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

Question 1: A 60-year-old male smoker presents with hemoptysis, weight loss, and a central lung mass on CT. Biopsy shows small blue cells. Which lung cancer type is this?

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

Correct answer: Small cell lung carcinoma

Small cell lung carcinoma presents as a central mass with small blue cells on biopsy and is strongly associated with smoking; it often presents with paraneoplastic syndromes.

Question 2: A patient admitted for elective surgery stops drinking alcohol. When does delirium tremens typically begin?

1-2 weeks after the last drink
48-96 hours after the last drink (Correct answer)
12-24 hours after the last drink
6-12 hours after the last drink

Correct answer: 48-96 hours after the last drink

Delirium tremens typically begins 48 to 96 hours after the last drink, after withdrawal seizures usually peak.

Question 3: A 16-year-old has fever, tonsillar exudates, tender anterior cervical nodes, and no cough; rapid strep test is positive. With no allergies, what is the treatment of choice?

Azithromycin
Doxycycline
Penicillin V or amoxicillin (Correct answer)
Ciprofloxacin

Correct answer: Penicillin V or amoxicillin

Penicillin or amoxicillin for 10 days is first-line for group A streptococcal pharyngitis.

Question 4: Which of the following is an example of a primary source in medical research?

An original clinical trial published in a peer-reviewed journal (Correct answer)
A systematic review of hypertension trials
A textbook chapter summarizing diabetes management
A news article reporting on a new vaccine

Correct answer: An original clinical trial published in a peer-reviewed journal

A primary source presents original, firsthand research data, such as an original clinical trial.

Question 5: Before starting clozapine for treatment-resistant schizophrenia, which laboratory monitoring is mandatory?

Thyroid-stimulating hormone
Serum prolactin
Absolute neutrophil count (Correct answer)
Serum lithium level

Correct answer: Absolute neutrophil count

Clozapine can cause severe neutropenia/agranulocytosis, so baseline and serial ANC monitoring is required.

Question 6: A 45-year-old male presents with low back pain and morning stiffness lasting more than 1 hour that improves with exercise. HLA-B27 is positive. What is the most likely diagnosis?

Osteoarthritis
Ankylosing spondylitis (Correct answer)
Lumbar disc herniation
Reactive arthritis

Correct answer: Ankylosing spondylitis

Ankylosing spondylitis is a seronegative spondyloarthropathy strongly associated with HLA-B27, presenting with inflammatory back pain, prolonged morning stiffness relieved by activity.

Question 7: Which of the aforementioned claims regarding Hashimoto's thyroiditis is accurate?

The condition is associated with prior radioactive exposure.
Antinuclear antibodies are pathognomonic for this disease
Patients diagnosed with this disorder have an increased incidence of thyroid cancer
Hashimoto’s thyroiditis is an autoimmune disease (Correct answer)

Correct answer: Hashimoto’s thyroiditis is an autoimmune disease

Hashimoto's thyroiditis is indeed an autoimmune disease, where the body's immune system mistakenly attacks and gradually destroys the thyroid gland. This chronic inflammation leads to hypothyroidism, making it the most common cause of an underactive thyroid in iodine-sufficient regions. The presence of specific autoantibodies, such as anti-thyroid peroxidase (TPO) and anti-thyroglobulin antibodies, supports this diagnosis.

Question 8: A 55-year-old male presents to the emergency department with an acute onset of pleuritic chest pain and dyspnea. He returned from an international flight yesterday. His heart rate is 115 bpm, and his O2 saturation is 90% on room air. A D-dimer is elevated. According to diagnostic algorithms for suspected pulmonary embolism (PE), what is the most appropriate next step for this hemodynamically stable patient?

Lower extremity venous duplex ultrasound
Ventilation/perfusion (V/Q) scan
CT pulmonary angiography (CTPA) (Correct answer)
Chest X-ray

Correct answer: CT pulmonary angiography (CTPA)

In a patient with a high clinical pretest probability for pulmonary embolism and an elevated D-dimer, CT pulmonary angiography (CTPA) is the diagnostic imaging modality of choice. It is readily available and provides definitive visualization of the pulmonary arteries. While a chest X-ray is often obtained to rule out other pathologies, it cannot confirm a PE. A V/Q scan is an alternative if CTPA is contraindicated. A lower extremity ultrasound can diagnose a DVT but cannot rule out a PE.

Question 9: Which drug is first-line for treating alcohol withdrawal in a hospitalized patient?

Propranolol
Benzodiazepines (Correct answer)
Buspirone
Haloperidol

Correct answer: Benzodiazepines

Benzodiazepines such as lorazepam and chlordiazepoxide are first-line. They reduce withdrawal symptoms and prevent seizures and delirium tremens.

Question 10: During a musculoskeletal exam, a patient has pain with passive range of motion of a joint. This finding most suggests:

Pathology within the joint itself (Correct answer)
Isolated tendon injury
Nerve entrapment
Muscle strain only

Correct answer: Pathology within the joint itself

Pain with passive range of motion implicates the joint capsule or intra-articular structures, as the examiner — not the patient's muscles — is generating the movement.

Question 11: Which one of the following conditions is NOT a long-term side effect of essential hypertension?

Asthma (Correct answer)
Renal failure
Diabetes
Neuropathy

Correct answer: Asthma

Essential hypertension, if left unmanaged over time, can lead to severe long-term complications affecting various organ systems, including renal failure, neuropathy due to vascular damage, and an increased risk of cardiovascular disease and diabetes. Asthma, however, is a chronic inflammatory disease of the airways and is not a direct long-term side effect or complication that develops as a result of essential hypertension.

Question 12: Which of the following DOES NOT characterize a typical pulmonary embolism clinical finding?

Anxiety and nervousness
Dyspnea
Chest pain
Slow breathing (Correct answer)

Correct answer: Slow breathing

Pulmonary embolism (PE) typically presents with acute onset dyspnea, chest pain, and anxiety. The body's physiological response to hypoxemia and increased respiratory drive is usually tachypnea (rapid breathing), not slow breathing (bradypnea). Slow breathing would be an atypical finding and could indicate severe respiratory compromise or other underlying issues.

Question 13: Which of the following is the most appropriate initial biochemical test to screen for pheochromocytoma?

Clonidine suppression test
CT scan of the abdomen
Serum cortisol level
Plasma free metanephrines or 24-hour urine fractionated metanephrines (Correct answer)

Correct answer: Plasma free metanephrines or 24-hour urine fractionated metanephrines

Plasma free metanephrines or 24-hour urine fractionated metanephrines are the preferred biochemical tests for screening pheochromocytoma due to high sensitivity.

Question 14: Which of the following is the most appropriate initial management for a patient presenting with anaphylaxis?

Intramuscular epinephrine (Correct answer)
Nebulized albuterol
IV diphenhydramine
IV corticosteroids

Correct answer: Intramuscular epinephrine

Intramuscular epinephrine in the lateral thigh is the first-line treatment for anaphylaxis due to its rapid onset and ability to reverse bronchospasm, vasodilation, and urticaria.

Question 15: What is the value of x if 3(2x − 4) = 2(x + 6)?

x = 5
x = 3
x = 9
x = 6 (Correct answer)

Correct answer: x = 6

Expanding: 6x − 12 = 2x + 12, so 4x = 24, giving x = 6.

Question 16: Which acne medication requires enrollment in the iPLEDGE program with two forms of contraception and monthly pregnancy tests?

Isotretinoin (Correct answer)
Topical tretinoin
Doxycycline
Spironolactone

Correct answer: Isotretinoin

Isotretinoin is highly teratogenic, so US prescribing is restricted through iPLEDGE.

Question 17: Before surgical resection of a pheochromocytoma, which medication should be started first?

Propranolol
Lisinopril
Phenoxybenzamine (Correct answer)
Hydrochlorothiazide

Correct answer: Phenoxybenzamine

Alpha blockade must precede beta blockade to prevent unopposed alpha-mediated hypertensive crisis.

Question 18: A patient presents with pain and swelling over the lateral epicondyle of the elbow, worsened by wrist extension and gripping. What is the most likely diagnosis?

Radial tunnel syndrome
Medial epicondylitis
Lateral epicondylitis (tennis elbow) (Correct answer)
Olecranon bursitis

Correct answer: Lateral epicondylitis (tennis elbow)

Lateral epicondylitis (tennis elbow) involves overuse of the forearm extensor muscles, causing pain at the lateral epicondyle worsened by wrist extension and gripping.

Question 19: Vancomycin given as a rapid infusion causes flushing and an erythematous rash of the face and upper body. What is the best management?

Add rifampin
Stop vancomycin permanently and label it an allergy
Give IM epinephrine and switch to linezolid
Slow the infusion rate and premedicate with an antihistamine (Correct answer)

Correct answer: Slow the infusion rate and premedicate with an antihistamine

Vancomycin infusion reaction (formerly red man syndrome) is non-IgE histamine release, so slowing the infusion and giving an antihistamine is enough.

Question 20: Which phase of pharmacokinetics involves the chemical transformation of a drug, typically in the liver?

Absorption
Metabolism (biotransformation) (Correct answer)
Excretion
Distribution

Correct answer: Metabolism (biotransformation)

Metabolism (biotransformation) refers to enzymatic modification of drugs, primarily by cytochrome P450 enzymes in the liver, to facilitate elimination.

Question 21: A patient on amiodarone develops hypothyroidism. What is the mechanism?

Increased TSH receptor antibodies
Decreased GnRH secretion
Inhibition of iodide uptake via Wolff-Chaikoff effect (Correct answer)
Direct thyroid gland destruction

Correct answer: Inhibition of iodide uptake via Wolff-Chaikoff effect

Amiodarone contains ~37% iodine by weight; the high iodine load can trigger the Wolff-Chaikoff effect, suppressing thyroid hormone synthesis.

Question 22: An 80-year-old has tense, pruritic bullae on the flexural thighs and abdomen; Nikolsky sign is negative and immunofluorescence shows linear IgG and C3 at the basement membrane. What is the diagnosis?

Pemphigus vulgaris
Porphyria cutanea tarda
Dermatitis herpetiformis
Bullous pemphigoid (Correct answer)

Correct answer: Bullous pemphigoid

Bullous pemphigoid causes subepidermal tense bullae in the elderly with linear IgG/C3 deposition at the BMZ.

Question 23: During review of systems (ROS), a patient reports 'constitutional symptoms.' Which cluster of symptoms does this term encompass?

Fever, chills, fatigue, weight loss, and night sweats (Correct answer)
Nausea, vomiting, and abdominal pain
Palpitations, syncope, and dyspnea
Headache, dizziness, and vision changes

Correct answer: Fever, chills, fatigue, weight loss, and night sweats

Constitutional symptoms refer to systemic, non-organ-specific complaints including fever, chills, fatigue, unintentional weight loss, and night sweats.

Question 24: A patient with low back pain radiating down the posterior leg to the foot has a positive straight leg raise at 45 degrees. Which nerve root is most likely involved?

L2
L3
L4
L5 or S1 (Correct answer)

Correct answer: L5 or S1

A positive straight leg raise combined with posterior leg pain radiating to the foot is classic for L5 or S1 nerve root compression, typically from a herniated disc.

Question 25: A patient with Alzheimer's disease has deficiency of which neurotransmitter?

Acetylcholine (Correct answer)
Serotonin
Dopamine
Norepinephrine

Correct answer: Acetylcholine

Alzheimer's disease is associated with loss of cholinergic neurons in the nucleus basalis of Meynert, leading to acetylcholine deficiency, which is the basis of cholinesterase inhibitor therapy.

Question 26: A 68-year-old female with a history of autoimmune gastritis presents with progressive fatigue, paresthesias in her lower extremities, and glossitis. A complete blood count reveals a macrocytic anemia. Which of the following is the most likely underlying deficiency?

Cobalamin (Vitamin B12) (Correct answer)
Pyridoxine (Vitamin B6)
Folate (Vitamin B9)
Iron

Correct answer: Cobalamin (Vitamin B12)

The patient's presentation of macrocytic anemia combined with neurological symptoms (paresthesias) is a classic manifestation of cobalamin (Vitamin B12) deficiency. [32, 34, 36] Her history of autoimmune gastritis is a major risk factor for pernicious anemia, which is the leading cause of B12 deficiency due to a lack of intrinsic factor needed for absorption. [3, 5, 7]

Question 27: A 4-week-old male infant presents with a 1-week history of non-bilious, projectile vomiting immediately after feeding. The mother reports he seems hungry all the time. On physical examination, an olive-sized mass is palpated in the epigastric region. What is the most appropriate next step to confirm the diagnosis?

Barium upper GI series
Empiric trial of thickened feeds
Abdominal ultrasound (Correct answer)
Abdominal X-ray

Correct answer: Abdominal ultrasound

The history and physical exam findings are classic for hypertrophic pyloric stenosis. Abdominal ultrasound is the preferred, most sensitive, and specific imaging modality to confirm the diagnosis. [13, 23, 24] It is non-invasive, avoids radiation exposure, and allows for direct measurement of the pyloric muscle thickness and channel length. [25, 28]

Question 28: A 55-year-old man with Type 2 DM presents with a foot ulcer and no sensation on 10-gram monofilament testing. Which diabetic complication does this represent?

Charcot arthropathy
Peripheral arterial disease
Diabetic nephropathy
Diabetic peripheral neuropathy (Correct answer)

Correct answer: Diabetic peripheral neuropathy

Loss of protective sensation on monofilament testing is the hallmark of diabetic peripheral neuropathy, a microvascular complication of diabetes.

Question 29: A patient on long-term haloperidol develops involuntary lip-smacking and tongue movements. Which FDA-approved medication treats this condition?

Benztropine
Propranolol
Valbenazine (Correct answer)
Diphenhydramine

Correct answer: Valbenazine

Valbenazine, a VMAT2 inhibitor, is FDA-approved for tardive dyskinesia.

Question 30: A 25-year-old woman presents with optic neuritis and new-onset sensory disturbances in her extremities. MRI shows periventricular white matter lesions. What is the most likely diagnosis?

CNS vasculitis
Vitamin B12 deficiency
Multiple sclerosis (Correct answer)
Neuromyelitis optica

Correct answer: Multiple sclerosis

Multiple sclerosis classically presents in young women with relapsing-remitting neurological symptoms, optic neuritis, and periventricular demyelinating lesions on MRI.

Question 31: A patient presents with jaundice. Which of the following questions in the history is LEAST relevant to the initial workup?

Alcohol consumption history
Current immunization status (Correct answer)
Recent travel abroad
Family history of Gilbert syndrome

Correct answer: Current immunization status

Immunization status is least immediately relevant; alcohol use, travel history, and family history of hemolytic or hepatic conditions directly inform the differential for jaundice.

Question 32: A 30-year-old with epilepsy presents in status epilepticus. After two doses of lorazepam, seizures persist. What is the next pharmacological treatment?

Oral valproate
Repeat lorazepam indefinitely
Oral phenytoin
IV levetiracetam or fosphenytoin (Correct answer)

Correct answer: IV levetiracetam or fosphenytoin

After benzodiazepine failure in status epilepticus, the next step is IV second-line agents such as levetiracetam, fosphenytoin, or valproate per established treatment algorithms.

Question 33: After a high-risk sexual exposure to HIV, within what time frame should post-exposure prophylaxis be started?

Within 24 hours only
Within 7 days
Within 2 weeks
Within 72 hours (Correct answer)

Correct answer: Within 72 hours

HIV PEP should begin as soon as possible and no later than 72 hours after exposure, and it is continued for 28 days.

Question 34: You are evaluating a 25-year-old woman who has a rash on her face. She says she might be reacting to a recently consumed meal, but she is unsure. The nasolabial fold is not spared, and the rash is reddish and macular on both cheeks. Which of the following would you now order?

Rheumatoid factor
Oral doxycycline (Vibramycin) (Correct answer)
Oral amoxicillin (Trimox)Oral doxycycline (Vibramycin)
ANA and complement levels
Oral prednisone

Correct answer: Oral doxycycline (Vibramycin)

Based on the description of the rash, the patient may be presented with a condition called "malar rash," which is a characteristic finding in systemic lupus erythematosus (SLE). Malar rash is a butterfly-shaped rash that spreads across the cheeks and bridge of the nose but does not spare the nasolabial folds. Given the possibility of SLE, ordering oral doxycycline would not be the appropriate course of action, as this medication is typically used to treat bacterial infections, such as acne or Lyme disease.

Question 35: A 28-year-old patient reports waking up with coughing and wheezing four nights per month. They use their albuterol inhaler approximately three times per week for symptom relief. Their FEV1 is 85% of predicted. According to the National Asthma Education and Prevention Program (NAEPP) guidelines, what is the most appropriate classification of this patient's asthma severity?

Severe persistent
Moderate persistent
Intermittent
Mild persistent (Correct answer)

Correct answer: Mild persistent

According to the NAEPP guidelines, mild persistent asthma is characterized by symptoms occurring more than two days a week (but not daily), nighttime awakenings 3-4 times a month, and SABA use more than two days a week (but not daily). This patient's symptom frequency fits squarely within the mild persistent category, guiding the initiation of appropriate daily controller therapy.

Question 36: A 29-year-old is diagnosed with Major Depressive Disorder (MDD) of moderate severity and has no other medical conditions. Which of the following is considered a first-line pharmacologic treatment for this patient?

