thiamine (vitamin B1) administration (Correct answer)
Lorazepam IV
Naloxone IV
Glucose infusion

Correct answer: Thiamine (vitamin B1) administration

This classic triad represents Wernicke encephalopathy; thiamine must be given before glucose to prevent worsening or precipitation of the syndrome.

Question 191: A 30-year-old G2P1 at 38 weeks presents in active labor. On exam, the presenting part is at +2 station. After 2 hours of adequate pushing, the fetal head is visible and crowning. Suddenly you note the turtle sign. What does this indicate?

Nuchal cord
Shoulder dystocia (Correct answer)
Fetal macrosomia
Cord prolapse

Correct answer: Shoulder dystocia

The turtle sign (retraction of the fetal head against the perineum after delivery) is pathognomonic for shoulder dystocia.

Question 192: Which approach best demonstrates mastery of neurology in PANRE 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 193: Which topical agent is first-line for treating impetigo in a child with a small, localized area of honey-crusted lesions?

Topical hydrocortisone
Topical clindamycin
Topical tretinoin
Topical mupirocin (Correct answer)

Correct answer: Topical mupirocin

Topical mupirocin is first-line for localized impetigo caused by Staphylococcus aureus or Streptococcus pyogenes.

Question 194: A 45-year-old man presents with diarrhea, flushing, and wheezing. Urine 5-HIAA levels are elevated. CT abdomen shows a liver mass. What is the most likely primary tumor location?

Pancreas
Stomach
Small intestine (Correct answer)
Colon

Correct answer: Small intestine

Carcinoid syndrome (diarrhea, flushing, wheezing) with elevated 5-HIAA and liver metastases most commonly originates from a small intestinal carcinoid tumor.

Question 195: A patient develops acute ST depression in V4-V6 during a stress test at 6 METs with chest pain and 20 mmHg drop in systolic BP. What is the appropriate next step?

Continue the test to achieve target heart rate
Administer nitroglycerin and resume testing
Stop the test immediately and arrange urgent evaluation (Correct answer)
Stop the test and schedule elective angiography

Correct answer: Stop the test immediately and arrange urgent evaluation

ST depression with hypotension and chest pain at low workload indicates high-risk findings, requiring immediate test termination and urgent cardiac evaluation.

Question 196: Which professional attribute is most valued in pulmonology within the PANRE field?

Accountability and commitment to standards (Correct answer)
Avoiding challenging situations
Prioritizing personal convenience
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 197: A patient with Hashimoto thyroiditis is euthyroid. What is the most appropriate management?

Administer high-dose steroids
Perform thyroidectomy
Monitor TSH periodically (Correct answer)
Start levothyroxine prophylactically

Correct answer: Monitor TSH periodically

Euthyroid Hashimoto thyroiditis requires no treatment; TSH should be monitored annually (or sooner if symptomatic) since hypothyroidism may develop over time.

Question 198: Which antibiotic is the drug of choice for Rocky Mountain Spotted Fever in all age groups, including children?

Ciprofloxacin
Amoxicillin
Doxycycline (Correct answer)
Azithromycin

Correct answer: Doxycycline

Doxycycline is the first-line treatment for RMSF in all patients, including children, due to its superior efficacy against Rickettsia species.

Question 199: What is the most important professional competency for PANRE certification in psychiatry?

Memorization of all reference materials
Speed of task completion
Ability to work alone exclusively
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 200: In PANRE practice, what is the best approach to quality improvement in psychiatry?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 201: A 60-year-old woman with no prior cardiac history develops new onset palpitations. EKG shows absent P waves, irregularly irregular rhythm, and rate of 130 bpm. She is hemodynamically stable. What is the first-line rate control agent?

Amiodarone IV
Metoprolol IV (Correct answer)
Adenosine IV
Digoxin IV

Correct answer: Metoprolol IV

IV metoprolol (a beta-blocker) is first-line for rate control in hemodynamically stable atrial fibrillation.

Question 202: A 45-year-old male presents with chronic cough, wheezing, and nasal polyps. He develops severe bronchospasm after taking ibuprofen for knee pain. What syndrome does he have?

Churg-Strauss syndrome
Reactive airways dysfunction syndrome
Aspirin-exacerbated respiratory disease (AERD) (Correct answer)
Exercise-induced bronchoconstriction

Correct answer: Aspirin-exacerbated respiratory disease (AERD)

Aspirin-exacerbated respiratory disease (Samter's triad) consists of asthma, nasal polyps, and NSAID-induced bronchospasm.

