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

Question 1: Which of the following is the recommended screening interval for colonoscopy in an average-risk patient with no findings on initial screening at age 50?

5 years
15 years
10 years (Correct answer)
3 years

Correct answer: 10 years

Current guidelines recommend repeat colonoscopy in 10 years for average-risk patients with a normal (no polyps) initial screening colonoscopy.

Question 2: Which of the following statements about end-of-life concerns for cystic fibrosis patients is accurate?

Most patients will live their 50s and 60s
Lung transplantation is not an option
Palliative care should be discussed (Correct answer)
All of the above

Correct answer: Palliative care should be discussed

Cystic fibrosis is a progressive, life-limiting disease that significantly impacts quality of life as it advances. Palliative care focuses on providing relief from symptoms, pain, and stress of a serious illness, aiming to improve quality of life for both the patient and their family. Discussing palliative care early is crucial for CF patients to ensure their values and preferences are honored throughout their disease trajectory, even alongside curative treatments like lung transplantation.

Question 3: Which of the following is NOT a feature of irritable bowel syndrome (IBS)?

Bloating and flatulence
Abdominal pain relieved by defecation
Alternating diarrhea and constipation
Nocturnal diarrhea awakening the patient (Correct answer)

Correct answer: Nocturnal diarrhea awakening the patient

Nocturnal diarrhea that awakens the patient is a red flag suggesting organic disease, not IBS, which is a functional disorder that does not cause nighttime symptoms.

Question 4: What is an endoscopic retrograde cholangiopancreatography's (ERCP) most common complication?

Perforation
Aspiration
Pancreatitis (Correct answer)
Cholangitis

Correct answer: Pancreatitis

Post-ERCP pancreatitis is the most common and often the most serious complication of endoscopic retrograde cholangiopancreatography. It occurs due to irritation or injury to the pancreatic duct during the procedure, leading to inflammation of the pancreas. While other complications like cholangitis, aspiration, and perforation can occur, pancreatitis is statistically the most frequent.

Question 5: A 40-year-old female presents with fatigue, constipation, and cold intolerance. TSH is 12 µIU/mL, free T4 is low. Anti-TPO antibodies are elevated. What is the most likely diagnosis?

Graves disease
Subacute thyroiditis
Secondary hypothyroidism
Hashimoto thyroiditis (Correct answer)

Correct answer: Hashimoto thyroiditis

Hashimoto thyroiditis is autoimmune hypothyroidism characterized by elevated TSH, low T4, and positive anti-TPO antibodies.

Question 6: A 55-year-old presents with slowly progressive dyspnea, pleural plaques on CT, and a restrictive pattern on PFTs. He worked in shipbuilding for 30 years. Which lung cancer type carries the highest risk in this patient?

Adenocarcinoma
Mesothelioma (Correct answer)
Small cell carcinoma
Squamous cell carcinoma

Correct answer: Mesothelioma

Asbestos exposure is the primary risk factor for malignant pleural mesothelioma, with pleural plaques being a marker of significant prior exposure.

Question 7: A 28-year-old woman at 10 weeks gestation presents with severe nausea, vomiting, and a uterus larger than expected for gestational age. β-hCG is markedly elevated. Ultrasound shows a 'snowstorm' pattern. What is the diagnosis?

Twin gestation
Threatened abortion
Ectopic pregnancy
Complete hydatidiform mole (Correct answer)

Correct answer: Complete hydatidiform mole

A complete hydatidiform mole presents with markedly elevated β-hCG, uterine size larger than dates, and a classic snowstorm ultrasound pattern.

Question 8: A 17-year-old female presents with primary amenorrhea, no breast development, and streak gonads on ultrasound. Karyotype is 45,X. Which associated cardiac defect must be screened for?

Bicuspid aortic valve and coarctation of the aorta (Correct answer)
Tetralogy of Fallot
Patent ductus arteriosus
Ventricular septal defect

Correct answer: Bicuspid aortic valve and coarctation of the aorta

Turner syndrome (45,X) is associated with bicuspid aortic valve in ~30% and coarctation of the aorta in ~10% of patients, requiring cardiac screening.