Amitriptyline
Lithium
Sertraline (Correct answer)
Alprazolam

Correct answer: Sertraline

Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, are considered the first-line pharmacologic choice for Major Depressive Disorder due to their favorable balance of efficacy and tolerability. Amitriptyline is a tricyclic antidepressant (TCA) with a less favorable side-effect profile and is not a first-line agent. Alprazolam is a benzodiazepine used for anxiety and is not a primary treatment for MDD. Lithium is a mood stabilizer primarily used for bipolar disorder.

Question 37: A patient has brief episodes of vertigo lasting under a minute when rolling over in bed. Dix-Hallpike produces torsional upbeating nystagmus. What is the best treatment?

Oral prednisone taper
Canalith repositioning (Epley maneuver) (Correct answer)
Vestibular nerve section
Meclizine daily for 6 months

Correct answer: Canalith repositioning (Epley maneuver)

Posterior canal BPPV is treated by canalith repositioning, which moves otoconia out of the semicircular canal.

Question 38: After a lower molar infection, a patient develops bilateral submandibular swelling, an elevated tongue, and drooling. What is the greatest immediate concern?

Septic arthritis of the TMJ
Cavernous sinus thrombosis
Facial nerve palsy
Airway compromise (Correct answer)

Correct answer: Airway compromise

Ludwig angina can rapidly obstruct the airway, so airway management takes priority with IV antibiotics.

Question 39: Which of the following might be a result of long-term phenytoin (Dilantin) use?

Increased liver function levels
Hyponatremia
Hypovitaminosis D (Correct answer)
Hypercalcemia
Leukocytosis

Correct answer: Hypovitaminosis D

Long-term phenytoin (Dilantin) use can lead to a condition called hypovitaminosis D, which refers to a deficiency of vitamin D in the body. Phenytoin can interfere with the metabolism and activation of vitamin D, leading to lower levels of active vitamin D (calcitriol) in the blood.

Question 40: A patient with polyuria has dilute urine after water deprivation; urine osmolality rises by 70% after desmopressin. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

A marked rise in urine osmolality after desmopressin indicates ADH deficiency with intact renal response.

Question 41: Which of the following is the most common overall cause of Cushing's syndrome?

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

Correct answer: Exogenous corticosteroid use

Exogenous corticosteroid use is the most common cause of Cushing's syndrome overall, making it iatrogenic in most cases.

Question 42: Bupropion is contraindicated in which patient?

A 22-year-old with bulimia nervosa (Correct answer)
A 50-year-old with seasonal affective disorder
A 30-year-old with SSRI-induced sexual dysfunction
A 45-year-old smoker wanting to quit

Correct answer: A 22-year-old with bulimia nervosa

Bupropion lowers the seizure threshold and carries higher seizure risk in patients with eating disorders.

Question 43: A 60-year-old smoker has painless gross hematuria. What is the most appropriate evaluation?

Cystoscopy and CT urography (Correct answer)
Urine culture and antibiotics
Renal ultrasound only
Repeat urinalysis in 6 months

Correct answer: Cystoscopy and CT urography

Painless gross hematuria in a smoker requires cystoscopy and upper tract imaging to rule out urothelial carcinoma.

Question 44: A 38-year-old male presents to his primary care provider after being bitten by a tick while hiking in New England two weeks ago. He now complains of fever, fatigue, and myalgias. On examination, a large, annular, erythematous rash approximately 15 cm in diameter with central clearing is noted on his thigh. Which of the following is the most appropriate term for this rash?

Nummular eczema
Urticaria
Tinea corporis
Erythema migrans (Correct answer)

Correct answer: Erythema migrans

Erythema migrans is the pathognomonic skin lesion of early localized Lyme disease, which occurs after a bite from an infected Ixodes tick. It classically appears as an expanding erythematous rash, often with central clearing, resembling a 'bull's-eye'. [7, 13, 14] Urticaria (hives) consists of pruritic wheals. Nummular eczema presents as coin-shaped, scaly plaques. Tinea corporis (ringworm) is a fungal infection with a scaly, advancing border and is typically pruritic.

Question 45: A patient taking an SSRI and tramadol develops agitation, diaphoresis, hyperreflexia, clonus and fever. What is the most likely diagnosis?

Anticholinergic toxicity
Malignant hyperthermia
Neuroleptic malignant syndrome
Serotonin syndrome (Correct answer)

Correct answer: Serotonin syndrome

Serotonin syndrome follows excess serotonergic activity, such as an SSRI combined with tramadol. It presents with autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia) and altered mental status.

Question 46: A 28-year-old woman presents with palpitations, heat intolerance, weight loss, and exophthalmos. TSH is undetectable and free T4 is elevated. What is the most likely diagnosis?

Toxic multinodular goiter
Graves' disease (Correct answer)
Hashimoto's thyroiditis
Subacute thyroiditis

Correct answer: Graves' disease

Graves' disease is an autoimmune hyperthyroid condition, and exophthalmos (Graves' ophthalmopathy) is pathognomonic for this diagnosis.

Question 47: Which of the following metabolic outcomes is brought on by the release of insulin?

Causes glucose to be phosphorylated in kidney
Decreased blood sugar (Correct answer)
Increased breakdown of fats
Increased breakdown of proteins

Correct answer: Decreased blood sugar

Lowering blood sugar levels is one of insulin's main metabolic actions. Thus, diabetes mellitus is caused by a lack of insulin or a resistance to its effects.

Question 48: On auscultation, a mid-systolic click followed by a late systolic murmur is characteristic of:

Mitral valve prolapse (Correct answer)
Aortic stenosis
Aortic regurgitation
Ventricular septal defect

Correct answer: Mitral valve prolapse

A mid-systolic click followed by a late systolic murmur is the hallmark auscultatory finding of mitral valve prolapse.

Question 49: A previously unvaccinated adult is bitten by a bat. Besides wound care, what is the correct rabies post-exposure prophylaxis?

Rabies immune globulin only
Observe the patient for 10 days before deciding
Rabies vaccine on days 0, 3, 7, and 14 plus rabies immune globulin on day 0 (Correct answer)
Rabies vaccine on days 0 and 3 only

Correct answer: Rabies vaccine on days 0, 3, 7, and 14 plus rabies immune globulin on day 0

Unvaccinated patients get HRIG infiltrated at the wound plus a 4-dose vaccine series (5 doses if immunocompromised).

Question 50: Which type of seizure is characterized by sudden loss of muscle tone causing the patient to fall?

Atonic seizure (Correct answer)
Myoclonic seizure
Tonic-clonic seizure
Absence seizure

Correct answer: Atonic seizure

Atonic (drop) seizures involve sudden loss of postural muscle tone, causing the patient to fall abruptly without warning.

Question 51: Rough, sandpaper-like scaly erythematous macules on the sun-exposed scalp of a fair-skinned 70-year-old are precursors to which malignancy?

Squamous cell carcinoma (Correct answer)
Basal cell carcinoma
Melanoma
Merkel cell carcinoma

Correct answer: Squamous cell carcinoma

Actinic keratoses are premalignant lesions that can progress to squamous cell carcinoma.

Question 52: A child is found to carry a germline RET proto-oncogene mutation associated with MEN 2A. Which intervention is recommended?

Prophylactic total thyroidectomy (Correct answer)
Pituitary MRI every year
Annual serum calcium only
Bilateral adrenalectomy

Correct answer: Prophylactic total thyroidectomy

RET carriers nearly always develop medullary thyroid carcinoma, so prophylactic thyroidectomy is advised in childhood.

Question 53: Which pathogen is intrinsically resistant to all cephalosporins?

Haemophilus influenzae
Escherichia coli
Streptococcus pneumoniae
Enterococcus faecalis (Correct answer)

Correct answer: Enterococcus faecalis

Enterococci are intrinsically resistant to cephalosporins, which is why ampicillin is the drug of choice for susceptible E. faecalis.

Question 54: Which enzyme is responsible for the rate-limiting step in cholesterol biosynthesis?

HMG-CoA reductase (Correct answer)
Squalene synthase
Lanosterol synthase
Acetyl-CoA carboxylase

Correct answer: HMG-CoA reductase

HMG-CoA reductase catalyzes the conversion of HMG-CoA to mevalonate, the committed and rate-limiting step in cholesterol synthesis, and is the target of statins.

Question 55: A patient has recurrent vertigo episodes lasting seconds, triggered by head turning, with a positive Dix-Hallpike test. What is the best initial treatment?

Epley maneuver (Correct answer)
Intratympanic gentamicin
Oral prednisone
Meclizine daily indefinitely

Correct answer: Epley maneuver

This is benign paroxysmal positional vertigo. The canalith repositioning (Epley) maneuver is first-line treatment.

Question 56: A beaker holds 500 mL. If 20% of the liquid evaporates and then 50 mL is added, how many mL remain?

450 mL (Correct answer)
430 mL
420 mL
440 mL

Correct answer: 450 mL

500 × 0.80 = 400 mL after evaporation; 400 + 50 = 450 mL.

Question 57: At what eGFR is metformin contraindicated per FDA labeling?

Below 15 mL/min/1.73 m2 only
Below 45 mL/min/1.73 m2
Below 30 mL/min/1.73 m2 (Correct answer)
Below 60 mL/min/1.73 m2

Correct answer: Below 30 mL/min/1.73 m2

Metformin is contraindicated below eGFR 30 because of lactic acidosis risk, and initiation is not recommended at 30-45.

Question 58: A 70-year-old presents with progressive resting tremor, bradykinesia, and cogwheel rigidity. What is the most likely diagnosis?

Wilson's disease
Huntington's disease
Parkinson's disease (Correct answer)
Essential tremor

Correct answer: Parkinson's disease

Parkinson's disease presents with the classic triad of resting tremor, bradykinesia, and rigidity, typically beginning unilaterally in older adults.

Question 59: A patient has 3+ pitting edema to the knee bilaterally. Which of the following would be LEAST likely to cause this finding?

Heart failure
Cirrhosis
Peripheral arterial disease (Correct answer)
Nephrotic syndrome

Correct answer: Peripheral arterial disease

Peripheral arterial disease (PAD) causes ischemia, not dependent edema; bilateral pitting edema results from volume overload or reduced oncotic pressure.

Question 60: A patient stable on lithium is started on a new medication and develops coarse tremor, ataxia, and confusion two weeks later. Which medication most likely caused this?

Acetaminophen
Hydrochlorothiazide (Correct answer)
Amlodipine
Levothyroxine

Correct answer: Hydrochlorothiazide

Thiazide diuretics reduce renal lithium clearance, raising serum levels into the toxic range.

Question 61: Which hormone stimulates osteoclast activity, increases renal calcium reabsorption, and raises serum calcium levels?

Calcitonin
Cortisol
Parathyroid hormone (PTH) (Correct answer)
Vitamin D3 (calcitriol)

Correct answer: Parathyroid hormone (PTH)

PTH raises serum calcium by stimulating osteoclast-mediated bone resorption, increasing renal calcium reabsorption, and promoting renal 1-alpha-hydroxylase activity to activate vitamin D.

Question 62: A college student with fever, exudative pharyngitis, posterior cervical lymphadenopathy, and fatigue develops a diffuse rash after taking amoxicillin. What advice is most important?

Begin a 10-day course of penicillin
Start oral acyclovir immediately
Avoid contact sports for at least 3–4 weeks (Correct answer)
Schedule a tonsillectomy

Correct answer: Avoid contact sports for at least 3–4 weeks

Infectious mononucleosis causes splenomegaly, and contact sports are avoided to prevent splenic rupture.

Question 63: A 19-year-old has a single 3-cm oval salmon-colored scaly patch on the trunk, followed 10 days later by smaller oval lesions aligned along skin cleavage lines. What is the most likely diagnosis?

Guttate psoriasis
Secondary syphilis
Pityriasis rosea (Correct answer)
Tinea corporis

Correct answer: Pityriasis rosea

A herald patch followed by a Christmas-tree distribution eruption is classic for pityriasis rosea.

Question 64: A 45-year-old patient is diagnosed with hypertrophic cardiomyopathy (HCM). Which of the following should be strongly advised against for this patient?

Genetic counseling for first-degree relatives
Annual screening with echocardiography
Participation in competitive, high-intensity sports (Correct answer)
Treatment with beta-blockers for symptomatic relief

Correct answer: Participation in competitive, high-intensity sports

Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death in young athletes. The dynamic left ventricular outflow tract obstruction can worsen with intense physical exertion and dehydration. Therefore, patients with HCM are typically restricted from competitive, high-intensity sports to reduce this risk. Beta-blockers are a first-line treatment, and regular screening and genetic counseling are standard parts of management.

Question 65: A 65-year-old man has nocturia and weak stream. Which medication improves symptoms and can reduce prostate size over months?

Tamsulosin
Finasteride (Correct answer)
Sildenafil
Oxybutynin

Correct answer: Finasteride

5-alpha-reductase inhibitors like finasteride shrink the prostate and lower PSA by about 50%.

Question 66: Which test is the most appropriate to confirm active Clostridioides difficile infection in a patient with watery diarrhea after antibiotic use?

Stool ova and parasites
Blood cultures
Colonoscopy with biopsy as first test
Stool toxin or PCR testing for C. difficile (Correct answer)

Correct answer: Stool toxin or PCR testing for C. difficile

Diagnosis rests on stool testing for toxin and/or the toxin gene by PCR in a patient with unformed stools. First-line treatment is oral fidaxomicin or vancomycin.

Question 67: Which medication class is contraindicated in patients with gout who are taking allopurinol and develop a skin rash?

Ampicillin-class antibiotics (Correct answer)
NSAIDs
Colchicine
Corticosteroids

Correct answer: Ampicillin-class antibiotics

Aminopenicillins (ampicillin, amoxicillin) increase the risk of severe drug reactions including Stevens-Johnson syndrome when used with allopurinol.

Question 68: A patient with AIDS has headache, fever, and elevated opening pressure on lumbar puncture, and India ink stain shows encapsulated yeast. What is the preferred induction therapy?

Amphotericin B plus flucytosine (Correct answer)
Fluconazole alone
Voriconazole plus TMP-SMX
Caspofungin

Correct answer: Amphotericin B plus flucytosine

Cryptococcal meningitis induction therapy is liposomal amphotericin B plus flucytosine, followed by fluconazole consolidation.

Question 69: Which of the following electrocardiogram (ECG) findings is most characteristic of acute pericarditis?

Deep, symmetric T-wave inversions
Diffuse ST-segment elevation and PR-segment depression (Correct answer)
ST-segment elevation in a localized coronary distribution
Development of pathologic Q waves

Correct answer: Diffuse ST-segment elevation and PR-segment depression

The classic ECG finding in acute pericarditis is diffuse, concave-up ST-segment elevation across multiple limb and precordial leads, which does not conform to a specific coronary artery territory. This is often accompanied by PR-segment depression, particularly in lead II. Localized ST elevation and Q waves are more indicative of a myocardial infarction.

Question 70: A patient with a history of chronic alcohol use presents with gait ataxia, ophthalmoplegia, and confusion. These findings form which classic triad?

Wernicke encephalopathy (Correct answer)
Korsakoff psychosis
Alcohol withdrawal delirium
Hepatic encephalopathy

Correct answer: Wernicke encephalopathy

The triad of ophthalmoplegia, ataxia, and confusion (altered mental status) defines Wernicke encephalopathy, caused by thiamine (B1) deficiency.

Question 71: A few hours after receiving penicillin for secondary syphilis, a patient develops fever, chills, myalgias, and a worse rash. What is the most likely explanation?

Anaphylaxis
Jarisch-Herxheimer reaction (Correct answer)
Serum sickness
Stevens-Johnson syndrome

Correct answer: Jarisch-Herxheimer reaction

The Jarisch-Herxheimer reaction is an acute febrile response to lysed spirochetes, and it is managed supportively.

Question 72: Blood cultures grow Streptococcus gallolyticus (formerly S. bovis) in a patient with endocarditis. What additional evaluation is indicated?

Thyroid function tests
Bone marrow biopsy
Renal ultrasound
Colonoscopy (Correct answer)

Correct answer: Colonoscopy

S. gallolyticus bacteremia is strongly associated with colorectal neoplasia, so colonoscopy is warranted.

Question 73: A patient with myasthenia gravis will show which characteristic pattern on repetitive nerve stimulation?

Fibrillation potentials
Incremental response
Decremental response (Correct answer)
No change

Correct answer: Decremental response

Myasthenia gravis is characterized by a decremental response on repetitive nerve stimulation due to depletion of acetylcholine at the neuromuscular junction.

Question 74: Which HLA allele must be tested for before starting abacavir?

HLA-DR4
HLA-B*57:01 (Correct answer)
HLA-B27
HLA-B*15:02

Correct answer: HLA-B*57:01

HLA-B*57:01 carriers are at high risk for a severe abacavir hypersensitivity reaction, so the drug is contraindicated in them.

Question 75: A 72-year-old male presents with a progressive, multi-year history of exertional dyspnea and a dry, non-productive cough. Physical examination is notable for digital clubbing and fine, bibasilar inspiratory 'Velcro-like' crackles. Pulmonary function tests demonstrate a restrictive pattern. Which of the following is the most likely diagnosis?