Question 203: Which organism is the most common cause of septic arthritis in adults under 30 years old?

Streptococcus pyogenes
Neisseria gonorrhoeae (Correct answer)
Staphylococcus aureus
Escherichia coli

Correct answer: Neisseria gonorrhoeae

Neisseria gonorrhoeae is the most common cause of septic arthritis in sexually active adults under 30 due to hematogenous dissemination.

Question 204: Which imaging finding is pathognomonic for diffuse axonal injury after traumatic brain injury?

Cerebral edema on CT
Hyperdense subdural collection
Midline shift on CT
Petechial hemorrhages at gray-white junction on MRI (Correct answer)

Correct answer: Petechial hemorrhages at gray-white junction on MRI

Diffuse axonal injury is best seen on MRI as petechial hemorrhages or signal changes at the gray-white matter junction, corpus callosum, and brainstem from rotational shear forces.

Question 205: A 62-year-old man presents with grouped, crusted vesicles in the L3 dermatomal distribution 2 weeks after resolution of his acute zoster rash. He reports burning pain 8/10 in the same area. What is this complication called?

Zoster sine herpete
Post-herpetic neuralgia (Correct answer)
Ramsay Hunt syndrome
Disseminated zoster

Correct answer: Post-herpetic neuralgia

Post-herpetic neuralgia is defined as pain persisting more than 90 days after the onset of herpes zoster and is the most common complication, especially in elderly patients.

Question 206: A 35-year-old presents with episodic severe headache, diaphoresis, palpitations, and hypertension. Which test confirms the diagnosis?

Serum cortisol
24-hour urine catecholamines and metanephrines (Correct answer)
Thyroid function tests
MRI pituitary

Correct answer: 24-hour urine catecholamines and metanephrines

Pheochromocytoma presents with paroxysmal hypertension, diaphoresis, and headache; diagnosis is confirmed by elevated 24-hour urine metanephrines and catecholamines.

Question 207: Which approach best demonstrates mastery of endocrinology in PANRE practice?

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

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 208: A 28-year-old female non-smoker presents with recurrent pneumothoraces and dyspnea. HRCT shows bilateral diffuse thin-walled cysts. She is taking oral contraceptives. What is the most likely diagnosis?

Birt-Hogg-Dubé syndrome
Lymphangioleiomyomatosis (LAM) (Correct answer)
Langerhans cell histiocytosis
Pulmonary Langerhans cell histiocytosis

Correct answer: Lymphangioleiomyomatosis (LAM)

Lymphangioleiomyomatosis presents in women of childbearing age with diffuse bilateral thin-walled cysts, recurrent pneumothoraces, and chylothorax.

Question 209: Which of the following best describes the mechanism of action of lactulose in hepatic encephalopathy?

Enhances hepatic ammonia metabolism
Increases renal ammonia excretion
Kills urease-producing bacteria in the colon
Acidifies colonic content, converting NH3 to NH4+ and reducing absorption (Correct answer)

Correct answer: Acidifies colonic content, converting NH3 to NH4+ and reducing absorption

Lactulose is metabolized to lactic and acetic acid, acidifying the colon and trapping ammonia as ammonium ion (NH4+), which is then excreted in stool.

Question 210: Which cognitive distortion is most characteristic of generalized anxiety disorder?

Ideas of reference
Catastrophizing (Correct answer)
Thought insertion
Splitting

Correct answer: Catastrophizing

Catastrophizing—assuming worst-case outcomes—is a hallmark cognitive distortion in generalized anxiety disorder.

Question 211: A 68-year-old with new-onset psychosis, no psychiatric history, and recent urinary incontinence and gait disturbance is most likely experiencing which condition?

Normal pressure hydrocephalus with psychosis
Late-onset schizophrenia
Lewy body dementia (Correct answer)
Vascular dementia

Correct answer: Lewy body dementia

Lewy body dementia classically presents with parkinsonism, visual hallucinations, and fluctuating cognition in an older adult.

Question 212: Which GLP-1 receptor agonist is approved for weight management in non-diabetic obese patients?

Semaglutide (2.4 mg subcutaneous weekly) (Correct answer)
Dulaglutide
Exenatide
Liraglutide 1.2 mg

Correct answer: Semaglutide (2.4 mg subcutaneous weekly)

Semaglutide 2.4 mg weekly (Wegovy) is FDA-approved for chronic weight management in adults with obesity or overweight with at least one weight-related comorbidity.

Question 213: A patient on chronic NSAID therapy develops pyuria without bacteriuria and eosinophiluria. What is the most likely diagnosis?

