PANCE PANCE Evaluation 2 — Questions and Answers
Question 1: A 58-year-old male presents with exertional chest pain radiating to the left arm for the past 3 weeks. EKG shows ST-segment depression in leads V4-V6. Which is the most appropriate next step?
- Administer sublingual nitroglycerin and discharge
- Perform exercise stress testing
- Admit and obtain serial troponins with cardiology consult (Correct answer)
- Start aspirin and schedule outpatient stress test in 2 weeks
Correct answer: Admit and obtain serial troponins with cardiology consult
New onset exertional chest pain with EKG changes warrants inpatient evaluation with serial cardiac biomarkers to rule out ACS.
Question 2: A 34-year-old woman presents with a 2-week history of fatigue, weight gain, cold intolerance, and constipation. Which lab finding would you expect?
- Low TSH, high free T4
- High TSH, low free T4 (Correct answer)
- Normal TSH, low free T4
- Low TSH, low free T4
Correct answer: High TSH, low free T4
Primary hypothyroidism causes elevated TSH (pituitary compensation) and low free T4 due to decreased thyroid output.
Question 3: A 6-year-old child is brought in for evaluation of a 3-day sore throat, fever of 38.9°C, and enlarged anterior cervical lymph nodes. No cough is present. What is the Centor score and recommended management?
- Score 1 — no antibiotics needed
- Score 2 — perform rapid strep test
- Score 3 — perform rapid strep test or empirically treat (Correct answer)
- Score 4 — empirically treat with antibiotics without testing
Correct answer: Score 3 — perform rapid strep test or empirically treat
Exudate, tender anterior cervical lymphadenopathy, fever, and absence of cough each score 1 point (age <15 adds 1), giving a score of 3-4, warranting strep testing or empiric treatment.
Question 4: On auscultation, a patient has a harsh systolic murmur that increases in intensity with the Valsalva maneuver. Which condition is most likely?
- Mitral regurgitation
- Aortic stenosis
- Hypertrophic obstructive cardiomyopathy (HOCM) (Correct answer)
- Ventricular septal defect
Correct answer: Hypertrophic obstructive cardiomyopathy (HOCM)
HOCM murmurs increase with Valsalva (decreased preload worsens outflow obstruction), distinguishing it from most other murmurs.
Question 5: A 45-year-old male with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?
- Glucose 50% IV bolus
- Thiamine 100 mg IV before glucose (Correct answer)
- Naloxone 0.4 mg IV
- Folic acid 1 mg IV
Correct answer: Thiamine 100 mg IV before glucose
Wernicke encephalopathy requires immediate thiamine before glucose to prevent precipitating or worsening the condition.
Question 6: A 72-year-old woman has a T-score of -2.7 on DEXA scan with no prior fracture. She is currently taking calcium and vitamin D. What is the most appropriate additional therapy?
- Estrogen replacement therapy
- Calcitonin nasal spray
- Oral bisphosphonate (e.g., alendronate) (Correct answer)
- Teriparatide injection
Correct answer: Oral bisphosphonate (e.g., alendronate)
A T-score ≤ -2.5 meets WHO criteria for osteoporosis, and bisphosphonates are the first-line pharmacologic treatment.
Question 7: A 22-year-old college student presents with fever, severe headache, nuchal rigidity, and a petechial rash. Which organism is the most likely cause?
- Streptococcus pneumoniae
- Listeria monocytogenes
- Neisseria meningitidis (Correct answer)
- Haemophilus influenzae
Correct answer: Neisseria meningitidis
Neisseria meningitidis causes bacterial meningitis with a classic petechial/purpuric rash due to septicemia, particularly in young adults.
PANCE PANCE Evaluation 2
A 58-year-old male presents with exertional chest pain radiating to the left arm for the past 3 weeks.
EKG shows ST-segment depression in leads V4-V6.
Which is the most appropriate next step?