Congestive heart failure
Chronic obstructive pulmonary disease (COPD)
Idiopathic pulmonary fibrosis (IPF) (Correct answer)
Asthma

Correct answer: Idiopathic pulmonary fibrosis (IPF)

The combination of insidious onset dyspnea in an older adult, digital clubbing, characteristic 'Velcro-like' crackles on auscultation, and a restrictive pattern on PFTs is classic for Idiopathic Pulmonary Fibrosis (IPF). COPD and asthma would show an obstructive pattern, and while heart failure can cause crackles, they are typically described as 'wet' or 'coarse', and the other features are not characteristic.

Question 76: bachelor's an about 4 yrs of healthcare experience

all PA programs meet the same
typical applicant already has (Correct answer)
in general a Baccalaureate degree
science gpa cummulative gpa

Correct answer: typical applicant already has

The typical PA program applicant already has a bachelor's degree plus about four years of hands-on healthcare experience. The other options describe program accreditation standards or GPA requirements rather than the applicant's expected background.

Question 77: A patient with Rocky Mountain spotted fever should receive which treatment immediately, even before confirmatory testing?

Amoxicillin
Ciprofloxacin
Azithromycin alone
Doxycycline (Correct answer)

Correct answer: Doxycycline

Rickettsia rickettsii infection can be fatal if untreated. Doxycycline should be started on clinical suspicion, including in children, and not delayed for lab confirmation.

Question 78: Which vitamin requires intrinsic factor for absorption and is deficient in pernicious anemia?

Vitamin B6 (pyridoxine)
Folate
Vitamin B12 (cobalamin) (Correct answer)
Vitamin B1 (thiamine)

Correct answer: Vitamin B12 (cobalamin)

Vitamin B12 binds intrinsic factor produced by gastric parietal cells for absorption in the terminal ileum; autoimmune destruction of parietal cells causes pernicious anemia.

Question 79: A 35-year-old man has fever, perineal pain, dysuria, and an exquisitely tender boggy prostate. What should be avoided?

Fluoroquinolone therapy
Vigorous prostatic massage (Correct answer)
Urine culture
Blood cultures if febrile

Correct answer: Vigorous prostatic massage

Prostatic massage in acute bacterial prostatitis is contraindicated as it may cause bacteremia.

Question 80: An 80-year-old postoperative patient has acute-onset confusion that fluctuates during the day with marked inattention. What is the most likely diagnosis?

Frontotemporal dementia
Alzheimer disease
Delirium (Correct answer)
Major depressive disorder with pseudodementia

Correct answer: Delirium

Acute onset, fluctuating course, and impaired attention are hallmarks of delirium.

Question 81: A patient with HIV has a CD4 count of 150 cells/mm³. Which prophylaxis should be started?

Fluconazole
Isoniazid
Trimethoprim-sulfamethoxazole (Correct answer)
Azithromycin alone

Correct answer: Trimethoprim-sulfamethoxazole

Pneumocystis jirovecii pneumonia prophylaxis with TMP-SMX is indicated when the CD4 count falls below 200 cells/mm³.

Question 82: A patient has 3 days of migratory pruritic wheals that each resolve within 24 hours, without angioedema or respiratory symptoms. What is first-line therapy?

Second-generation H1 antihistamine such as cetirizine (Correct answer)
Intramuscular epinephrine
Prolonged oral prednisone taper
Montelukast monotherapy

Correct answer: Second-generation H1 antihistamine such as cetirizine

Non-sedating second-generation H1 antihistamines are first-line for acute urticaria.

Question 83: Which sentence contains a dangling modifier?

The student, running quickly, missed the bus.
Because she ran quickly, the student missed the bus.
Running quickly, the bus was missed by the student. (Correct answer)
The student ran quickly but missed the bus.

Correct answer: Running quickly, the bus was missed by the student.

In the first option, the participial phrase 'Running quickly' incorrectly modifies 'the bus' rather than the student.

Question 84: According to DSM-5, which criterion is required to diagnose ADHD?

Symptoms present before age 6
Abnormal neuropsychological testing
Several symptoms present before age 12 in two or more settings (Correct answer)
Symptoms in at least one setting for 1 month

Correct answer: Several symptoms present before age 12 in two or more settings

ADHD requires several symptoms before age 12 that occur in two or more settings for at least 6 months.

Question 85: A painless, firm testicular mass in a 28-year-old man with elevated AFP points to which tumor type?

Pure seminoma
Nonseminomatous germ cell tumor (Correct answer)
Testicular lymphoma
Leydig cell tumor

Correct answer: Nonseminomatous germ cell tumor

Elevated AFP excludes pure seminoma and indicates a nonseminomatous component such as yolk sac tumor.

Question 86: Which genetic mutation pattern is associated with familial adenomatous polyposis (FAP)?

Trinucleotide repeat expansion in TP53
X-linked dominant mutation in BRCA2
Autosomal recessive mutation in MLH1
Autosomal dominant loss-of-function mutation in APC (Correct answer)

Correct answer: Autosomal dominant loss-of-function mutation in APC

FAP results from autosomal dominant loss-of-function mutations in the APC tumor suppressor gene, causing hundreds to thousands of colorectal polyps.

Question 87: Which of the following is the most common type of thyroid cancer, accounting for approximately 80% of cases?

Medullary thyroid carcinoma
Anaplastic thyroid carcinoma
Follicular thyroid carcinoma
Papillary thyroid carcinoma (Correct answer)

Correct answer: Papillary thyroid carcinoma

Papillary thyroid carcinoma is the most common thyroid cancer with the best prognosis; it spreads via lymphatics and is associated with radiation exposure.

Question 88: A 68-year-old farmer has a pearly, translucent papule with rolled borders and telangiectasias on the nose. What is the most likely diagnosis?

Squamous cell carcinoma
Seborrheic keratosis
Basal cell carcinoma (Correct answer)
Actinic keratosis

Correct answer: Basal cell carcinoma

Basal cell carcinoma is the most common skin cancer. It typically appears as a pearly papule with rolled borders and telangiectasias on sun-exposed areas such as the face.

Question 89: A 3-year-old with no penicillin allergy and no recent antibiotics has a bulging, erythematous tympanic membrane and fever. What is the first-line antibiotic?

Ciprofloxacin otic drops
Azithromycin
Cephalexin
High-dose amoxicillin (Correct answer)

Correct answer: High-dose amoxicillin

High-dose amoxicillin (80–90 mg/kg/day) is first-line for acute otitis media to cover resistant S. pneumoniae.

Question 90: A young man has hematuria, sensorineural hearing loss, and anterior lenticonus. What is the most likely diagnosis?

Thin basement membrane disease
Medullary sponge kidney
Fabry disease
Alport syndrome (Correct answer)

Correct answer: Alport syndrome

Alport syndrome results from type IV collagen defects affecting the kidney, ear, and eye.

Question 91: A patient started on a new antibiotic develops fever, rash, and AKI with urine eosinophils. What is the most likely diagnosis?

Post-streptococcal glomerulonephritis
Renal vein thrombosis
Acute interstitial nephritis (Correct answer)
IgA nephropathy

Correct answer: Acute interstitial nephritis

The triad of fever, rash, and eosinophiluria after drug exposure suggests drug-induced acute interstitial nephritis.

Question 92: A 55-year-old man reports chest pain that worsens with inspiration and is relieved by leaning forward. Which component of the history is MOST critical to document next?

Smoking history
Family history of cardiac disease
Current medications
Onset and duration of pain (Correct answer)

Correct answer: Onset and duration of pain

Pleuritic chest pain relieved by leaning forward suggests pericarditis; documenting onset and duration is essential to characterize the presentation.

Question 93: A 4-year-old has an asymptomatic smooth abdominal mass that does not cross the midline. What is the most likely diagnosis?

Polycystic kidney
Wilms tumor (Correct answer)
Hepatoblastoma
Neuroblastoma

Correct answer: Wilms tumor

Wilms tumor typically presents as a smooth flank mass that does not cross the midline, unlike neuroblastoma.

Question 94: A 28-year-old woman with galactorrhea and amenorrhea has a 6-mm pituitary adenoma and prolactin of 150 ng/mL. What is first-line therapy?

Octreotide
Cabergoline (Correct answer)
Transsphenoidal surgery
Pituitary radiation

Correct answer: Cabergoline

Dopamine agonists, preferably cabergoline, normalize prolactin and shrink most prolactinomas.

Question 95: Which medication is classified as a disease-modifying antirheumatic drug (DMARD) and is first-line for rheumatoid arthritis?

Ibuprofen
Celecoxib
Prednisone
Methotrexate (Correct answer)

Correct answer: Methotrexate

Methotrexate is the anchor DMARD and first-line agent for rheumatoid arthritis, slowing disease progression and joint damage.

Question 96: A 35-year-old man presents with coarse facial features, enlarged hands and feet, headaches, and bitemporal hemianopsia. IGF-1 is markedly elevated. What is the most likely diagnosis?

Cushing's disease
Prolactinoma
Acromegaly (Correct answer)
Gigantism

Correct answer: Acromegaly

Acromegaly is caused by excess GH after epiphyseal closure, leading to coarse acral features and elevated IGF-1; a pituitary tumor causes the visual field defect.

Question 97: Which word is the MOST precise synonym for 'prognosis'?

Diagnosis
Treatment
Symptom
Outlook (Correct answer)

Correct answer: Outlook

Prognosis refers to the predicted course or likely outcome of a disease, which is best captured by 'outlook.'

Question 98: A 13-year-old repeatedly bullies peers, has set fires, and has been cruel to animals for the past year. What is the most likely diagnosis?

Antisocial personality disorder
Conduct disorder (Correct answer)
Oppositional defiant disorder
Intermittent explosive disorder

Correct answer: Conduct disorder

Violating others' basic rights through aggression, property destruction, and cruelty defines conduct disorder.

Question 99: A 19-year-old male presents with a 24-hour history of periumbilical pain that has now localized to the right lower quadrant. He reports anorexia and nausea. On examination, he has a low-grade fever and tenderness to palpation at McBurney's point. When the examiner palpates deeply in the left lower quadrant, the patient experiences sharp pain in the right lower quadrant. What is the name of this physical exam sign?

Rovsing's sign (Correct answer)
Psoas sign
Obturator sign
Murphy's sign

Correct answer: Rovsing's sign

Rovsing's sign is pain felt in the right lower quadrant upon palpation of the left lower quadrant. This sign is suggestive of peritoneal irritation in the right lower quadrant, as seen in acute appendicitis. Murphy's sign is associated with cholecystitis, while the Psoas and Obturator signs are other maneuvers used to detect appendicitis.

Question 100: A hunter develops an ulcerated skin lesion with tender regional lymphadenopathy after skinning a rabbit. What is the most likely organism?

Bacillus anthracis
Pasteurella multocida
Yersinia pestis
Francisella tularensis (Correct answer)

Correct answer: Francisella tularensis

Ulceroglandular tularemia follows contact with infected rabbits and presents with an ulcer and regional lymphadenopathy.

Question 101: A 55-year-old male complains of a chronic, gnawing epigastric pain that improves with meals but worsens 2-3 hours later. He has no alarm symptoms. Which of the following is considered the most accurate diagnostic test for an active Helicobacter pylori infection in this patient?

Stool antigen assay
Serology testing
Urea breath test
Upper endoscopy with biopsy (Correct answer)

Correct answer: Upper endoscopy with biopsy

While the urea breath test and stool antigen assay are excellent non-invasive tests, upper endoscopy with biopsy is considered the most accurate or 'gold standard' for the diagnosis of an active H. pylori infection. [30, 39] It allows for direct histological examination, rapid urease testing, and culture. In a patient over 50 with new-onset dyspepsia, endoscopy is also indicated to rule out other pathology like malignancy.

Question 102: A 68-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden-onset 'tearing' chest pain that radiates to his back. On examination, his blood pressure is 190/110 mmHg in the right arm and 155/90 mmHg in the left arm. A new diastolic murmur is auscultated at the right sternal border. Which of the following is the most likely diagnosis?

Acute myocardial infarction
Pulmonary embolism
Pericarditis
Aortic dissection (Correct answer)

Correct answer: Aortic dissection

The classic presentation of a sudden-onset 'tearing' or 'ripping' chest pain radiating to the interscapular area of the back, accompanied by a significant blood pressure differential between the upper extremities (>20 mmHg systolic), and a new diastolic murmur of aortic regurgitation strongly suggests an acute aortic dissection.

Question 103: Which of the following best describes the pathophysiology of Type 2 Diabetes Mellitus?

Peripheral insulin resistance combined with progressive beta-cell dysfunction (Correct answer)
Downregulation of hepatic glucose transporters only
Autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency
Excess glucagon secretion from alpha cells as the primary mechanism

Correct answer: Peripheral insulin resistance combined with progressive beta-cell dysfunction

Type 2 DM involves both peripheral insulin resistance and progressive pancreatic beta-cell dysfunction, leading to relative insulin deficiency over time.

Question 104: What is the time window for administration of IV alteplase (tPA) in acute ischemic stroke?

Within 1 hour of symptom onset
Within 6 hours of symptom onset
Within 3–4.5 hours of symptom onset (Correct answer)
Within 12 hours of symptom onset

Correct answer: Within 3–4.5 hours of symptom onset

IV alteplase is approved for administration within 3 hours of symptom onset, with select patients eligible up to 4.5 hours based on AHA/ASA guidelines.

Question 105: A newborn girl has ambiguous genitalia, and on day 7 develops hyponatremia, hyperkalemia, and hypotension. Which lab is most likely elevated?

17-hydroxyprogesterone (Correct answer)
Plasma aldosterone
Serum cortisol
11-deoxycorticosterone with hypokalemia

Correct answer: 17-hydroxyprogesterone

21-hydroxylase deficiency blocks cortisol and aldosterone synthesis, causing 17-hydroxyprogesterone accumulation and salt wasting.

Question 106: A patient is prescribed doxycycline for Lyme disease. Which counseling point is most important?

Take at bedtime only
Avoid prolonged sun exposure due to photosensitivity (Correct answer)
Avoid all exercise during therapy
Take with a full glass of milk

Correct answer: Avoid prolonged sun exposure due to photosensitivity

Tetracyclines including doxycycline cause photosensitivity reactions; patients should use sunscreen and avoid prolonged UV exposure.

Question 107: An elderly woman leaks urine with a sudden strong urge and cannot reach the bathroom in time. What is first-line therapy?

Bladder training and behavioral therapy (Correct answer)
Intermittent catheterization
Pessary placement
Midurethral sling

Correct answer: Bladder training and behavioral therapy

Behavioral therapy including bladder training is first-line for urge incontinence before antimuscarinics or beta-3 agonists.

Question 108: What is the appropriate empiric antibiotic regimen for suspected bacterial meningitis in a 65-year-old?

Vancomycin plus ceftriaxone
Vancomycin, ceftriaxone, and ampicillin (Correct answer)
Ampicillin plus gentamicin
Ceftriaxone alone

Correct answer: Vancomycin, ceftriaxone, and ampicillin

Adults over 50 need ampicillin added for Listeria coverage on top of vancomycin plus a third-generation cephalosporin.

Question 109: A 50-year-old presents with symmetric ascending weakness and areflexia following a GI infection 3 weeks prior. CSF shows albuminocytologic dissociation. What is the most likely diagnosis?

Amyotrophic lateral sclerosis
Multiple sclerosis
Myasthenia gravis
Guillain-Barré syndrome (Correct answer)

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome presents with ascending flaccid paralysis, areflexia, and CSF albuminocytologic dissociation (elevated protein with normal cell count), often following infection.

Question 110: Which therapy is the most effective long-term treatment for bipolar disorder maintenance, and what monitoring is required?

Clonazepam; CBC
Sertraline; liver function
Lithium; serum levels, renal and thyroid function (Correct answer)
Bupropion; ECG

Correct answer: Lithium; serum levels, renal and thyroid function

Lithium is a mainstay of maintenance therapy. It has a narrow therapeutic index, so serum levels, renal function and thyroid function must be monitored.

Question 111: Which of the following is the Rocky Mountain spotted fever-causing organism?

Corynebacterium
Rickettsia rickettsii (Correct answer)
Bordetella pertussis
Rickettsia siberica

Correct answer: Rickettsia rickettsii

Rocky Mountain spotted fever (RMSF) is a serious bacterial infection transmitted to humans through the bite of infected ticks. The specific causative agent for this disease is the bacterium *Rickettsia rickettsii*. This organism infects the endothelial cells lining blood vessels, leading to vasculitis and the characteristic rash associated with RMSF.

Question 112: A patient develops painful, grouped vesicles on an erythematous base in a unilateral T6 dermatomal distribution. Which is the best treatment?

Oral terbinafine
Topical hydrocortisone
Oral valacyclovir (Correct answer)
Oral cephalexin

Correct answer: Oral valacyclovir

This is herpes zoster (shingles). Oral antivirals such as valacyclovir, acyclovir or famciclovir are most effective when started within 72 hours of rash onset.

Question 113: A patient on sertraline who recently added tramadol presents with agitation, diaphoresis, hyperreflexia, and inducible clonus. What is the most likely diagnosis?

Serotonin syndrome (Correct answer)
Neuroleptic malignant syndrome
Anticholinergic toxicity
Malignant hyperthermia

Correct answer: Serotonin syndrome

Hyperreflexia and clonus with rapid onset after combining serotonergic agents is characteristic of serotonin syndrome.