Question 9: Which electrolyte abnormality is most characteristic of chronic kidney disease due to impaired excretion?

Hyperphosphatemia (Correct answer)
Hypercalcemia
Hypernatremia
Hypokalemia

Correct answer: Hyperphosphatemia

Impaired phosphate excretion in CKD leads to hyperphosphatemia, which also drives secondary hyperparathyroidism.

Question 10: What role does collaboration play in gastrointestinal for PANCE professionals?

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

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

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

Question 11: A 30-year-old female presents with bilateral hand stiffness in the morning lasting 2 hours, fatigue, and symmetric swollen PIPs and MCPs. RF is negative but anti-CCP is positive. What is the diagnosis?

Systemic lupus erythematosus
Seropositive rheumatoid arthritis (Correct answer)
Seronegative rheumatoid arthritis
Psoriatic arthritis

Correct answer: Seropositive rheumatoid arthritis

Anti-CCP antibody is more specific than RF for RA; a positive anti-CCP with negative RF still qualifies as seropositive RA by current classification criteria.

Question 12: A 65-year-old woman with RA on methotrexate develops bilateral hip pain worsened by weight-bearing. X-ray shows subchondral collapse. What complication has occurred?

Septic arthritis
Trochanteric bursitis
Stress fracture
Avascular necrosis (Correct answer)

Correct answer: Avascular necrosis

Long-term corticosteroid use (often used in RA management) is a major risk factor for avascular necrosis of the femoral head, presenting with subchondral collapse on imaging.

Question 13: A 25-year-old basketball player twists his knee and feels a pop. He develops a knee effusion within 2 hours and has a positive Lachman test. What structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

ACL tears present with a pop, rapid hemarthrosis, and positive Lachman test; they are common in pivoting sports like basketball.

Question 14: Which pulmonary function test pattern is characteristic of a fixed upper airway obstruction such as tracheal stenosis?

Decreased DLCO with normal spirometry
Increased RV with normal FEV1/FVC
Decreased FEV1/FVC with normal TLC
Flattening of both inspiratory and expiratory loops on flow-volume curve (Correct answer)

Correct answer: Flattening of both inspiratory and expiratory loops on flow-volume curve

Fixed upper airway obstruction flattens both the inspiratory and expiratory limbs of the flow-volume loop due to fixed resistance regardless of effort.

Question 15: A 22-year-old female with hypermobile joints presents with recurrent shoulder dislocations. Anterior apprehension test is positive. What is the most common direction of glenohumeral instability?

Inferior
Posterior
Anterior (Correct answer)
Multidirectional

Correct answer: Anterior

Anterior shoulder instability is the most common type, often due to labral tears (Bankart lesion) following trauma or repetitive stress in hypermobile individuals.

Question 16: A 40-year-old male with chronic kidney disease stage 3 presents with lab values: sodium 138, potassium 5.8, bicarbonate 18, BUN 42, creatinine 2.4. Which acid-base disturbance is present?

Metabolic alkalosis
Anion gap metabolic acidosis (Correct answer)
Respiratory acidosis
Non-anion gap metabolic acidosis

Correct answer: Anion gap metabolic acidosis

CKD causes accumulation of uremic acids (phosphate, sulfate, urate) creating an elevated anion gap metabolic acidosis.

Question 17: Which medication class is first-line for reducing proteinuria and slowing CKD progression in a patient with diabetic nephropathy?

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

Correct answer: ACE inhibitors

ACE inhibitors reduce intraglomerular pressure and proteinuria, slowing progression of diabetic nephropathy.

Question 18: A 9-year-old presents with a painless, firm, non-tender nodule on the upper eyelid that has been present for 3 weeks. There is no erythema or purulent discharge. What is the most likely diagnosis?

Chalazion (Correct answer)
Hordeolum (stye)
Preseptal cellulitis
Dacryocystitis

Correct answer: Chalazion

A chalazion is a chronic, painless granulomatous inflammation of a meibomian gland, presenting as a firm, non-tender eyelid nodule without acute inflammation.