Membranous glomerulonephritis
Acute interstitial nephritis (AIN) (Correct answer)
Bladder cancer
Urinary tract infection

Correct answer: Acute interstitial nephritis (AIN)

NSAID-induced acute interstitial nephritis classically presents with sterile pyuria and eosinophiluria due to a hypersensitivity reaction in the renal interstitium.

Question 214: A 70-year-old man has a serum calcium of 11.4 mg/dL, PTH of 85 pg/mL (elevated), and eGFR of 72. He is asymptomatic. What is the best management?

Observation with monitoring of calcium, BMD, and renal function (Correct answer)
IV bisphosphonate infusion
Cinacalcet immediately
Emergent parathyroidectomy

Correct answer: Observation with monitoring of calcium, BMD, and renal function

Asymptomatic primary hyperparathyroidism with mild hypercalcemia and preserved renal function can be managed with watchful observation using periodic monitoring of calcium, BMD, and renal function per surgical guidelines.

Question 215: A 30-year-old male presents with a 'dinner fork' deformity of the wrist after a fall on an outstretched hand. X-ray confirms a Colles fracture. What is the hallmark of this fracture?

Intra-articular fracture of the radiocarpal joint
Ulnar styloid avulsion only
Dorsal angulation of the distal radius with radial shortening (Correct answer)
Volar angulation of the distal radius

Correct answer: Dorsal angulation of the distal radius with radial shortening

Colles fracture is a distal radius fracture with dorsal angulation and radial shortening, classically causing the 'dinner fork' deformity.

Question 216: A 3-year-old with atopic dermatitis and egg allergy develops widespread vesicular lesions over pre-existing eczematous skin. Tzanck smear shows multinucleated giant cells. What is the most serious complication to monitor for?

Kaposi varicelliform eruption causing herpetic encephalitis (Correct answer)
Corneal dendritic ulcers
Scarring alopecia at scalp sites
Secondary bacterial superinfection with MRSA

Correct answer: Kaposi varicelliform eruption causing herpetic encephalitis

Eczema herpeticum (Kaposi varicelliform eruption) can disseminate to the CNS causing herpetic encephalitis, which is a life-threatening complication requiring prompt IV acyclovir.

Question 217: A 55-year-old woman presents with fatigue, arthralgias, and elevated transaminases (AST/ALT 3× ULN). ANA titer is 1:320 and anti-smooth muscle antibody is positive. Liver biopsy shows interface hepatitis. What is the diagnosis?

Drug-induced liver injury
Autoimmune hepatitis (Correct answer)
Primary biliary cholangitis
Wilson's disease

Correct answer: Autoimmune hepatitis

Autoimmune hepatitis is characterized by elevated transaminases, positive ANA and anti-smooth muscle antibodies, and interface hepatitis on biopsy.

Question 218: A patient with a right MCA stroke has difficulty speaking but understands language perfectly. Which type of aphasia is this?

Global aphasia
Wernicke aphasia
Conduction aphasia
Broca aphasia (Correct answer)

Correct answer: Broca aphasia

Broca aphasia (expressive/non-fluent aphasia) involves damage to Broca's area in the left frontal lobe, producing halting speech with preserved comprehension.

Question 219: A patient with myasthenia gravis undergoes elective surgery. Which medication should be avoided perioperatively due to risk of cholinergic crisis if combined with pyridostigmine?

Ondansetron
Propofol
Succinylcholine (Correct answer)
Fentanyl

Correct answer: Succinylcholine

Succinylcholine is a depolarizing neuromuscular blocker metabolized by acetylcholinesterase; pyridostigmine inhibits this enzyme, leading to prolonged paralysis or crisis.

Question 220: A 62-year-old man with type 2 diabetes and established cardiovascular disease needs intensified glycemic therapy. Which drug class has demonstrated cardiovascular mortality benefit?

SGLT-2 inhibitors (Correct answer)
Sulfonylureas
Thiazolidinediones
Alpha-glucosidase inhibitors

Correct answer: SGLT-2 inhibitors

SGLT-2 inhibitors (e.g., empagliflozin, canagliflozin) have demonstrated significant reductions in cardiovascular mortality and heart failure hospitalization in patients with established CVD.

Question 221: A 55-year-old woman with type 2 diabetes has an eGFR of 38 mL/min/1.73m². Which medication should be discontinued?

Glipizide
Insulin glargine
Metformin (Correct answer)
Sitagliptin

Correct answer: Metformin

Metformin is contraindicated when eGFR falls below 30 and should be used with caution (many guidelines recommend discontinuing) at eGFR <45 due to risk of lactic acidosis.