Question 114: A nurse repeatedly injects herself with insulin to cause hypoglycemia and be admitted, with no financial or legal gain. What is the diagnosis?

Conversion disorder
Factitious disorder imposed on self (Correct answer)
Somatic symptom disorder
Malingering

Correct answer: Factitious disorder imposed on self

Intentionally producing symptoms to assume the sick role without external incentive is factitious disorder.

Question 115: Which beta-blocker is cardioselective and preferred in a patient with reactive airway disease requiring antihypertensive therapy?

Labetalol
Carvedilol
Propranolol
Metoprolol succinate (Correct answer)

Correct answer: Metoprolol succinate

Metoprolol succinate is a beta-1 selective blocker with minimal effect on beta-2 receptors in the bronchi at usual doses.

Question 116: What is the first-line psychotherapy for obsessive-compulsive disorder?

Psychodynamic psychotherapy
Hypnotherapy
Interpersonal therapy
Exposure and response prevention (Correct answer)

Correct answer: Exposure and response prevention

Exposure and response prevention, a form of CBT, is the most effective psychotherapy for OCD.

Question 117: Which medication is the first-line systemic treatment for severe nodulocystic acne unresponsive to other therapy?

Isotretinoin (Correct answer)
Oral acyclovir
Topical benzoyl peroxide alone
Oral fluconazole

Correct answer: Isotretinoin

Isotretinoin is reserved for severe, scarring or refractory nodulocystic acne. It is highly teratogenic and requires iPLEDGE enrollment and pregnancy monitoring.

Question 118: A patient has had recurrent major depressive episodes and one 5-day period of elevated mood and decreased need for sleep without impairment or hospitalization. What is the diagnosis?

Bipolar I disorder
Cyclothymic disorder
Bipolar II disorder (Correct answer)
Major depressive disorder with anxious distress

Correct answer: Bipolar II disorder

Hypomania plus at least one major depressive episode, without any full manic episode, defines bipolar II disorder.

Question 119: A patient with Type 2 DM on metformin develops lactic acidosis after a hospitalization for cardiac catheterization with contrast. Which medication is most likely responsible?

Pioglitazone
Metformin (Correct answer)
Glipizide
Sitagliptin

Correct answer: Metformin

Metformin can cause lactic acidosis, especially when combined with IV contrast, renal impairment, or hypoxic states; it should be held before contrast procedures.

Question 120: A patient with AIDS and a CD4 count of 30 cells/mm³ reports painless floaters and vision loss, and fundoscopy shows hemorrhages with fluffy white retinal infiltrates. What is the most likely diagnosis?

CMV retinitis (Correct answer)
Candida endophthalmitis
HIV retinopathy (cotton-wool spots only)
Toxoplasma chorioretinitis

Correct answer: CMV retinitis

CMV retinitis appears when CD4 is below 50 cells/mm³, with a 'pizza pie' or 'cottage cheese and ketchup' fundus.

Question 121: Which of the following negative effects of beta channel blockers is NOT one of them?

Hypotension
Impotence
Bradycardia
Hypertension (Correct answer)

Correct answer: Hypertension

Beta-blockers work by blocking beta-adrenergic receptors, which leads to a decrease in heart rate, reduced myocardial contractility, and vasodilation. These actions collectively result in a *reduction* of blood pressure, making hypotension a common side effect. Therefore, hypertension is not a negative effect; instead, beta-blockers are frequently prescribed to *treat* hypertension.

Question 122: A child with otitis media has a penicillin allergy documented as hives. Which antibiotic is most appropriate?

Cephalexin
Cefdinir (Correct answer)
Amoxicillin-clavulanate
Azithromycin

Correct answer: Cefdinir

Cross-reactivity between penicillins and cephalosporins is low (<2%); cefdinir is acceptable for non-anaphylactic penicillin allergy in otitis media.

Question 123: A patient has decreased need for sleep, grandiosity, pressured speech and risky spending for 10 days. Which is the most appropriate diagnosis?

Schizophrenia
Generalized anxiety disorder
Major depressive disorder
Bipolar I disorder, manic episode (Correct answer)

Correct answer: Bipolar I disorder, manic episode

A manic episode lasting at least 1 week (or any duration if hospitalized) with elevated mood, decreased need for sleep, grandiosity and pressured speech indicates bipolar I disorder.

Question 124: A patient taking an MAO inhibitor for depression eats aged cheese and develops a hypertensive crisis. What is the mechanism?

Tyramine directly activates alpha-2 adrenergic receptors
Tyramine blocks calcium channels
Tyramine inhibits renal dopamine clearance
Tyramine displaces norepinephrine from nerve terminals causing massive release (Correct answer)

Correct answer: Tyramine displaces norepinephrine from nerve terminals causing massive release

MAO normally metabolizes tyramine; when inhibited, dietary tyramine enters systemic circulation, displacing NE from storage vesicles causing a catecholamine surge.

Question 125: A patient with sudden painless 'curtain-like' vision loss and new floaters most likely has which condition?

Conjunctivitis
Acute angle-closure glaucoma
Retinal detachment (Correct answer)
Dacryocystitis

Correct answer: Retinal detachment

Retinal detachment classically causes floaters, flashes and a curtain-like visual field defect without pain. It is an ophthalmologic emergency.

Question 126: A 30-year-old woman presents with galactorrhea, amenorrhea, and bitemporal headaches. MRI shows a pituitary mass and prolactin is 160 ng/mL. What is the first-line treatment?

Leuprolide acetate
Dopamine agonist (cabergoline or bromocriptine) (Correct answer)
Cranial radiation therapy
Transsphenoidal surgical resection

Correct answer: Dopamine agonist (cabergoline or bromocriptine)

Dopamine agonists are the first-line treatment for prolactinomas, as they suppress prolactin secretion and reduce tumor size.

Question 127: A 6-year-old develops cola-colored urine, periorbital edema, and hypertension 2 weeks after pharyngitis. Which lab is expected?

Positive anti-GBM antibody
Elevated IgE
Low C3 complement (Correct answer)
Elevated C3

Correct answer: Low C3 complement

Post-streptococcal glomerulonephritis causes transiently low C3 that normalizes within 6-8 weeks.

Question 128: What is the current CDC-recommended treatment for uncomplicated gonorrhea in an adult weighing under 150 kg?

Ceftriaxone 250 mg IM plus azithromycin 1 g PO
Ceftriaxone 500 mg IM once (Correct answer)
Ciprofloxacin 500 mg PO once
Cefixime 400 mg PO plus doxycycline

Correct answer: Ceftriaxone 500 mg IM once

Since 2020, CDC guidelines recommend a single 500 mg IM dose of ceftriaxone, plus doxycycline if chlamydia has not been ruled out.

Question 129: Velvety, hyperpigmented plaques on the posterior neck and axillae of an obese adolescent most strongly suggest which underlying condition?

Addison disease
Hemochromatosis
Hypothyroidism
Insulin resistance (Correct answer)

Correct answer: Insulin resistance

Acanthosis nigricans is most commonly associated with insulin resistance and obesity.

Question 130: Which of the following cardiomyopathies on a chest radiograph exhibits an inflated balloon-like heart and pulmonary congestion?

Both restrictive and hypertrophic cardiomyopathies
Dilated cardiomyopathy (Correct answer)
Restrictive cardiomyopathy
Hypertrophic cardiomyopathy

Correct answer: Dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is characterized by significant enlargement of the heart chambers, particularly the ventricles. On a chest radiograph, this appears as marked cardiomegaly, often described as an 'inflated balloon-like heart.' The impaired pumping function also frequently leads to pulmonary congestion and edema, which would be visible on the X-ray.

Question 131: A 4-year-old child is brought to the clinic with a 5-day history of pronounced facial puffiness, especially around the eyes in the morning, and swelling in the legs. The parents also report recent weight gain. Urinalysis reveals 4+ proteinuria, but is negative for blood and white blood cells. Which of the following is the most likely diagnosis?

IgA nephropathy
Post-streptococcal glomerulonephritis
Urinary tract infection
Minimal change disease (Correct answer)

Correct answer: Minimal change disease

The clinical presentation of a young child with significant edema and massive, selective proteinuria (proteinuria without hematuria) is classic for nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children. [1, 4, 8] Post-streptococcal glomerulonephritis typically presents with hematuria, hypertension, and a history of a recent streptococcal infection. IgA nephropathy is the most common cause of glomerulonephritis worldwide but typically presents with gross hematuria following a mucosal infection. A urinary tract infection would present with pyuria and bacteriuria, not massive proteinuria.

Question 132: An ICU patient with septic shock has low total T3, elevated reverse T3, and a low-normal TSH. What is the most likely diagnosis?

Hashimoto thyroiditis
Nonthyroidal illness (euthyroid sick) syndrome (Correct answer)
Subclinical hypothyroidism
Central hypothyroidism

Correct answer: Nonthyroidal illness (euthyroid sick) syndrome

Severe illness reduces peripheral T4-to-T3 conversion and raises reverse T3 without true thyroid disease.

Question 133: Which heart valves are shutting when the first heart sound is made?

Aortic and tricuspid valves
Aortic and pulmonic valves
Mitral and tricuspid valves (Correct answer)
Aortic and mitral valves

Correct answer: Mitral and tricuspid valves

The first heart sound, S1, commonly referred to as the 'lub' sound, marks the beginning of ventricular systole (contraction). It is produced by the simultaneous closure of the atrioventricular (AV) valves: the mitral valve, located between the left atrium and left ventricle, and the tricuspid valve, located between the right atrium and right ventricle. This closure prevents the backflow of blood into the atria as the ventricles begin to contract.

Question 134: Which antibiotic class carries an FDA boxed warning for tendon rupture, especially in older adults and patients on corticosteroids?

Fluoroquinolones (Correct answer)
Cephalosporins
Tetracyclines
Macrolides

Correct answer: Fluoroquinolones

Fluoroquinolones raise the risk of tendinitis and Achilles tendon rupture, and corticosteroid use and age over 60 increase the risk further.

Question 135: During a pelvic exam, the PA notes a blue-gray discoloration of the cervix and vaginal walls in a patient with amenorrhea. This is known as:

Goodell's sign
Chadwick's sign (Correct answer)
Cullen's sign
Hegar's sign

Correct answer: Chadwick's sign

Chadwick's sign is the blue-violet discoloration of the vagina and cervix due to increased vascularity, appearing in early pregnancy.

Question 136: Which of the following pleural effusions is brought on by chronic heart failure, cirrhosis, or nephrotic syndrome?

Exudative
Transudative (Correct answer)
Mixed
Combined

Correct answer: Transudative

Transudative pleural effusions occur due to systemic factors that alter hydrostatic or oncotic pressures, leading to fluid leakage into the pleural space. Conditions like chronic heart failure (increased hydrostatic pressure), cirrhosis (decreased oncotic pressure due to low albumin), and nephrotic syndrome (protein loss leading to decreased oncotic pressure) are classic causes of transudative effusions.

Question 137: At what CD4 count should primary prophylaxis against Pneumocystis jirovecii pneumonia be started in a patient with HIV?

Below 500 cells/mm³
Below 350 cells/mm³
Below 200 cells/mm³ (Correct answer)
Below 50 cells/mm³

Correct answer: Below 200 cells/mm³

PJP prophylaxis, usually with TMP-SMX, is indicated when the CD4 count falls below 200 cells/mm³ or with oropharyngeal candidiasis.

Question 138: Which treatment is recommended for primary syphilis in a nonpregnant patient without penicillin allergy?

Azithromycin 2 g PO once
Aqueous penicillin G IV for 14 days
Benzathine penicillin G 2.4 million units IM once (Correct answer)
Doxycycline 100 mg BID for 7 days

Correct answer: Benzathine penicillin G 2.4 million units IM once

Early syphilis (primary, secondary, or early latent) is treated with one IM dose of benzathine penicillin G 2.4 million units.

Question 139: A 55-year-old is newly diagnosed with moderate-to-severe, active rheumatoid arthritis. Which of the following disease-modifying antirheumatic drugs (DMARDs) is most commonly recommended as initial monotherapy?

Hydroxychloroquine
Adalimumab
Prednisone
Methotrexate (Correct answer)

Correct answer: Methotrexate

Methotrexate is strongly recommended by the American College of Rheumatology (ACR) as the initial DMARD of choice for patients with moderate-to-severe rheumatoid arthritis. It serves as the anchor drug in RA therapy. Adalimumab is a biologic DMARD, typically added later if methotrexate monotherapy is insufficient. Hydroxychloroquine is generally used for milder disease. Prednisone is a corticosteroid used for bridging therapy or controlling flares but not as a long-term monotherapy DMARD.

Question 140: A 34-year-old male complains of recurrent episodes of excruciating, unilateral pain behind his right eye, which he describes as a 'hot poker' sensation. The attacks last for 60-90 minutes and occur several times a day for weeks at a time. During these episodes, he also experiences right-sided nasal congestion and tearing from his right eye. Which of the following is the most likely diagnosis?

Migraine with aura
Trigeminal neuralgia
Tension-type headache
Cluster headache (Correct answer)

Correct answer: Cluster headache

This patient's presentation is classic for a cluster headache. Key features include the severe, unilateral, periorbital pain of relatively short duration, occurring in cyclical 'clusters'. The associated ipsilateral autonomic symptoms (lacrimation, nasal congestion) are also characteristic of this headache syndrome. [3, 16, 17] Migraines are typically throbbing and last longer. Tension headaches are bilateral and pressing. Trigeminal neuralgia involves brief, electric shock-like pains in the distribution of the trigeminal nerve.

Question 141: A 66-year-old male with a significant smoking history presents with increased dyspnea, wheezing, and a change in sputum color from white to green over the past three days. His baseline oxygen saturation is 91% on 2L nasal cannula, but today it is 87%. According to the GOLD guidelines, which of the following is the most critical initial intervention for his acute COPD exacerbation?

Administer high-flow oxygen to achieve an SpO2 of >95%
Obtain an urgent CT angiogram of the chest
Initiate systemic corticosteroids and inhaled short-acting bronchodilators (Correct answer)
Start broad-spectrum intravenous antibiotics immediately

Correct answer: Initiate systemic corticosteroids and inhaled short-acting bronchodilators

The cornerstones of managing an acute COPD exacerbation are rapid-acting inhaled bronchodilators (beta-agonists and anticholinergics) to relieve bronchospasm and systemic glucocorticoids to reduce airway inflammation. While oxygen is necessary for hypoxemia, the target saturation is typically 88-92% to avoid suppressing the hypoxic respiratory drive. Antibiotics are indicated for increased sputum purulence (as seen here), but bronchodilators and steroids are the priority intervention. A CT angiogram would be considered if pulmonary embolism was highly suspected but is not the first-line step for a typical exacerbation.

Question 142: On thyroid examination, which technique best differentiates a thyroid mass from another neck mass?

Transilluminate the mass
Auscultate for a bruit over the mass
Palpate for lymph nodes in the posterior triangle
Ask the patient to swallow and observe if the mass moves superiorly (Correct answer)

Correct answer: Ask the patient to swallow and observe if the mass moves superiorly

Thyroid masses move upward with swallowing because the thyroid is attached to the trachea by the pretracheal fascia.

Question 143: A patient with gout and hyperuricemia is started on allopurinol. When should urate-lowering therapy ideally begin relative to an acute gout flare?

Six months after the last flare
Only after the acute flare has resolved, typically 2-4 weeks later (Correct answer)
Only after two confirmed flares
Immediately during the acute attack

Correct answer: Only after the acute flare has resolved, typically 2-4 weeks later

Initiating urate-lowering therapy during an acute flare can prolong or worsen symptoms; it is generally started 2-4 weeks after resolution.

Question 144: A patient with newly diagnosed seizure disorder is started on phenytoin. Which finding on CBC would be a serious adverse effect requiring dose adjustment?

Mild thrombocytosis
Basophilia
Megaloblastic anemia (Correct answer)
Polycythemia vera

Correct answer: Megaloblastic anemia

Phenytoin inhibits folate absorption, leading to megaloblastic anemia; folic acid supplementation may be necessary.

Question 145: A 45-year-old man has resistant hypertension despite three antihypertensives and persistent hypokalemia. The aldosterone-to-renin ratio is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism (Conn's syndrome) (Correct answer)
Cushing's syndrome
Pheochromocytoma
Renovascular hypertension

Correct answer: Primary hyperaldosteronism (Conn's syndrome)

Primary hyperaldosteronism causes autonomous aldosterone excess, resulting in resistant hypertension, hypokalemia, and an elevated aldosterone-to-renin ratio.

Question 146: Which of the following diseases, which can be brought on by heart failure, features bouts of deep breathing interspersed with periods of no breathing?

Kussmaul breathing (Correct answer)
Tachypnea
Obstructive breathing
Ataxic breathing

Correct answer: Kussmaul breathing

Kussmaul breathing is characterized by deep, rapid, and labored breathing, which is a compensatory mechanism for severe metabolic acidosis. While typically associated with conditions like diabetic ketoacidosis, advanced heart failure can lead to poor tissue perfusion and lactic acidosis, triggering this profound breathing pattern to expel excess carbon dioxide. Although the description 'interspersed with periods of no breathing' more accurately describes Cheyne-Stokes respiration, Kussmaul breathing represents a severe, deep respiratory effort that can manifest in the context of advanced heart failure and its metabolic complications.