Question 19: A 55-year-old diabetic patient presents with severe right ear pain, purulent otorrhea, and facial nerve palsy. CT scan shows bony erosion at the skull base. Which organism is responsible for this condition?

Pseudomonas aeruginosa (Correct answer)
Staphylococcus aureus
Streptococcus pneumoniae
Aspergillus fumigatus

Correct answer: Pseudomonas aeruginosa

Malignant (necrotizing) external otitis in diabetics is almost exclusively caused by Pseudomonas aeruginosa, which can extend to cause skull base osteomyelitis and cranial nerve palsies.

Question 20: A 5-year-old presents with a limp and hip pain. X-ray shows flattening and fragmentation of the femoral head. Labs are normal. What is the most likely diagnosis?

Transient synovitis
Slipped capital femoral epiphysis
Septic arthritis
Legg-Calvé-Perthes disease (Correct answer)

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children, presenting with limp and X-ray showing femoral head fragmentation.

Question 21: A 48-year-old woman presents with thick, yellow, crumbling toenails with subungual debris and onycholysis. KOH preparation confirms dermatophyte infection. What is the preferred treatment for onychomycosis?

Topical clotrimazole cream
Topical ciclopirox lacquer
Nail avulsion only
Oral terbinafine for 12 weeks (Correct answer)

Correct answer: Oral terbinafine for 12 weeks

Oral terbinafine for 12 weeks (toenails) achieves significantly higher cure rates than topical agents for onychomycosis due to subungual penetration.

Question 22: Which approach is recommended for troubleshooting pulmonary system issues?

Use systematic isolation and testing methods (Correct answer)
Rely solely on past experience
Wait for the problem to resolve itself
Replace all components simultaneously

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 23: A 52-year-old woman presents with progressive proximal muscle weakness making it difficult to rise from a chair, a heliotrope rash on her eyelids, and Gottron papules on her knuckles. What laboratory finding is most helpful in confirming the diagnosis?

Elevated creatine kinase (Correct answer)
Positive ANA
Elevated rheumatoid factor
Elevated ESR

Correct answer: Elevated creatine kinase

Elevated creatine kinase reflects muscle inflammation and damage in dermatomyositis, making it the most useful confirmatory lab alongside the characteristic skin findings.

Question 24: 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
Normal TSH, low free T4
Low TSH, low free T4
High TSH, low free T4 (Correct answer)

Correct answer: High TSH, low free T4

Primary hypothyroidism causes elevated TSH (pituitary compensation) and low free T4 due to decreased thyroid output.

Question 25: A patient has colicky flank pain radiating to the groin, hematuria, and nausea. KUB shows a radiopaque stone at the ureterovesical junction. What is the most common stone type?

Calcium oxalate (Correct answer)
Struvite
Cystine
Uric acid

Correct answer: Calcium oxalate

Calcium oxalate stones are the most common nephrolithiasis type, appearing radiopaque on plain film.

Question 26: A 70-year-old presents with sudden onset severe abdominal pain out of proportion to exam, with a history of atrial fibrillation. Lactate is elevated. What is the most likely diagnosis?

Ischemic colitis
Perforated peptic ulcer
Acute mesenteric ischemia (Correct answer)
Acute pancreatitis

Correct answer: Acute mesenteric ischemia

Acute mesenteric ischemia from embolism (commonly from atrial fibrillation) causes severe pain disproportionate to exam findings with elevated lactate from bowel ischemia.

Question 27: A child develops oliguria, microangiopathic hemolytic anemia, and thrombocytopenia after a bloody diarrheal illness. What is the diagnosis?

DIC
ITP
Hemolytic uremic syndrome (Correct answer)
Thrombotic thrombocytopenic purpura

Correct answer: Hemolytic uremic syndrome

HUS classically follows E. coli O157:H7 infection and presents with the triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI.

Question 28: A 55-year-old male presents with sudden onset of severe 'tearing' chest pain radiating to the back. BP is 180/100 mmHg in the right arm and 160/90 in the left. Which diagnosis is most likely?

