PANCE PANCE Analysis 2 — Questions and Answers
Question 1: A 58-year-old man presents with crushing chest pain radiating to the left arm. ECG shows ST elevations in leads II, III, and aVF. Which coronary artery is most likely occluded?
- Left anterior descending artery
- Right coronary artery (Correct answer)
- Left circumflex artery
- Left main coronary artery
Correct answer: Right coronary artery
ST elevations in leads II, III, and aVF indicate an inferior MI, which is most commonly caused by occlusion of the right coronary artery.
Question 2: A patient with type 2 diabetes and CKD stage 3 requires glucose-lowering therapy. Which agent is contraindicated due to risk of lactic acidosis?
- Sitagliptin
- Metformin (Correct answer)
- Glipizide
- Empagliflozin
Correct answer: Metformin
Metformin is contraindicated when eGFR is below 30 mL/min due to risk of lactic acidosis from impaired renal clearance.
Question 3: A 35-year-old woman presents with episodic hypertension, headache, diaphoresis, and palpitations. Plasma free metanephrines are markedly elevated. What is the most appropriate next step?
- Start beta-blocker immediately
- CT scan of the abdomen and pelvis (Correct answer)
- 24-hour urine catecholamines
- Adrenal vein sampling
Correct answer: CT scan of the abdomen and pelvis
Once biochemical confirmation of pheochromocytoma is established, CT of the abdomen and pelvis is performed to localize the tumor before surgical resection.
Question 4: A 22-year-old college student presents with fever, severe headache, photophobia, and a non-blanching petechial rash. What is the most immediate treatment?
- Obtain blood cultures, then administer IV ceftriaxone
- Perform lumbar puncture before starting antibiotics
- Administer IV ceftriaxone immediately without delay (Correct answer)
- Start oral doxycycline empirically
Correct answer: Administer IV ceftriaxone immediately without delay
In suspected bacterial meningitis with a petechial rash (suggesting meningococcemia), IV antibiotics must be given immediately without waiting for lumbar puncture to prevent death.
Question 5: A 70-year-old man on warfarin for atrial fibrillation presents with an INR of 8.5 and active GI bleeding. What is the most appropriate reversal strategy?
- Vitamin K 10 mg IV alone
- Fresh frozen plasma alone
- 4-factor prothrombin complex concentrate plus vitamin K IV (Correct answer)
- Protamine sulfate IV
Correct answer: 4-factor prothrombin complex concentrate plus vitamin K IV
For life-threatening bleeding on warfarin, 4-factor PCC provides rapid reversal combined with IV vitamin K for sustained effect.
Question 6: A 28-year-old woman at 32 weeks gestation develops blood pressure of 156/104 mmHg, 3+ proteinuria, and a severe headache. Which medication is the first-line treatment for seizure prophylaxis?
- Lorazepam
- Phenytoin
- Magnesium sulfate (Correct answer)
- Labetalol
Correct answer: Magnesium sulfate
Magnesium sulfate is the drug of choice for prevention and treatment of eclamptic seizures in women with severe preeclampsia.
Question 7: A 45-year-old man with HIV (CD4 count 80 cells/µL) presents with dyspnea, dry cough, and bilateral interstitial infiltrates on CXR. LDH is elevated. What is the most likely diagnosis?
- Tuberculosis
- Pneumocystis jirovecii pneumonia (Correct answer)
- Cytomegalovirus pneumonitis
- Bacterial pneumonia
Correct answer: Pneumocystis jirovecii pneumonia
PCP is the most common opportunistic pulmonary infection in HIV patients with CD4 <200, presenting with bilateral interstitial infiltrates and elevated LDH.
PANCE PANCE Analysis 2
A 58-year-old man presents with crushing chest pain radiating to the left arm.
ECG shows ST elevations in leads II, III, and aVF.
Which coronary artery is most likely occluded?