Question 147: Fluorescein staining reveals a branching dendritic ulcer on the cornea. Which medication should be avoided?

Oral acyclovir
Topical corticosteroids (Correct answer)
Topical trifluridine
Topical ganciclovir gel

Correct answer: Topical corticosteroids

Topical steroids can worsen HSV epithelial keratitis and lead to corneal perforation.

Question 148: Preload in cardiac physiology refers to which hemodynamic parameter?

Aortic diastolic pressure
Heart rate at rest
Systemic vascular resistance
End-diastolic ventricular volume (or pressure) (Correct answer)

Correct answer: End-diastolic ventricular volume (or pressure)

Preload represents the degree of ventricular stretch before contraction, best approximated by end-diastolic volume, and follows the Frank-Starling mechanism.

Question 149: A patient with minimal or no physical symptoms is persistently convinced she has cancer despite repeated negative workups. What is the most likely diagnosis?

Factitious disorder
Conversion disorder
Somatic symptom disorder
Illness anxiety disorder (Correct answer)

Correct answer: Illness anxiety disorder

Preoccupation with having a serious illness despite minimal somatic symptoms defines illness anxiety disorder.

Question 150: A patient has a bright red, raised, sharply demarcated, indurated plaque on the cheek with fever. Which organism is most likely?

Streptococcus pyogenes (Correct answer)
Pasteurella multocida
Staphylococcus aureus
Pseudomonas aeruginosa

Correct answer: Streptococcus pyogenes

Erysipelas involves the upper dermis and superficial lymphatics and is most often caused by group A streptococcus.

Question 151: A 35-year-old patient describes a history of debilitating, unilateral, throbbing headaches occurring 2-3 times per month, accompanied by photophobia and nausea. Which of the following is the most appropriate first-line abortive medication for moderate to severe acute attacks?

Sumatriptan (Correct answer)
Amitriptyline
Propranolol
Verapamil

Correct answer: Sumatriptan

Triptans, such as sumatriptan, are serotonin 1B/1D receptor agonists and are considered first-line abortive therapy for moderate to severe migraine headaches. Propranolol and amitriptyline are used for migraine prophylaxis (prevention), not for treating an acute attack. Verapamil is more commonly used for the prophylaxis of cluster headaches.

Question 152: Which of the following tests is most accurate for determining whether someone has primary hypothyroidism?

Determining thyroxine levels
Determining triiodothyronine levels
Determining thyroid stimulating hormone (TSH) levels (Correct answer)
Determining T4 levels

Correct answer: Determining thyroid stimulating hormone (TSH) levels

In primary hypothyroidism, the thyroid gland itself is underactive, leading to insufficient production of thyroid hormones (T3 and T4). The pituitary gland, sensing these low hormone levels, compensates by increasing the secretion of Thyroid Stimulating Hormone (TSH) in an attempt to stimulate the thyroid. Therefore, an elevated TSH level is the most sensitive and accurate indicator of primary hypothyroidism, often rising even before T4 levels significantly drop.

Question 153: Which of the following is the most common cause of primary hypothyroidism in the United States?

Hashimoto's thyroiditis (Correct answer)
Iodine deficiency
Subacute thyroiditis
Surgical thyroidectomy

Correct answer: Hashimoto's thyroiditis

Hashimoto's thyroiditis is an autoimmune condition and the most common cause of primary hypothyroidism in iodine-sufficient countries.

Question 154: A patient with potassium of 7.0 mEq/L has widened QRS complexes. What is the first treatment to give?

IV calcium gluconate (Correct answer)
Oral sodium bicarbonate
Sodium polystyrene sulfonate
Furosemide

Correct answer: IV calcium gluconate

IV calcium stabilizes the cardiac membrane immediately but does not lower potassium.

Question 155: A KOH prep of hypopigmented scaly macules on the upper back shows a 'spaghetti and meatballs' pattern. Which organism is responsible?

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

Correct answer: Malassezia furfur

Tinea (pityriasis) versicolor is caused by Malassezia yeast showing short hyphae and spores on KOH.

Question 156: A patient from Arizona has a community-acquired pneumonia-like illness, erythema nodosum, and arthralgias. What is the most likely organism?

Cryptococcus gattii
Histoplasma capsulatum
Blastomyces dermatitidis
Coccidioides immitis (Correct answer)

Correct answer: Coccidioides immitis

Coccidioidomycosis (valley fever) is endemic to the Southwest and often presents with pneumonia, erythema nodosum, and arthralgias ('desert rheumatism').

Question 157: According to the 2021 United States Preventive Services Task Force (USPSTF) recommendations, which of the following patients is the most appropriate candidate for annual low-dose computed tomography (LDCT) screening for lung cancer?

A 45-year-old current smoker with a 25 pack-year history.
A 65-year-old current smoker with a 25 pack-year history. (Correct answer)
An 82-year-old former smoker with a 40 pack-year history who quit 10 years ago.
A 70-year-old who quit smoking 20 years ago but had a 30 pack-year history.

Correct answer: A 65-year-old current smoker with a 25 pack-year history.

The 2021 USPSTF guidelines recommend annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. The 65-year-old patient meets all three criteria (age, pack-year history, and current smoking status). The 70-year-old is ineligible because they quit more than 15 years ago. The 45-year-old is too young, and the 82-year-old is too old.

Question 158: A hiker in North Carolina has fever, headache, and a petechial rash that started on the wrists and ankles and spread to the palms and soles. What is the empiric treatment?

Ceftriaxone
Amoxicillin
Azithromycin
Doxycycline (Correct answer)

Correct answer: Doxycycline

Suspected Rocky Mountain spotted fever should be treated right away with doxycycline at any age, because delay increases mortality.

Question 159: A patient in diabetic ketoacidosis develops facial pain, nasal congestion, and a black necrotic eschar on the nasal turbinate. What is the most likely diagnosis?

Aspergilloma
Rhinocerebral mucormycosis (Correct answer)
Wegener granulomatosis
Nasal squamous cell carcinoma

Correct answer: Rhinocerebral mucormycosis

Mucormycosis is an angioinvasive fungal infection in DKA patients requiring emergent debridement and amphotericin B.

Question 160: Who established MEDEX?

Eugene Stead
Henry Silver
Charles Hudson
Richard Smith (Correct answer)

Correct answer: Richard Smith

MEDEX (Medicine Extension) was established in 1969 by Richard Smith and John Coombs at the University of Washington School of Medicine in Seattle, Washington, to train physician assistants to provide primary care services in rural and underserved areas.

Question 161: A patient with a vesicular rash on the forehead also has vesicles on the tip of the nose. What does this finding predict?

Involvement of the maxillary branch of CN V
Increased risk of ocular involvement (Correct answer)
Postherpetic neuralgia will not occur
Bacterial superinfection of the rash

Correct answer: Increased risk of ocular involvement

Hutchinson sign reflects nasociliary nerve involvement and strongly predicts herpes zoster ophthalmicus with eye complications.

Question 162: A patient with Clostridium difficile infection (CDI) has a first recurrence after metronidazole treatment. What is the preferred management?

IV metronidazole plus oral vancomycin
Fidaxomicin or vancomycin tapered/pulsed regimen (Correct answer)
Repeat metronidazole course
Oral vancomycin standard course

Correct answer: Fidaxomicin or vancomycin tapered/pulsed regimen

IDSA guidelines recommend fidaxomicin or a vancomycin tapered/pulsed regimen for first recurrence of CDI to reduce further recurrence rates.

Question 163: Which medication is first-line for a patient with major depressive disorder and no contraindications?

Alprazolam
Haloperidol
Lithium
Sertraline (Correct answer)

Correct answer: Sertraline

SSRIs such as sertraline, escitalopram and fluoxetine are first-line for major depressive disorder because of their efficacy and safety profile.

Question 164: A 75-year-old female is being treated for heart failure with reduced ejection fraction (HFrEF). Which of the following medication classes has been shown to improve mortality in patients with HFrEF and should be considered a cornerstone of therapy?

Beta-blockers (Correct answer)
Loop diuretics
Digoxin
Calcium channel blockers

Correct answer: Beta-blockers

Beta-blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) are one of the primary classes of medications, along with ACE inhibitors/ARBs/ARNIs, that have been proven to reduce mortality and hospitalizations in patients with HFrEF. Loop diuretics manage symptoms but do not improve mortality. Digoxin can reduce hospitalizations but does not have a mortality benefit. Most calcium channel blockers are not recommended in HFrEF.

Question 165: A 24-year-old has had hallucinations and disorganized speech for 3 months with no mood episodes or substance use. What is the most likely diagnosis?

Delusional disorder
Schizophreniform disorder (Correct answer)
Schizophrenia
Brief psychotic disorder

Correct answer: Schizophreniform disorder

Schizophrenia-like symptoms lasting 1 to 6 months meet criteria for schizophreniform disorder.

Question 166: A patient has fever, productive cough and lobar consolidation. Which organism is the most common cause of community-acquired pneumonia?

Klebsiella pneumoniae
Pneumocystis jirovecii
Streptococcus pneumoniae (Correct answer)
Pseudomonas aeruginosa

Correct answer: Streptococcus pneumoniae

Streptococcus pneumoniae is the most common cause of community-acquired bacterial pneumonia in adults.

Question 167: Which of the following is the most appropriate initial imaging study for a patient with suspected osteoporosis?

MRI of the hip
Plain X-ray of the spine
DEXA scan (Correct answer)
CT scan of the lumbar spine

Correct answer: DEXA scan

DEXA (dual-energy X-ray absorptiometry) scan is the gold standard for measuring bone mineral density and diagnosing osteoporosis.

Question 168: A 45-year-old with resistant hypertension and spontaneous hypokalemia needs screening for the most likely secondary cause. Which test is best?

Overnight dexamethasone suppression test
24-hour urine metanephrines
Plasma aldosterone-to-renin ratio (Correct answer)
Renal artery duplex ultrasound

Correct answer: Plasma aldosterone-to-renin ratio

Primary aldosteronism is screened with an elevated plasma aldosterone concentration to plasma renin activity ratio.

Question 169: A 35-year-old man who is displaying severe psychotic symptoms is being examined by you. He also experiences hallucinations and delusions. Additionally, he has a history of hypertrophic cardiomyopathy. Which of the following drugs would you be extremely hesitant to administer to this patient?

Oxazepam (Serax)
Lithium carbonate (Lithobid)
Olanzapine (Zyprexa)
Diazepam (Valium)
Haloperidol (Haldol) (Correct answer)

Correct answer: Haloperidol (Haldol)

Given the patient's history of hypertrophic cardiomyopathy and severe psychotic symptoms, administering haloperidol (Haldol) would be extremely hesitant. Haloperidol belongs to a class of antipsychotic medications known as typical antipsychotics, and it has the potential to cause significant cardiac side effects, including arrhythmias, QT prolongation, and sudden cardiac death. These effects can be particularly risky for patients with pre-existing cardiac conditions such as hypertrophic cardiomyopathy.

Question 170: Which laboratory finding best supports prerenal acute kidney injury?

Urine sodium greater than 40 mEq/L
FENa greater than 2%
FENa less than 1% (Correct answer)
Urine osmolality below 350 mOsm/kg

Correct answer: FENa less than 1%

Intact tubules avidly reabsorb sodium in prerenal states, giving a FENa below 1%.

Question 171: A patient with medullary thyroid carcinoma is found to have a RET proto-oncogene mutation. Which familial syndrome should be investigated?

Multiple Endocrine Neoplasia Type 1 (MEN1)
Multiple Endocrine Neoplasia Type 2 (MEN2) (Correct answer)
Von Hippel-Lindau disease
Neurofibromatosis type 1

Correct answer: Multiple Endocrine Neoplasia Type 2 (MEN2)

Medullary thyroid carcinoma is a component of MEN2, which is caused by RET proto-oncogene mutations and also includes pheochromocytoma.

Question 172: The renin-angiotensin-aldosterone system (RAAS) is activated primarily by which stimulus?

Decreased renal perfusion pressure (Correct answer)
Elevated serum sodium
Hyperkalemia alone
Increased atrial natriuretic peptide

Correct answer: Decreased renal perfusion pressure

Decreased renal perfusion pressure triggers juxtaglomerular cells to release renin, initiating the RAAS cascade to restore blood pressure and volume.

Question 173: What is the minimum symptom duration required for a diagnosis of generalized anxiety disorder?

1 month
2 years
2 weeks
6 months (Correct answer)

Correct answer: 6 months

GAD requires excessive worry occurring more days than not for at least 6 months.

Question 174: In an 8-month-old with atopic dermatitis, which distribution is most typical?

Diaper area
Cheeks, scalp, and extensor surfaces (Correct answer)
Antecubital and popliteal flexures only
Palms and soles

Correct answer: Cheeks, scalp, and extensor surfaces

Infantile atopic dermatitis favors the face and extensor surfaces, sparing the diaper area, while older children and adults have flexural involvement.

Question 175: A child has periorbital edema, proteinuria over 3.5 g/day, hypoalbuminemia and hyperlipidemia. What is the most common cause in children?

IgA nephropathy
Diabetic nephropathy
Minimal change disease (Correct answer)
Poststreptococcal glomerulonephritis

Correct answer: Minimal change disease

These findings describe nephrotic syndrome. Minimal change disease is the most common cause in children and responds well to corticosteroids.

Question 176: Two days after parathyroidectomy for severe primary hyperparathyroidism, a patient develops perioral numbness and a positive Chvostek sign. Which lab pattern is expected with hungry bone syndrome?

High calcium, low phosphate, high PTH
Normal calcium, high magnesium, high phosphate
Low calcium, low phosphate, low magnesium (Correct answer)
Low calcium, high phosphate, low PTH only

Correct answer: Low calcium, low phosphate, low magnesium

Rapid bone remineralization after PTH drop pulls calcium, phosphate, and magnesium out of the serum.

Question 177: A teenager has an anterior epistaxis that does not stop. After the patient leans forward, what is the best first step?

Posterior nasal packing
Immediate surgical ligation
Sustained pressure on the soft part of the nose for 10-15 minutes (Correct answer)
Lie supine with the head back

Correct answer: Sustained pressure on the soft part of the nose for 10-15 minutes

Most epistaxis is anterior, from Kiesselbach's plexus. Initial management is sitting forward and applying firm pressure to the nostrils for 10-15 minutes, then topical vasoconstrictors or packing if needed.

Question 178: A 30-year-old has mild asymptomatic hypercalcemia, high-normal PTH, and a calcium-to-creatinine clearance ratio of 0.005; her father has similar labs. What is the best management?

Bisphosphonate therapy
Cinacalcet
Reassurance and no surgery (Correct answer)
Parathyroidectomy

Correct answer: Reassurance and no surgery

Familial hypocalciuric hypercalcemia is a benign CaSR mutation that does not improve with parathyroidectomy.

Question 179: A patient with HIV has multiple ring-enhancing brain lesions and a positive Toxoplasma IgG. What is the first-line treatment?

Ceftriaxone and vancomycin
Amphotericin B
Pyrimethamine, sulfadiazine, and leucovorin (Correct answer)
Ganciclovir

Correct answer: Pyrimethamine, sulfadiazine, and leucovorin

CNS toxoplasmosis is treated with pyrimethamine plus sulfadiazine, with leucovorin given to prevent bone marrow suppression.

Question 180: A euvolemic patient with small cell lung cancer has serum sodium 124 mEq/L. Which lab pattern supports SIADH?

Serum osm low, urine osm >100, urine Na >40 (Correct answer)
Serum osm low, urine osm <100, urine Na <20
Serum osm high, urine osm low, urine Na <20
Serum osm normal, urine osm high, urine Na <10

Correct answer: Serum osm low, urine osm >100, urine Na >40

SIADH causes hypotonic hyponatremia with inappropriately concentrated urine and elevated urine sodium in a euvolemic patient.

Question 181: A 40-year-old woman presents with moon facies, central obesity, purple striae, and easy bruising. 24-hour urinary free cortisol is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism
Acromegaly
Cushing's syndrome (Correct answer)
Addison's disease

Correct answer: Cushing's syndrome

Cushing's syndrome results from chronic excess cortisol and presents with moon facies, buffalo hump, purple striae, and central obesity.

Question 182: What is the most common cause of osteomyelitis in adults in the United States?

Pseudomonas aeruginosa
Streptococcus pyogenes
Staphylococcus aureus (Correct answer)
Escherichia coli

Correct answer: Staphylococcus aureus

Staphylococcus aureus is the most common causative organism of osteomyelitis in adults, accounting for the majority of hematogenous and contiguous cases.

Question 183: A researcher wants to determine the median of the following data set: 7, 3, 12, 5, 9. What is the median?

5
7 (Correct answer)
3
9

Correct answer: 7

Ordered: 3, 5, 7, 9, 12 — the middle value is 7.

Question 184: A 22-year-old man has gross hematuria 1-2 days after an upper respiratory infection. What is the most likely diagnosis?

Membranous nephropathy
Minimal change disease
IgA nephropathy (Correct answer)
Post-streptococcal glomerulonephritis

Correct answer: IgA nephropathy

IgA nephropathy classically causes synpharyngitic hematuria within days of a mucosal infection.