Esophageal rupture
Aortic dissection (Correct answer)
Pulmonary embolism
Acute MI

Correct answer: Aortic dissection

Aortic dissection classically presents with tearing chest pain radiating to the back and a blood pressure differential between arms.

Question 29: A patient has urine sodium of 10 mEq/L, urine osmolality 700 mOsm/kg, and elevated BUN. What is the most likely cause of AKI?

Glomerulonephritis
Postrenal obstruction
Acute tubular necrosis
Prerenal azotemia (Correct answer)

Correct answer: Prerenal azotemia

Low urine sodium and high urine osmolality indicate intact tubular function with appropriate sodium conservation, consistent with prerenal AKI.

Question 30: A patient with known primary pulmonary hypertension develops worsening dyspnea. Echocardiogram shows RV systolic pressure of 80 mmHg. Which medication class acts by increasing cyclic GMP to cause pulmonary vasodilation?

Prostacyclin analogs (epoprostenol)
Phosphodiesterase-5 inhibitors (sildenafil) (Correct answer)
Calcium channel blockers (nifedipine)
Endothelin receptor antagonists (bosentan)

Correct answer: Phosphodiesterase-5 inhibitors (sildenafil)

PDE-5 inhibitors prevent breakdown of cGMP, sustaining NO-mediated pulmonary vasodilation and reducing pulmonary vascular resistance.

Question 31: A 22-year-old woman presents with salt craving, hyperpigmentation, hypotension, and hyponatremia with hyperkalemia. Morning cortisol is 3 mcg/dL. What is the diagnosis?

Cushing syndrome
Primary adrenal insufficiency (Addison disease) (Correct answer)
Hyperaldosteronism
Secondary adrenal insufficiency

Correct answer: Primary adrenal insufficiency (Addison disease)

Primary adrenal insufficiency causes hyperpigmentation (elevated ACTH) and both glucocorticoid and mineralocorticoid deficiency, causing hyperkalemia and hyponatremia.

Question 32: A patient with multiple myeloma develops worsening renal function. Which renal complication is most directly caused by light chain deposition in tubules?

Cast nephropathy (Correct answer)
Renal artery stenosis
IgA nephropathy
Minimal change disease

Correct answer: Cast nephropathy

Bence-Jones proteins (free light chains) precipitate in renal tubules, causing tubular injury and cast nephropathy (myeloma kidney).

Question 33: A 3-year-old presents with vesicles on an erythematous base in a dermatomal distribution on the trunk. The child's mother has active chickenpox. What is the most likely diagnosis?

Hand-foot-mouth disease
Eczema herpeticum
Primary varicella (chickenpox) (Correct answer)
Herpes zoster (shingles)

Correct answer: Primary varicella (chickenpox)

A young child exposed to varicella presenting with vesicles on an erythematous base is most consistent with primary varicella (chickenpox), not zoster (which requires prior VZV infection).

Question 34: A 25-year-old male presents with painless enlargement of the right testis. Ultrasound shows a solid intratesticular mass. AFP is elevated. What is the most likely tumor type?

Lymphoma
Seminoma
Leydig cell tumor
Yolk sac tumor (Correct answer)

Correct answer: Yolk sac tumor

Non-seminomatous germ cell tumors (yolk sac tumor) produce AFP; seminomas do not, making AFP elevation characteristic of non-seminomatous tumors.

Question 35: A 19-year-old sexually active woman is diagnosed with her second episode of chlamydial cervicitis within 6 months. Her partner was treated after the first episode. What additional step is most critical now?

Initiate long-term suppressive azithromycin
Switch to a different antibiotic class for treatment
Test for HIV and other STIs (Correct answer)
Refer for colposcopy

Correct answer: Test for HIV and other STIs

Repeat STI infections increase risk of HIV and other sexually transmitted infections, making comprehensive STI testing including HIV essential at this visit.

Question 36: In PANCE certification, what does redundancy in system design primarily provide?

Simplified maintenance
Fault tolerance and high availability (Correct answer)
Lower initial cost
Increased complexity

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 37: A 52-year-old man has a serum calcium of 11.8 mg/dL, PTH of 95 pg/mL, and is asymptomatic. What is the most likely diagnosis?