Question 222: A 38-year-old G3P2 at 36 weeks presents with severe headache, visual disturbances, and BP 158/106 mmHg. Her 24-hour urine protein is 450 mg. What is the definitive treatment?

Oral nifedipine and outpatient management
Magnesium sulfate and deliver (Correct answer)
IV labetalol and close monitoring
Bed rest until term

Correct answer: Magnesium sulfate and deliver

Severe preeclampsia at 36 weeks requires delivery (the only cure) along with magnesium sulfate for seizure prophylaxis and antihypertensives.

Question 223: A 25-year-old male has a 2 cm pink, dome-shaped nodule on his back that was removed and found to contain a cyst wall lined by stratified squamous epithelium with a granular layer, filled with cheesy keratin. What is the correct diagnosis?

Pilar cyst
Milia
Epidermoid cyst (Correct answer)
Steatocystoma

Correct answer: Epidermoid cyst

Epidermoid cysts (formerly 'sebaceous cysts') are lined by stratified squamous epithelium with a granular layer and contain laminated keratin; pilar cysts lack the granular layer.

Question 224: A 35-year-old man presents with a new 7 mm pigmented lesion with asymmetry, irregular borders, two colors (brown and black), and recent size change. The ABCDE criteria suggest malignancy. What is the next best step?

Topical imiquimod and recheck in 6 weeks
Excisional biopsy with 1–3 mm margins (Correct answer)
Shave biopsy with 1 mm margins
Punch biopsy of the darkest area only

Correct answer: Excisional biopsy with 1–3 mm margins

Excisional biopsy with narrow margins (1–3 mm) is preferred for suspected melanoma to provide accurate Breslow thickness measurement for staging and prognosis.

Question 225: What is the most important professional competency for PANRE certification in obstetrics and gynecology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 226: A 62-year-old woman with osteoporosis on alendronate for 5 years develops sudden mid-shaft femur pain while walking. X-ray shows a transverse fracture with cortical thickening. What is the cause?

Osteosarcoma
Stress fracture from overuse
Pathologic fracture from metastatic disease
Atypical femur fracture from bisphosphonate use (Correct answer)

Correct answer: Atypical femur fracture from bisphosphonate use

Long-term bisphosphonate use is associated with atypical subtrochanteric and femoral shaft fractures with characteristic transverse pattern and cortical beaking.

Question 227: A 70-year-old woman develops hypotension, bradycardia, and cool extremities after an inferior MI. Which territory is most likely involved?

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

Correct answer: Right coronary artery

The right coronary artery supplies the inferior wall and the AV node, making RCA occlusion the likely cause of inferior MI with bradycardia.

Question 228: A 5-year-old boy presents with a limp and hip pain. X-ray shows flattening and increased density of the femoral head. What is the diagnosis?

Developmental dysplasia of the hip
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease (Correct answer)
Septic arthritis

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children aged 4–10, appearing as a flattened, sclerotic femoral head on X-ray.

Question 229: A 3-year-old child is brought in with a barking cough, inspiratory stridor, and low-grade fever. Which pathogen is most likely responsible?

Parainfluenza virus (Correct answer)
Haemophilus influenzae type b
Bordetella pertussis
Respiratory syncytial virus

Correct answer: Parainfluenza virus

Croup (laryngotracheobronchitis) is most commonly caused by parainfluenza virus type 1 and presents with the characteristic barking cough and stridor.

Question 230: Which test is used to diagnose carpal tunnel syndrome at the bedside?

Phalen test and Tinel sign (Correct answer)
Allen test
Watson test
Finkelstein test

Correct answer: Phalen test and Tinel sign

Phalen test (wrist flexion for 60 seconds reproducing symptoms) and Tinel sign (percussion over carpal tunnel) are classic bedside tests for carpal tunnel syndrome.

Question 231: Which of the following does NOT indicate that you have Cushing syndrome?

Thin skin with striae
"Moon face"
Central obesity
Decreased hair growth (Correct answer)

Correct answer: Decreased hair growth

Decreased hair growth is NOT a characteristic symptom of Cushing syndrome. Cushing syndrome, caused by prolonged exposure to high cortisol levels, typically presents with symptoms such as central obesity, 'moon face,' thin skin with striae, and often hirsutism (increased hair growth), especially in women. Increased hair growth, not decreased, is a common dermatological manifestation.

Question 232: A thyroid nodule biopsy returns as Bethesda Category IV (follicular neoplasm). What is the next step?