Question 185: Which histologic feature is the most important prognostic factor in a newly diagnosed localized cutaneous melanoma?

Clark level
Breslow thickness (Correct answer)
Lesion diameter
Color variegation

Correct answer: Breslow thickness

Breslow depth (thickness in mm) is the strongest prognostic factor for localized melanoma and guides staging.

Question 186: A patient is found unresponsive with pinpoint pupils and a respiratory rate of 6/min. What is the most appropriate initial pharmacologic treatment?

Flumazenil
Physostigmine
Naloxone (Correct answer)
Activated charcoal

Correct answer: Naloxone

Miosis with respiratory depression suggests opioid toxicity, which is reversed by naloxone.

Question 187: A 55-year-old male with a history of poorly controlled hypertension presents with a headache and confusion. His blood pressure is measured at 220/130 mmHg. Fundoscopic examination reveals papilledema. Which of the following is the most appropriate immediate step in management?

Admit to the ICU and initiate an intravenous antihypertensive infusion (Correct answer)
Schedule an outpatient cardiology consultation for the following week
Administer oral clonidine and discharge home with follow-up
Prescribe a high-dose oral diuretic and recheck blood pressure in 24 hours

Correct answer: Admit to the ICU and initiate an intravenous antihypertensive infusion

This patient is presenting with a hypertensive emergency, defined as severely elevated blood pressure (typically >180/120 mmHg) with evidence of end-organ damage (in this case, papilledema indicating hypertensive encephalopathy). The standard of care is immediate admission to an ICU for continuous monitoring and a controlled reduction of blood pressure using an intravenous antihypertensive agent like nicardipine or labetalol.

Question 188: A 28-year-old woman with Type 1 DM is found unresponsive with fingerstick glucose of 28 mg/dL. No IV access is available. What is the most appropriate immediate treatment?

Intramuscular glucagon injection (Correct answer)
Oral glucose gel under the tongue
Dextrose 50% IV push
Orange juice by mouth

Correct answer: Intramuscular glucagon injection

IM glucagon is the correct treatment for an unconscious hypoglycemic patient without IV access, as oral agents cannot be safely administered.

Question 189: What causes a hypercoagulable state the majority of the time?

Prothrombin gene mutation
Factor V Leiden mutation (Correct answer)
Antiphospholipid antibody syndrome
Antithrombin III deficiency
Nephrotic syndrome

Correct answer: Factor V Leiden mutation

The Factor V Leiden mutation is one of the most common genetic causes of a hypercoagulable state. In this genetic condition, a mutation in the Factor V gene leads to a form of the protein resistant to inactivation by activated protein C, which normally helps to prevent blood clotting. This can increase the risk of developing blood clots, especially in the veins (venous thrombosis), which can lead to deep vein thrombosis (DVT) or pulmonary embolism (PE). Other common causes of a hypercoagulable state include deficiencies in anticoagulant proteins such as protein C, protein S, and antithrombin III and acquired conditions such as cancer, pregnancy, and certain medications.

Question 190: Carpal tunnel syndrome results from compression of which nerve?

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

Correct answer: Median nerve

Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel, causing numbness and tingling in the thumb, index, middle, and radial half of the ring finger.

Question 191: After a delivery complicated by massive hemorrhage, a woman is unable to breastfeed and later develops amenorrhea and fatigue. What is the most likely cause?

Postpartum thyroiditis
Sheehan syndrome (Correct answer)
Prolactinoma
Lymphocytic hypophysitis

Correct answer: Sheehan syndrome

Postpartum pituitary ischemic necrosis causes hypopituitarism, with failure of lactation often the first sign.

Question 192: A 68-year-old female with diabetes presents with a 3-day history of fever, productive cough, and new-onset confusion. On examination, her respiratory rate is 32 breaths/min, blood pressure is 88/58 mmHg, and her BUN is 25 mg/dL. Which of the following is the most appropriate action based on the CURB-65 score?

Observe in the emergency department for 4-6 hours before making a disposition decision
Discharge home with oral antibiotics
Admit to the intensive care unit for management of severe pneumonia (Correct answer)
Admit to a general medical ward for inpatient treatment

Correct answer: Admit to the intensive care unit for management of severe pneumonia

The patient scores 4 points on the CURB-65 scale: Confusion (1), Urea >20 mg/dL (1), Respiratory rate ≥30 (1), and Blood pressure <90 systolic (1). A score of 3 or more indicates severe pneumonia with a high risk of mortality, warranting urgent admission to the hospital, typically to an intensive care unit (ICU), for aggressive management.

Question 193: Which of the following BEST illustrates a non sequitur in argumentation?

She is an excellent surgeon, so she would make a great PA educator. (Correct answer)
All antibiotics kill bacteria; penicillin is an antibiotic; therefore penicillin kills bacteria.
Studies show exercise reduces blood pressure, so patients should exercise more.
The patient's fever broke after treatment, suggesting the medication was effective.

Correct answer: She is an excellent surgeon, so she would make a great PA educator.

A non sequitur presents a conclusion that does not logically follow from the premise; surgical skill does not necessarily translate to teaching ability.

Question 194: Which physical exam finding is most specific for medial meniscus tear?

Positive Lachman test
Positive McMurray test with medial joint line pain (Correct answer)
Positive anterior drawer test
Positive valgus stress test

Correct answer: Positive McMurray test with medial joint line pain

The McMurray test with clicking and medial joint line pain during knee extension from a flexed position is most specific for a medial meniscus tear.

Question 195: A 58-year-old male with type 2 diabetes, hypertension, and a history of myocardial infarction has an A1c of 8.1% despite being on metformin. Which of the following medication classes, when added to his regimen, has been shown to reduce cardiovascular mortality in patients with established atherosclerotic cardiovascular disease?

Sulfonylureas
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors (Correct answer)
Dipeptidyl peptidase-4 (DPP-4) inhibitors
Thiazolidinediones (TZDs)

Correct answer: Sodium-glucose cotransporter-2 (SGLT-2) inhibitors

For patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD), SGLT-2 inhibitors (e.g., empagliflozin, canagliflozin) have demonstrated a significant benefit in reducing cardiovascular mortality and hospitalizations for heart failure. While DPP-4 inhibitors, sulfonylureas, and TZDs are effective at lowering blood glucose, they have not shown the same cardiovascular mortality benefit in this high-risk population.

Question 196: In psoriasis, the Koebner phenomenon refers to which finding?

New lesions developing at sites of skin trauma (Correct answer)
Blister extension with lateral pressure
Urtication after stroking a lesion
Pinpoint bleeding when scale is removed

Correct answer: New lesions developing at sites of skin trauma

Koebnerization is the appearance of psoriatic lesions at sites of injury such as scratches or surgical scars.

Question 197: A patient reports painful swelling under the jaw that worsens during meals. Which gland is most commonly affected by sialolithiasis?

Submandibular gland (Correct answer)
Minor salivary glands
Sublingual gland
Parotid gland

Correct answer: Submandibular gland

About 80–90% of salivary stones form in the submandibular gland due to its viscous, alkaline saliva and upward-draining Wharton duct.

Question 198: A patient with HIV and a CD4 count of 40 cells/mm³ has fever, weight loss, and diarrhea, and blood cultures grow acid-fast bacilli. What is the most likely organism?

Mycobacterium leprae
Mycobacterium tuberculosis
Mycobacterium marinum
Mycobacterium avium complex (Correct answer)

Correct answer: Mycobacterium avium complex

Disseminated MAC typically occurs when CD4 is below 50 cells/mm³ and presents with fever, weight loss, diarrhea, and mycobacteremia.

Question 199: A hospitalized patient with severe anorexia nervosa develops heart failure and weakness 3 days after starting nutritional rehabilitation. Which electrolyte abnormality is most characteristic?

Hyperkalemia
Hypercalcemia
Hypophosphatemia (Correct answer)
Hypernatremia

Correct answer: Hypophosphatemia

Refeeding syndrome is hallmarked by hypophosphatemia as insulin drives phosphate into cells.

Question 200: Which of the following is the most important initial intervention in the management of Diabetic Ketoacidosis (DKA)?

Oral potassium replacement
Sodium bicarbonate infusion
IV insulin bolus
IV fluid resuscitation with normal saline (Correct answer)

Correct answer: IV fluid resuscitation with normal saline

IV fluid resuscitation is the most critical initial step in DKA to correct severe dehydration before initiating insulin therapy.

Question 201: A 50-year-old woman presents with fatigue, weight gain, cold intolerance, constipation, and dry skin. TSH is 9.2 mIU/L and free T4 is low. What is the first-line treatment?

Methimazole
Radioactive iodine ablation
Propylthiouracil
Levothyroxine (Correct answer)

Correct answer: Levothyroxine

Primary hypothyroidism is treated with levothyroxine (synthetic T4) to replace the deficient thyroid hormone.

Question 202: Which of the following conditions is typically accompanied by loss of weight, depression, exhaustion, and recurrent, vague stomach pain?

Cushing syndrome
Adrenocortical insufficiency
Pancreatic carcinoma (Correct answer)
Pheochromocytoma

Correct answer: Pancreatic carcinoma

Always keep pancreatic cancer in mind when treating depressed middle-aged individuals. Weight loss, stomach ache, apathy, low energy, lethargy, anhedonia, and sadness are a few of its symptoms.

Question 203: Which of the following cardiovascular disorders frequently exhibits an irregularly irregular pulse as a typical clinical sign?

Atrial fibrillation (Correct answer)
Cardiomegaly
Ventricular fibrillation
CHF

Correct answer: Atrial fibrillation

Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to uncoordinated atrial contractions. This results in an irregular transmission of impulses to the ventricles, causing the heart to beat in a completely unpredictable and irregular rhythm. This distinct pattern is clinically recognized as an irregularly irregular pulse, making it a hallmark sign of atrial fibrillation.

Question 204: A hiker has an expanding erythematous rash with central clearing, fatigue and arthralgias after a tick bite in the Northeast. What is the best treatment?

Acyclovir
Doxycycline (Correct answer)
Fluconazole
Ivermectin

Correct answer: Doxycycline

This is early Lyme disease caused by Borrelia burgdorferi (erythema migrans). Doxycycline for 10 days is first-line for adults.

Question 205: All of the following are true with regard to the EKG findings of premature atrial contractions EXCEPT:

The QRS is usually narrow
P waves are invariably absent (Correct answer)
P waves may be present
Extra P waves may be hidden within the QRS complex or T waves

Correct answer: P waves are invariably absent

Premature atrial contractions (PACs) originate in the atria, meaning there must be an atrial depolarization event, which manifests as a P wave on an EKG. While the P wave may be abnormal in shape, hidden within other waves, or premature, its complete and invariable absence is characteristic of rhythms like atrial fibrillation, not PACs.

Question 206: Which finding is most characteristic of psoriasis vulgaris?

Flaccid bullae with a positive Nikolsky sign
Honey-colored crusted lesions
Target lesions on the palms
Silvery-scaled erythematous plaques on extensor surfaces (Correct answer)

Correct answer: Silvery-scaled erythematous plaques on extensor surfaces

Psoriasis causes well-demarcated erythematous plaques with silvery scale, typically on the elbows, knees and scalp. The Auspitz sign (pinpoint bleeding when scale is removed) may be present.

Question 207: A patient from Connecticut has fever, leukopenia, thrombocytopenia, and elevated transaminases after a tick bite, with morulae seen in neutrophils. What is the most likely diagnosis?

Tularemia
Human granulocytic anaplasmosis (Correct answer)
Lyme disease
Babesiosis

Correct answer: Human granulocytic anaplasmosis

Anaplasmosis, transmitted by Ixodes ticks, shows morulae in granulocytes along with cytopenias and transaminitis.

Question 208: A patient has hemoptysis and rapidly progressive glomerulonephritis with linear IgG deposits on immunofluorescence. What is the diagnosis?

Henoch-Schonlein purpura
Goodpasture syndrome (Correct answer)
Lupus nephritis
Granulomatosis with polyangiitis

Correct answer: Goodpasture syndrome

Linear IgG deposition along the GBM is characteristic of anti-GBM (Goodpasture) disease.

Question 209: Well-demarcated depigmented macules on the hands and periorificial face that fluoresce chalk-white under Wood lamp are most associated with which condition?

Autoimmune thyroid disease (Correct answer)
Rheumatic fever
Lyme disease
Hemochromatosis

Correct answer: Autoimmune thyroid disease

Vitiligo is an autoimmune melanocyte disorder frequently associated with autoimmune thyroid disease.

Question 210: A patient presents with sudden severe headache, nuchal rigidity, photophobia, and fever. CSF analysis shows cloudy fluid, elevated protein, low glucose, and neutrophilic pleocytosis. What is the most appropriate immediate treatment?

IV ceftriaxone and dexamethasone empirically (Correct answer)
IV acyclovir only
Oral amoxicillin and close outpatient follow-up
Await culture results before starting antibiotics

Correct answer: IV ceftriaxone and dexamethasone empirically

Bacterial meningitis is a medical emergency; empiric IV ceftriaxone and dexamethasone (to reduce inflammation) should be started immediately without waiting for culture results.

Question 211: A 65-year-old male presents with sudden onset right-sided facial droop, arm weakness, and aphasia that resolved completely within 45 minutes. What is the most likely diagnosis?

Transient ischemic attack (TIA) (Correct answer)
Complex migraine
Ischemic stroke
Todd's paralysis

Correct answer: Transient ischemic attack (TIA)

A transient ischemic attack (TIA) presents with stroke-like symptoms that resolve completely within 24 hours (typically minutes), with no infarction on imaging.

Question 212: A 70-year-old woman sustains a hip fracture after a minor fall. DEXA shows a T-score of -3.1. Which bisphosphonate is FDA-approved for reducing fracture risk in postmenopausal osteoporosis?

Colchicine
Methotrexate
Alendronate (Correct answer)
Raloxifene

Correct answer: Alendronate

Alendronate is a bisphosphonate FDA-approved for treating postmenopausal osteoporosis and reducing vertebral, hip, and nonvertebral fracture risk.

Question 213: A 55-year-old woman presents with bilateral knee pain worse with activity and relieved by rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Psoriatic arthritis
Gout
Rheumatoid arthritis
Osteoarthritis (Correct answer)

Correct answer: Osteoarthritis

Osteoarthritis is characterized by joint space narrowing, osteophytes, and pain worsened by activity, most commonly affecting weight-bearing joints.

Question 214: A 55-year-old man with Type 2 DM, HbA1c 9.5%, BMI 34, and established cardiovascular disease is on metformin and a sulfonylurea. Which additional agent provides the most proven cardiovascular mortality benefit?

Empagliflozin (SGLT2 inhibitor) (Correct answer)
Pioglitazone
Glargine insulin
Sitagliptin (DPP-4 inhibitor)

Correct answer: Empagliflozin (SGLT2 inhibitor)

SGLT2 inhibitors such as empagliflozin have demonstrated significant cardiovascular mortality reduction in patients with established cardiovascular disease and Type 2 DM.

Question 215: A diabetic patient has severe pain disproportionate to the exam, rapidly spreading erythema, crepitus, and hemodynamic instability. What is the most important next step?

Emergent surgical debridement plus broad-spectrum antibiotics (Correct answer)
Warm compresses and elevation
Outpatient oral cephalexin
MRI before any intervention

Correct answer: Emergent surgical debridement plus broad-spectrum antibiotics

Necrotizing fasciitis is a surgical emergency, and imaging must not delay debridement and broad-spectrum IV antibiotics.

Question 216: At which well-child visits does the AAP recommend autism-specific screening with a tool such as the M-CHAT?

18 and 24 months (Correct answer)
Only when parents raise concerns
3 and 4 years
6 and 12 months

Correct answer: 18 and 24 months

The AAP recommends universal autism-specific screening at 18 and 24 months.

Question 217: A malnourished patient with alcohol use disorder presents with confusion, ophthalmoplegia, and ataxia. What should be given first?

IV naloxone
Oral folate
IV dextrose 50%
IV thiamine (Correct answer)

Correct answer: IV thiamine

Thiamine should be given before or with glucose to treat Wernicke encephalopathy and avoid precipitating it.

Question 218: Which of the following does NOT contribute to left-sided heart failure?

Endocarditis
Aortic valve disease
Pulmonary hypertension (Correct answer)
Mitral regurgitation

Correct answer: Pulmonary hypertension

Left-sided heart failure occurs when the left ventricle cannot effectively pump blood to the systemic circulation, often due to conditions affecting the left heart like mitral regurgitation or aortic valve disease. While severe left-sided heart failure can *lead to* pulmonary hypertension as blood backs up into the lungs, primary pulmonary hypertension itself is a condition of high pressure in the pulmonary arteries that primarily causes *right-sided* heart failure, as the right ventricle struggles to pump against this increased resistance.

Question 219: In critical reading, 'inferring' means:

Summarizing the author's argument
Identifying grammatical errors in the text
Drawing a conclusion based on evidence not directly stated (Correct answer)
Restating what the author explicitly wrote

Correct answer: Drawing a conclusion based on evidence not directly stated

Inference involves reading between the lines to reach conclusions supported by implicit evidence.

Question 220: A patient's apical pulse is palpated at the 6th intercostal space, anterior axillary line. This displacement suggests:

Normal variant in a thin patient
Right ventricular enlargement
Pericardial effusion
Left ventricular hypertrophy or dilation (Correct answer)

Correct answer: Left ventricular hypertrophy or dilation

The point of maximal impulse (PMI) displaced laterally and inferiorly from the 5th ICS, MCL suggests left ventricular enlargement.

Question 221: Of the following cells, which one develops into osteoblasts, which create bone for remodeling and repair?

Osteocytes
Osteogenic cells (Correct answer)
Osteoclasts
Osteons

Correct answer: Osteogenic cells

Osteogenic cells, also known as osteoprogenitor cells, are undifferentiated stem cells found in the periosteum and endosteum of bones. These specialized cells have the unique capacity to differentiate into osteoblasts. Osteoblasts are then responsible for synthesizing and secreting the organic matrix of bone, known as osteoid, and initiating its mineralization, which is crucial for bone formation, remodeling, and repair.

Question 222: A patient with celiac disease has intensely pruritic grouped vesicles on the elbows and buttocks. Which medication provides rapid symptom relief?

Dapsone (Correct answer)
Acyclovir
Methotrexate
Ivermectin

Correct answer: Dapsone

Dermatitis herpetiformis responds rapidly to dapsone, while a strict gluten-free diet is the long-term treatment.

Question 223: A T-score of -2.8 on DEXA scan indicates which diagnosis according to WHO criteria?

Osteoporosis (Correct answer)
Normal bone density
Severe osteoporosis with fracture
Osteopenia

Correct answer: Osteoporosis

A T-score of -2.5 or below indicates osteoporosis per WHO criteria; a T-score between -1.0 and -2.5 indicates osteopenia.

Question 224: A child has multiple firm, dome-shaped, flesh-colored papules with central umbilication on the trunk. Which virus causes these lesions?

Human papillomavirus
Coxsackievirus A16
Herpes simplex virus type 1
Poxvirus (Correct answer)

Correct answer: Poxvirus

Molluscum contagiosum is caused by a poxvirus and produces umbilicated papules.

Question 225: Bell's palsy involves dysfunction of which cranial nerve?

CN V (Trigeminal)
CN VII (Facial) (Correct answer)
CN X (Vagus)
CN IX (Glossopharyngeal)

Correct answer: CN VII (Facial)

Bell's palsy is idiopathic peripheral CN VII (facial nerve) palsy causing ipsilateral upper and lower facial weakness, distinguishing it from central causes which spare the forehead.

Question 226: A 6-year-old has ear pain, fever and a bulging, erythematous tympanic membrane with decreased mobility. What is the first-line antibiotic?

Azithromycin
Ciprofloxacin
Doxycycline
Amoxicillin (Correct answer)

Correct answer: Amoxicillin

Acute otitis media is treated first with high-dose amoxicillin. Alternatives such as amoxicillin-clavulanate or cephalosporins are used for treatment failure or recent amoxicillin exposure.

Question 227: A 7-year-old has a scaly patch of alopecia with broken hairs and posterior cervical lymphadenopathy; KOH shows hyphae. What is the appropriate treatment?

Oral griseofulvin (Correct answer)
Single-dose oral fluconazole
Topical nystatin
Topical ketoconazole alone

Correct answer: Oral griseofulvin

Tinea capitis requires systemic therapy such as griseofulvin or terbinafine because topicals cannot penetrate the hair shaft.

Question 228: A 45-year-old with type 2 diabetes and established cardiovascular disease is started on an antidiabetic agent. Which class has demonstrated cardiovascular mortality benefit?

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

Correct answer: SGLT-2 inhibitors

SGLT-2 inhibitors (e.g., empagliflozin) have demonstrated significant reduction in major adverse cardiovascular events in large outcome trials.

Question 229: Which of the following cardiovascular diseases has aberrant pupillary reflexes (Argyll Robertson pupil) as a potential cause?

Aortic regurgitation
Myocarditis
Thoracic aortic aneurysm (Correct answer)
Coarctation of the aorta

Correct answer: Thoracic aortic aneurysm

Syphilis of the central nervous system is characterized by the Argyll Robertson pupil, which constricts with accommodation but not in response to light. This condition frequently leads to thoracic aortic aneurysm.

Question 230: Which is the recommended treatment for uncomplicated gonorrhea?

Topical clindamycin
Oral penicillin V
Oral metronidazole
Ceftriaxone intramuscularly (Correct answer)

Correct answer: Ceftriaxone intramuscularly

Current CDC guidance recommends a single dose of intramuscular ceftriaxone for uncomplicated gonorrhea, and doxycycline is added if chlamydia has not been excluded.

Question 231: A patient with Type 1 DM presents with nausea, vomiting, abdominal pain, Kussmaul respirations, and fruity breath odor. Blood glucose is 380 mg/dL. What is the most likely diagnosis?

Lactic acidosis
Diabetic ketoacidosis (Correct answer)
Hyperosmolar hyperglycemic state
Alcoholic ketoacidosis

Correct answer: Diabetic ketoacidosis

DKA presents with hyperglycemia, anion gap metabolic acidosis, Kussmaul respirations, and fruity breath due to ketone production.

Question 232: The BEST way to strengthen an argument in an academic paper is to:

Use emotional language to persuade the reader
Present only one perspective without acknowledging counterarguments
Cite peer-reviewed evidence that directly supports the claim (Correct answer)
Repeat the thesis multiple times throughout the paper

Correct answer: Cite peer-reviewed evidence that directly supports the claim

Peer-reviewed evidence provides credible, verifiable support that directly strengthens academic arguments.

Question 233: Amt of time spent in school

Admissions test
% of females
Median age
Main difference between PA and physician (Correct answer)

Correct answer: Main difference between PA and physician

The main difference between a PA and a physician is the amount of time spent in school—physician training (medical school plus residency) takes substantially longer than the master's-level PA pathway. Female percentage, median age, and admissions tests are demographic or process details, not the fundamental structural difference between the two careers.

Question 234: A patient presents with pain in the heel that is worst with the first steps in the morning and improves after walking. What is the most likely diagnosis?

Tarsal tunnel syndrome
Plantar fasciitis (Correct answer)
Calcaneal stress fracture
Achilles tendinopathy

Correct answer: Plantar fasciitis

Plantar fasciitis classically presents with heel pain that is worst with the first steps after rest (post-static dyskinesia) and improves with continued ambulation.

Question 235: You have spent five years researching Condition X. You have located several individuals who have Condition X. You've also found a blood test that, if it returns a positive result, can show that Condition X is present. What word best represents the blood test's capacity to identify people who actually have Condition X in the population?

Statistical significance
Specificity
Prevelance
Incidence
Sensitivity (Correct answer)

Correct answer: Sensitivity

Sensitivity is a term used to describe the ability of a diagnostic test (like the blood test in this case) to correctly identify individuals who have the condition (Condition X in this scenario) among those who truly have it. In other words, it measures the proportion of true positive results among all individuals with the condition.

Question 236: A 48-year-old male with a long history of heavy alcohol consumption presents with jaundice, ascites, and fever. His laboratory results show an AST of 300 U/L, an ALT of 120 U/L, and an elevated GGT. Which of the following features is most characteristic of alcoholic liver disease?

AST:ALT ratio > 2:1 (Correct answer)
A normal GGT level
ALT > AST
Markedly elevated ALT (>1000 U/L)

Correct answer: AST:ALT ratio > 2:1

An AST to ALT ratio greater than 2:1 is a classic laboratory finding highly suggestive of alcoholic liver disease. [6, 8, 11] In most other forms of liver injury, the ALT is typically higher than or equal to the AST. The absolute levels of aminotransferases in alcoholic hepatitis are usually only moderately elevated (<500 U/L). [2, 14, 26]

Question 237: According to the most recent United States Preventive Services Task Force (USPSTF) recommendations, at what age should average-risk adults begin screening for colorectal cancer?

55
40
50
45 (Correct answer)

Correct answer: 45

In May 2021, the United States Preventive Services Task Force (USPSTF) updated its guidelines, lowering the recommended age for average-risk adults to begin screening for colorectal cancer from 50 to 45. [9, 12, 16] This change was based on data showing an increasing incidence of colorectal cancer in younger adults. [12]

Question 238: Which sign is used to diagnose De Quervain tenosynovitis?

Finkelstein test (Correct answer)
McMurray test
Tinel sign
Phalen sign

Correct answer: Finkelstein test

The Finkelstein test, where ulnar deviation of the wrist with the thumb enclosed in the fist reproduces pain over the radial styloid, is used to diagnose De Quervain tenosynovitis.

Question 239: A 7-year-old has honey-colored crusted lesions around the nose and mouth. What is the most appropriate treatment for limited disease?

Oral acyclovir
Topical clotrimazole
Oral prednisone
Topical mupirocin (Correct answer)

Correct answer: Topical mupirocin

This is nonbullous impetigo, caused by Staphylococcus aureus or group A Streptococcus. Limited disease is treated with topical mupirocin or retapamulin.

Question 240: A woman has a tender thyroid, fever, and thyrotoxicosis two weeks after a viral URI; ESR is elevated and radioactive iodine uptake is low. What is the initial treatment?

NSAIDs and a beta blocker (Correct answer)
Radioactive iodine ablation
Methimazole
Urgent thyroidectomy

Correct answer: NSAIDs and a beta blocker

Subacute granulomatous (de Quervain) thyroiditis is self-limited and treated symptomatically with NSAIDs and beta blockers.

Question 241: When obtaining a sexual history using the 5 P's framework, which of the following is NOT one of the 5 P's?

Partners
Pregnancy plans
Prior STIs (Correct answer)
Protection
Practices

Correct answer: Prior STIs

The 5 P's are Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy intention — 'Prior STIs' is phrased differently but the framework doesn't use that exact term as a standalone P.

Question 242: Which of the following hormones' release is suppressed by insulin?

Beta cells
Somatostatin
Glucagon (Correct answer)
ADH

Correct answer: Glucagon

Increases in insulin levels prevent the pancreatic -cells from releasing glucagon. This paracrine function is a fundamental part of how insulin regulates glucagon's activation of adipose tissue lipolysis and hepatic gluconeogenesis.

Question 243: A patient with new-onset unilateral facial nerve palsy after a summer tick exposure in Wisconsin is diagnosed with early disseminated Lyme disease. What is the recommended oral therapy?

Ciprofloxacin for 10 days
Amoxicillin for 7 days
Azithromycin for 3 days
Doxycycline for 14-21 days (Correct answer)

Correct answer: Doxycycline for 14-21 days

Lyme facial palsy is treated with oral doxycycline for 14-21 days.

Question 244: After being criticized by his boss, a man comes home and yells at his children. Which defense mechanism is this?

Projection
Reaction formation
Sublimation
Displacement (Correct answer)

Correct answer: Displacement

Displacement redirects emotions from their original source to a safer target.

Question 245: A woman at 9 weeks gestation is diagnosed with Graves disease requiring antithyroid therapy. Which drug is preferred during the first trimester?

Methimazole
Propylthiouracil (Correct answer)
Potassium iodide alone
Radioactive iodine

Correct answer: Propylthiouracil

PTU is preferred in the first trimester because methimazole is associated with embryopathy such as aplasia cutis.

Question 246: Which of the following is a contraindication to IV tPA in acute ischemic stroke?

Age over 65
Blood pressure of 150/90 mmHg
Atrial fibrillation
Ischemic stroke or head trauma within the past 3 months (Correct answer)

Correct answer: Ischemic stroke or head trauma within the past 3 months

Recent ischemic stroke or serious head trauma within the prior 3 months is an absolute contraindication to IV tPA due to the risk of hemorrhagic transformation.

Question 247: A 25-year-old sexually active man has gradual scrotal pain relieved by testicular elevation. What is the most likely diagnosis?

Epididymitis (Correct answer)
Varicocele
Torsion of the appendix testis
Testicular torsion

Correct answer: Epididymitis

Pain relief with elevation (positive Prehn sign) and gradual onset suggest epididymitis.

Question 248: Which of the following statements regarding the assessment and treatment of lipomas is true?

They are usually painful and tender on examination
They are usually associated with a malignant condition
They usually require surgical removal to prevent further complications
They are associated with diabetes mellitus
They can usually be watched without surgical intervention (Correct answer)

Correct answer: They can usually be watched without surgical intervention

Lipomas are benign fatty tumors that are usually soft, painless, and slow-growing, so they can typically be observed without surgery. They are not malignant, not painful or tender, not linked to diabetes, and rarely require removal unless they cause symptoms or cosmetic concern.

Question 249: Which psychotherapy has the strongest evidence for reducing self-harm in borderline personality disorder?

Psychoanalysis
Dialectical behavior therapy (Correct answer)
Interpersonal therapy
Supportive therapy

Correct answer: Dialectical behavior therapy

Dialectical behavior therapy is the best-studied first-line treatment for borderline personality disorder and reduces self-harm.

Question 250: A patient's trachea is deviated to the left. Which finding on physical exam would suggest tension pneumothorax on the right?

Hyperresonance and absent breath sounds on the right (Correct answer)
Dullness to percussion on the right
Crackles bilaterally
Increased tactile fremitus on the right

Correct answer: Hyperresonance and absent breath sounds on the right

Tension pneumothorax causes hyperresonance and absent breath sounds on the affected side with tracheal deviation away from it.

Question 251: An asplenic patient who recently returned from Nantucket has fever, hemolytic anemia, and intraerythrocytic 'Maltese cross' forms on blood smear. What is the most likely organism?

Babesia microti (Correct answer)
Bartonella bacilliformis
Plasmodium falciparum
Ehrlichia chaffeensis

Correct answer: Babesia microti

Babesiosis is transmitted by Ixodes ticks in the Northeast, and its tetrad 'Maltese cross' forms help distinguish it from malaria.

Question 252: A scrotal mass feels like a 'bag of worms' that enlarges with Valsalva and is on the left side. Why is it more common on the left?

Left inguinal canal is wider
Left testicular artery is longer
Left gonadal vein drains into the left renal vein at a right angle (Correct answer)
Left vas deferens is absent

Correct answer: Left gonadal vein drains into the left renal vein at a right angle

The left gonadal vein enters the left renal vein at a right angle, increasing venous pressure and varicocele formation.

Question 253: When assessing a skin lesion, which ABCDE criterion refers to a lesion greater than 6mm in diameter?

Asymmetry
Color
Border
Evolution
Diameter (Correct answer)

Correct answer: Diameter

D in the ABCDE melanoma screening criteria stands for Diameter greater than 6mm, roughly the size of a pencil eraser.

Question 254: Before starting carbamazepine in a patient of Han Chinese ancestry, which test is recommended?

HLA-B*1502 testing (Correct answer)
CYP2D6 genotyping
TPMT activity
G6PD level

Correct answer: HLA-B*1502 testing

HLA-B*1502 is strongly associated with carbamazepine-induced Stevens-Johnson syndrome/TEN in patients of Asian ancestry.

Question 255: Which laboratory finding is most consistent with hyperkalemia requiring urgent treatment?

ST depression in V1
Prominent U waves
Prolonged PR with no other change
Peaked T waves on ECG (Correct answer)

Correct answer: Peaked T waves on ECG

Peaked T waves are an early ECG sign of hyperkalemia and can progress to a wide QRS and arrhythmias. IV calcium gluconate is given to stabilize the myocardium.

Question 256: The Fick principle is used to calculate cardiac output. Which formula correctly represents it?

CO = (CaO2 - CvO2) / VO2
CO = MAP / SVR
CO = VO2 / (CaO2 - CvO2) (Correct answer)
CO = HR × SV

Correct answer: CO = VO2 / (CaO2 - CvO2)

The Fick principle states cardiac output equals oxygen consumption divided by the arteriovenous oxygen content difference.

Question 257: Which neurotransmitter is deficient in Parkinson's disease?

Serotonin
Dopamine (Correct answer)
Acetylcholine
GABA

Correct answer: Dopamine

Parkinson's disease results from degeneration of dopaminergic neurons in the substantia nigra, leading to dopamine deficiency in the nigrostriatal pathway.

Question 258: Which is the most effective single-agent maintenance therapy for moderate persistent allergic rhinitis?

Oral montelukast
Oral pseudoephedrine
Intranasal oxymetazoline
Intranasal corticosteroid (Correct answer)

Correct answer: Intranasal corticosteroid

Intranasal corticosteroids are the most effective monotherapy for allergic rhinitis, including nasal congestion.

Question 259: A 35-year-old woman presents with weakness, fatigue, hyperpigmentation, hyponatremia, and hyperkalemia. Cortisol is low and ACTH is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism
Secondary adrenal insufficiency
Addison's disease (Correct answer)
Cushing's disease

Correct answer: Addison's disease

Addison's disease (primary adrenal insufficiency) features elevated ACTH causing hyperpigmentation, with low cortisol, hyponatremia, and hyperkalemia.

Question 260: A 45-year-old man with kidney stones, bone pain, and depression has calcium of 11.9 mg/dL and PTH four times normal. What is the definitive treatment?

Cinacalcet (calcimimetic agent)
Parathyroidectomy (Correct answer)
High-dose vitamin D supplementation
IV bisphosphonate therapy

Correct answer: Parathyroidectomy

Parathyroidectomy is the definitive treatment for symptomatic primary hyperparathyroidism, providing a surgical cure.