Immediate total thyroidectomy
Diagnostic thyroid lobectomy (Correct answer)
Repeat FNA in 6 months
Radioiodine ablation

Correct answer: Diagnostic thyroid lobectomy

Bethesda IV (follicular neoplasm) carries a 15-30% malignancy risk; diagnostic lobectomy is recommended as FNA cannot distinguish follicular adenoma from carcinoma (capsular/vascular invasion requires histology).

Question 233: Which of the following is the most sensitive and specific test for diagnosing H. pylori infection in a patient who cannot undergo endoscopy?

Stool antigen test
Urea breath test (Correct answer)
Serology (IgG antibody)
String test

Correct answer: Urea breath test

The urea breath test has the highest sensitivity and specificity among non-invasive tests for active H. pylori infection.

Question 234: A 17-year-old male complains of hip pain and a limp. X-ray shows the femoral head appearing to 'slip' posterior and inferior off the femoral neck. What is the diagnosis?

Transient synovitis
Developmental dysplasia of the hip
Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis (Correct answer)

Correct answer: Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) typically presents in obese adolescent males with hip or knee pain and a limp, requiring urgent surgical pinning.

Question 235: A 66-year-old man is found to have a 1.2 cm sessile polyp removed during colonoscopy. Pathology shows a tubular adenoma with low-grade dysplasia. When should the next colonoscopy be performed?

5 years
3 years (Correct answer)
1 year
10 years

Correct answer: 3 years

Current guidelines recommend repeat colonoscopy in 3 years for patients with 1-2 tubular adenomas <10 mm with low-grade dysplasia.

Question 236: A 70-year-old man presents with urinary incontinence, gait apraxia, and cognitive decline. MRI shows enlarged ventricles disproportionate to sulcal atrophy. Treatment?

Ventriculoperitoneal shunt (Correct answer)
Levodopa/carbidopa
Acetylcholinesterase inhibitor
High-dose steroids

Correct answer: Ventriculoperitoneal shunt

The triad of gait apraxia, cognitive decline, and urinary incontinence with disproportionate ventriculomegaly is normal pressure hydrocephalus, treated with VP shunt placement.

Question 237: Which type of lung cancer is most commonly associated with paraneoplastic hypercalcemia?

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

Correct answer: Squamous cell carcinoma

Squamous cell carcinoma of the lung most commonly causes hypercalcemia via PTHrP secretion as a paraneoplastic syndrome.

Question 238: A 32-year-old G1P0 at 34 weeks is diagnosed with preterm premature rupture of membranes (PPROM). She is GBS-negative and has no signs of infection. What is the standard of care?

Expectant management with latency antibiotics and antenatal corticosteroids (Correct answer)
Amnioinfusion to restore fluid
Immediate delivery by cesarean section
Cerclage placement

Correct answer: Expectant management with latency antibiotics and antenatal corticosteroids

PPROM between 34 and 36+6 weeks is managed expectantly with latency antibiotics and corticosteroids until delivery is indicated or spontaneous labor occurs.

Question 239: A 44-year-old man presents with jaundice, pruritus, and an elevated alkaline phosphatase. MRCP shows multifocal strictures of both intrahepatic and extrahepatic bile ducts with a 'beaded' appearance. What is the most likely diagnosis?

Autoimmune hepatitis
Cholangiocarcinoma
Primary biliary cholangitis
Primary sclerosing cholangitis (Correct answer)

Correct answer: Primary sclerosing cholangitis

The beaded appearance of multifocal bile duct strictures on MRCP is pathognomonic of primary sclerosing cholangitis.

Question 240: What is the causative organism of pertussis (whooping cough)?

Streptococcus pyogenes
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Bordetella pertussis (Correct answer)

Correct answer: Bordetella pertussis

Bordetella pertussis is the gram-negative coccobacillus responsible for pertussis, causing paroxysmal coughing fits with an inspiratory whoop.

Question 241: Which medication augmentation strategy is FDA-approved for treatment-resistant major depressive disorder in adults?

Gabapentin
Buspirone
Clonazepam
Aripiprazole (Correct answer)

Correct answer: Aripiprazole

Aripiprazole is FDA-approved as an adjunct to antidepressants for treatment-resistant MDD.

Physician Assistant National Recertifying Examination (PANRE)

The PANRE is the recertification examination administered by the NCCPA to physician assistants, assessing clinical knowledge across all major organ systems to maintain PA-C certification. It covers 378 diseases and disorders organized by body system with emphasis on history and physical, diagnosis, and clinical intervention.

240

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240 min

Time Limit

70%

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