Question 261: A patient describes new floaters, flashes of light, and a curtain descending over the visual field of one eye. What is the most appropriate next step?

Prescribe artificial tears and follow up in 2 weeks
Start topical prednisolone acetate
Emergent ophthalmology referral (Correct answer)
Order an outpatient MRI of the orbits

Correct answer: Emergent ophthalmology referral

These symptoms indicate retinal detachment, an ophthalmologic emergency requiring prompt repair to preserve vision.

Question 262: A PA is treating a patient with type 2 diabetes and hypertension. Which antihypertensive class provides the most renal protection in diabetic nephropathy?

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

Correct answer: ACE inhibitors

ACE inhibitors reduce proteinuria and slow the progression of diabetic nephropathy by decreasing intraglomerular pressure.

Question 263: An adult with nephrotic syndrome and anti-PLA2R antibodies most likely has which condition?

Membranous nephropathy (Correct answer)
IgA nephropathy
Alport syndrome
Minimal change disease

Correct answer: Membranous nephropathy

Anti-phospholipase A2 receptor antibodies are found in most cases of primary membranous nephropathy.

Question 264: You are assessing a 45-year-old lady who has undergone a solid organ transplant in the past. She appears with a fever and a change in mental status while taking immunosuppressive. She lacks arousal and has lost all energy. It's debatable whether she experienced a seizure at home. Hemorrhagic alterations and enhanced enhancement in the temporal lobe were visible on an MRI. Which of the following is she currently in need of?

Intravenous azithromycin (Zithromax)
Plasmapheresis
Intravenous methylprednisolone (Medrol)
Oral amoxicillin (Trimox)
Intravenous acyclovir (Zovirax) (Correct answer)

Correct answer: Intravenous acyclovir (Zovirax)

The patient is exhibiting signs and symptoms suggestive of herpes simplex virus encephalitis (inflammation of the brain caused by the herpes simplex virus), which is a medical emergency. The MRI findings of hemorrhagic alterations and enhanced enhancement in the temporal lobe are consistent with this condition.

Question 265: A 16-year-old male presents with knee pain after a twisting injury during basketball. Exam shows a positive Lachman test and anterior drawer sign. What structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

The Lachman test and anterior drawer sign both assess anterior tibial translation and are positive with anterior cruciate ligament (ACL) tears.

Question 266: Which finding on physical examination is most consistent with a complete rotator cuff tear?

Inability to initiate abduction with preserved passive range of motion (Correct answer)
Tenderness over the acromioclavicular joint
Painful arc between 60–120 degrees of abduction
Positive apprehension sign

Correct answer: Inability to initiate abduction with preserved passive range of motion

A complete rotator cuff tear results in inability to initiate active abduction while passive range of motion remains intact due to loss of musculotendinous continuity.

Question 267: How many PAs are employed in general pediatrics?

5.6%
2.1%
1.9% (Correct answer)
1.3%

Correct answer: 1.9%

According to the 2020 Statistical Profile of Certified Physician Assistants, 1.8% of physician assistants (PAs) work in pediatrics, which includes both general pediatrics and pediatric subspecialties.

Question 268: A traveler returning from sub-Saharan Africa has fever and confusion, and a smear shows banana-shaped gametocytes with 8% parasitemia. What is the most appropriate treatment in the US?

Oral primaquine
Oral chloroquine
Oral doxycycline alone
IV artesunate (Correct answer)

Correct answer: IV artesunate

Severe falciparum malaria (altered mentation or parasitemia of 5% or more) needs IV artesunate, which is available in the US.

Question 269: A 25-year-old male is diagnosed with moderate-to-severe ileocolonic Crohn's disease. Which of the following biologic agents is often considered a first-line therapy for inducing and maintaining remission in this patient?

Prednisone
Metronidazole
Mesalamine (5-ASA)
Infliximab (an anti-TNF agent) (Correct answer)

Correct answer: Infliximab (an anti-TNF agent)

For moderate-to-severe Crohn's disease, biologic therapies such as anti-TNF agents (e.g., infliximab, adalimumab) are recommended as a first-line treatment to both induce and maintain clinical remission. [15, 29, 45] Corticosteroids like prednisone are used for short-term induction but not maintenance, while mesalamine has limited efficacy in moderate-to-severe disease. [4, 10]

Question 270: Which imaging modality is the preferred initial study for a patient presenting with acute stroke symptoms?

Carotid ultrasound
CT angiography
Non-contrast CT head (Correct answer)
MRI brain with contrast

Correct answer: Non-contrast CT head

Non-contrast CT head is the first-line imaging study in acute stroke to rapidly exclude hemorrhage before considering thrombolytic therapy.

Question 271: A painless genital ulcer with a clean base and indurated border, with painless lymphadenopathy, is most consistent with which infection?

Herpes simplex virus
Chancroid
Lymphogranuloma venereum
Primary syphilis (Correct answer)

Correct answer: Primary syphilis

A syphilitic chancre is classically a single painless, indurated, clean-based ulcer.

Question 272: Which of the following side effects is most frequently experienced after using angiotensin converting enzyme inhibitors for an extended period of time?

Cough (Correct answer)
Hypertension
CHF
Dyspnea

Correct answer: Cough

Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, a potent vasodilator, which contributes to their blood pressure-lowering effect. However, the accumulation of bradykinin in the respiratory tract can irritate the airways. This irritation frequently manifests as a persistent, dry cough, which is a well-known and common side effect leading many patients to discontinue the medication.

Question 273: A patient develops profuse watery diarrhea after a course of clindamycin and tests positive for C. difficile toxin. What is the preferred first-line treatment for an initial nonsevere episode?

Loperamide
Oral metronidazole
IV vancomycin
Oral fidaxomicin (Correct answer)

Correct answer: Oral fidaxomicin

Current IDSA guidelines prefer oral fidaxomicin, with oral vancomycin as an acceptable alternative, for an initial C. difficile episode.

Question 274: A 28-year-old has tender red nodules on both anterior shins and bilateral hilar lymphadenopathy on chest x-ray. Which condition is most likely?

Rosacea
Sarcoidosis (Correct answer)
Lichen planus
Psoriasis

Correct answer: Sarcoidosis

Erythema nodosum with bilateral hilar adenopathy (Löfgren syndrome) suggests sarcoidosis.

Question 275: An IV drug user has fever and a new murmur, and echocardiography shows a tricuspid valve vegetation. What is the most likely organism?

Viridans group streptococci
Streptococcus gallolyticus
Staphylococcus aureus (Correct answer)
Enterococcus faecalis

Correct answer: Staphylococcus aureus

S. aureus is the most common cause of endocarditis in people who inject drugs, and it often involves the tricuspid valve.

Question 276: For chronic obstructive pulmonary disease, all of the following are suggested treatment options EXCEPT:

Anticholinergics
Beta blockers (Correct answer)
Beta agonists
Systemic or inhaled corticosteroids

Correct answer: Beta blockers

Beta blockers are generally contraindicated or used with extreme caution in patients with chronic obstructive pulmonary disease (COPD). Non-selective beta blockers can block beta-2 receptors in the airways, leading to bronchoconstriction and worsening airflow obstruction. Standard treatments for COPD include bronchodilators like beta agonists and anticholinergics, as well as corticosteroids.

Question 277: A 30-year-old male presents with acute monoarticular arthritis of the first metatarsophalangeal joint, erythema, and severe pain. Synovial fluid analysis shows negatively birefringent needle-shaped crystals. What is the treatment of choice for an acute attack?

Colchicine or NSAIDs (Correct answer)
Prednisone taper over 6 weeks
Methotrexate
Allopurinol

Correct answer: Colchicine or NSAIDs

Colchicine and NSAIDs are first-line treatments for acute gout attacks; allopurinol is used for long-term urate-lowering therapy, not acute episodes.

Question 278: A 25-year-old woman has dysuria, frequency and urgency with no fever or flank pain. Which is the most appropriate first-line treatment for uncomplicated cystitis?

Amoxicillin for 3 days
IV ceftriaxone
Nitrofurantoin for 5 days (Correct answer)
Ciprofloxacin for 14 days

Correct answer: Nitrofurantoin for 5 days

Nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole for 3 days, or fosfomycin as a single dose are first-line for uncomplicated cystitis. Fluoroquinolones are reserved because of resistance and adverse effects.

Question 279: Which laboratory finding is most characteristic of rheumatoid arthritis?

Elevated alkaline phosphatase
Positive ANA with anti-dsDNA
Elevated uric acid
Positive rheumatoid factor and anti-CCP antibodies (Correct answer)

Correct answer: Positive rheumatoid factor and anti-CCP antibodies

Rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) antibodies are the hallmark serologic markers of rheumatoid arthritis.

Question 280: A hiker from Connecticut has an expanding annular erythematous lesion with central clearing on the thigh and no neurologic or cardiac findings. What is the treatment of choice for a nonpregnant adult?

Oral clindamycin
IV ceftriaxone
Oral TMP-SMX
Oral doxycycline (Correct answer)

Correct answer: Oral doxycycline

Erythema migrans of early localized Lyme disease is treated with oral doxycycline for 10-14 days.

Question 281: A 60-year-old woman is incidentally found to have calcium of 11.2 mg/dL, low phosphate, and PTH three times the upper limit of normal. She is largely asymptomatic. What is the most likely diagnosis?

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

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism is characterized by hypercalcemia, hypophosphatemia, and elevated PTH, most commonly from a parathyroid adenoma.

Question 282: What is the appropriate initial approach to a suspected testicular cancer after ultrasound confirms a solid intratesticular mass?

Scrotal orchiectomy
Watchful waiting with repeat ultrasound
Transscrotal needle biopsy
Radical inguinal orchiectomy (Correct answer)

Correct answer: Radical inguinal orchiectomy

Radical inguinal orchiectomy is diagnostic and therapeutic; transscrotal approaches risk altering lymphatic spread.

Question 283: Which finding best distinguishes papulopustular rosacea from acne vulgaris?

Typical onset in early adolescence
Presence of open comedones
Absence of comedones (Correct answer)
Predominant truncal involvement

Correct answer: Absence of comedones

Rosacea features central facial erythema, papules, and pustules without comedones.

Question 284: In the cell cycle, at which checkpoint is DNA integrity assessed before the cell commits to DNA replication?

G2/M checkpoint
Spindle assembly checkpoint
G1/S checkpoint (Correct answer)
Restriction point

Correct answer: G1/S checkpoint

The G1/S checkpoint (restriction point) assesses DNA integrity and cell size before the cell commits to S phase DNA replication.

Question 285: Renal cell carcinoma may cause erythrocytosis through ectopic production of which substance?

PTHrP
Renin
ACTH
Erythropoietin (Correct answer)

Correct answer: Erythropoietin

RCC can secrete erythropoietin, producing secondary polycythemia as a paraneoplastic syndrome.

Question 286: Which classic triad is associated with renal cell carcinoma, though present in only a minority of patients?

Fever, rash, eosinophiluria
Hematuria, flank pain, palpable flank mass (Correct answer)
Edema, proteinuria, hyperlipidemia
Dysuria, frequency, urgency

Correct answer: Hematuria, flank pain, palpable flank mass

Hematuria, flank pain, and a palpable mass form the classic but uncommon RCC triad.

Question 287: A family presents with intensely pruritic papules in finger web spaces and burrows on the wrists, worse at night. What is first-line treatment?

Topical mupirocin three times daily
Lindane lotion as first-line
Permethrin 5% cream applied neck down, repeated in 1 week (Correct answer)
Hydrocortisone 1% cream twice daily

Correct answer: Permethrin 5% cream applied neck down, repeated in 1 week

Permethrin 5% is first-line for scabies, with treatment of all close contacts and a repeat application in 7-14 days.

Question 288: Which organelle is responsible for protein sorting, post-translational modifications, and packaging for secretion?

Golgi apparatus (Correct answer)
Smooth endoplasmic reticulum
Rough endoplasmic reticulum
Lysosome

Correct answer: Golgi apparatus

The Golgi apparatus receives proteins from the RER, performs glycosylation and other modifications, and sorts them into vesicles for secretion or intracellular delivery.

Question 289: Which is the strongest single predictor of eventual completed suicide?

Previous suicide attempt (Correct answer)
Recent job loss
Family history of depression
Female sex

Correct answer: Previous suicide attempt

A prior suicide attempt is the strongest individual predictor of future completed suicide.

Question 290: Which of the following distinguishes essential tremor from Parkinson's tremor?

Essential tremor involves the legs primarily
Essential tremor is associated with bradykinesia
Essential tremor is an action/postural tremor; Parkinson's is a resting tremor (Correct answer)
Essential tremor occurs at rest; Parkinson's occurs with action

Correct answer: Essential tremor is an action/postural tremor; Parkinson's is a resting tremor

Essential tremor is a postural/action tremor that occurs during movement, while Parkinson's tremor is characteristically present at rest and suppressed by movement.

Question 291: A PA student must read a 180-page textbook chapter in 3 hours. At what rate must they read?

65 pages/hour
55 pages/hour
50 pages/hour
60 pages/hour (Correct answer)

Correct answer: 60 pages/hour

180 pages ÷ 3 hours = 60 pages per hour.

Question 292: The Lachman test is used to assess integrity of which structure?

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

Correct answer: Anterior cruciate ligament

The Lachman test, performed with the knee at 20-30° flexion with anterior tibial translation, evaluates ACL integrity and has high sensitivity for ACL tears.

Question 293: A 70-year-old man has nocturia, weak stream and hesitancy with a smooth, enlarged prostate. Which medication class relaxes the prostate smooth muscle for rapid relief?

Anticholinergics
5-alpha-reductase inhibitors
Loop diuretics
Alpha-1 blockers (Correct answer)

Correct answer: Alpha-1 blockers

Alpha-1 blockers such as tamsulosin relax prostatic and bladder neck smooth muscle and relieve BPH symptoms quickly. 5-alpha-reductase inhibitors shrink the prostate over months.

Question 294: A 30-year-old woman on oral contraceptives develops symmetric brown patches on the cheeks and upper lip. Besides strict sun protection, which topical therapy is first-line?

Long-term high-potency topical corticosteroid
Topical mupirocin
Topical terbinafine
Hydroquinone (Correct answer)

Correct answer: Hydroquinone

Melasma is treated with photoprotection and depigmenting agents such as hydroquinone, often in triple combination cream.

Question 295: A PA student elicits Murphy's sign during an abdominal exam. The correct technique is to:

Press over the epigastrium while the patient exhales
Apply pressure over McBurney's point and release suddenly
Percuss the right flank while the patient is in lateral decubitus
Hook fingers under the right costal margin and ask the patient to inhale deeply (Correct answer)

Correct answer: Hook fingers under the right costal margin and ask the patient to inhale deeply

Murphy's sign is elicited by hooking the fingers under the right costal margin during deep inspiration; pain and inspiratory arrest suggests acute cholecystitis.

Question 296: Why should buprenorphine induction be delayed until a patient shows moderate opioid withdrawal?

Its high receptor affinity can displace full agonists and precipitate withdrawal (Correct answer)
It is ineffective while other opioids are in the system
It must first be converted to an active metabolite
Buprenorphine causes severe respiratory depression if given early

Correct answer: Its high receptor affinity can displace full agonists and precipitate withdrawal

As a high-affinity partial agonist, buprenorphine displaces full agonists and can precipitate abrupt withdrawal if given too early.

Question 297: Which opioid analgesic has active metabolites that accumulate in renal failure and can cause CNS toxicity?

Buprenorphine
Hydromorphone
Fentanyl
Morphine (Correct answer)

Correct answer: Morphine

Morphine-6-glucuronide accumulates in renal failure and can cause prolonged sedation, respiratory depression, and seizures.

Question 298: A 24-year-old female presents for a routine physical exam. On cardiac auscultation, a mid-systolic click followed by a late systolic murmur is heard best at the apex. The murmur is accentuated when she stands up from a squatting position. What is the most likely valvular abnormality?

Mitral valve prolapse (Correct answer)
Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation

Correct answer: Mitral valve prolapse

A mid-systolic click is the pathognomonic finding for mitral valve prolapse. The click is caused by the sudden tensing of the chordae tendineae as the valve leaflets prolapse into the left atrium during systole. Maneuvers that decrease venous return and left ventricular volume, such as standing, cause the click and murmur to occur earlier in systole and become more prominent.

Question 299: A passage states that 'correlation does not imply causation.' A student concludes that ice cream sales cause drowning because both rise in summer. This is an example of:

Confounding variable error (Correct answer)
Attrition bias
Confirmation bias
Selection bias

Correct answer: Confounding variable error

A confounding variable (summer/heat) explains both ice cream sales and drowning rates, creating a false causal link.

Question 300: A neutropenic leukemia patient has persistent fever on broad-spectrum antibiotics, and chest CT shows nodules with a surrounding 'halo sign.' What is the treatment of choice?

Amphotericin B deoxycholate plus flucytosine
Caspofungin
Fluconazole
Voriconazole (Correct answer)

Correct answer: Voriconazole

The halo sign in a neutropenic patient suggests invasive aspergillosis, for which voriconazole is first-line.

Physician Assistant National Certifying Exam (PANCE)

The PANCE is the entry-level certification exam administered by NCCPA that assesses medical and surgical knowledge essential for physician assistants; passing it is required to practice as a PA in the United States.

300

Questions

300 min

Time Limit

65%

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