Hypoparathyroidism
Vitamin D toxicity
Humoral hypercalcemia of malignancy
Primary hyperparathyroidism (Correct answer)

Correct answer: Primary hyperparathyroidism

Elevated calcium with elevated (or inappropriately normal) PTH is the hallmark of primary hyperparathyroidism.

Question 38: What constitutes a risk factor for endometriosis development?

Lengthened menstrual cycles
Delayed childbearing (Correct answer)
Short periods
Multiple pregnancies

Correct answer: Delayed childbearing

Delayed childbearing is a significant risk factor for endometriosis because it increases the number of menstrual cycles a woman experiences throughout her reproductive life. Each menstrual cycle provides an opportunity for endometrial tissue to reflux and implant outside the uterus, contributing to the development and progression of endometriosis. Other factors like early menarche and short, heavy periods also increase exposure to menstrual flow.

Question 39: A 45-year-old construction worker develops slowly progressive bilateral hand weakness with wasting of thenar and hypothenar muscles, fasciculations, and hyperreflexia. The most likely diagnosis is:

Amyotrophic lateral sclerosis (Correct answer)
Cervical myelopathy
Multifocal motor neuropathy
Syringomyelia

Correct answer: Amyotrophic lateral sclerosis

ALS presents with combined upper (hyperreflexia, spasticity) and lower (fasciculations, weakness, atrophy) motor neuron signs without sensory involvement.

Question 40: A 45-year-old woman presents with a salmon-colored, well-demarcated plaque with silvery scale on her elbows and knees. Which finding would most likely be seen on biopsy?

Perivascular lymphocytic infiltrate with plasma cells
Spongiosis with eosinophilic infiltrate
Interface dermatitis with vacuolar change
Acanthosis with parakeratosis and Munro microabscesses (Correct answer)

Correct answer: Acanthosis with parakeratosis and Munro microabscesses

Psoriasis classically shows acanthosis, parakeratosis, and Munro microabscesses (neutrophils in the stratum corneum).

Question 41: A 70-year-old woman presents with a firm, painless, flesh-colored papule on her lower eyelid that has grown slowly over 2 years. The border is irregular and there is perineural invasion on biopsy. What subtype of cutaneous cancer is most aggressive?

Morpheaform (sclerosing) basal cell carcinoma (Correct answer)
Pigmented BCC
Nodular basal cell carcinoma
Superficial BCC

Correct answer: Morpheaform (sclerosing) basal cell carcinoma

Morpheaform (sclerosing) BCC has the most aggressive behavior, with subclinical extension and perineural invasion, requiring Mohs surgery for adequate margins.

Question 42: A 30-year-old marathon runner collapses during a race. His ECG shows deep T-wave inversions in V1-V4 and epsilon waves. What is the most likely diagnosis?

Brugada syndrome
Hypertrophic cardiomyopathy
Long QT syndrome
Arrhythmogenic right ventricular cardiomyopathy (ARVC) (Correct answer)

Correct answer: Arrhythmogenic right ventricular cardiomyopathy (ARVC)

ARVC is characterized by epsilon waves, T-wave inversions in right precordial leads, and fatty replacement of the right ventricular myocardium, causing ventricular arrhythmias.

Question 43: A laboring patient at 8 cm dilation has a Category III fetal heart rate tracing (sinusoidal pattern). What is the immediate next step?

Administer terbutaline and reassess
Amnioinfusion
Apply fetal scalp electrode for better monitoring
Prepare for emergent cesarean delivery (Correct answer)

Correct answer: Prepare for emergent cesarean delivery

A sinusoidal fetal heart rate pattern is a Category III (abnormal) tracing indicating severe fetal compromise requiring emergent cesarean delivery.

Question 44: A 70-year-old has macrocytic anemia, glossitis, and neurologic symptoms. Labs show elevated methylmalonic acid and homocysteine. What is the deficiency?

Vitamin B12 (Correct answer)
Pyridoxine
Folate
Thiamine

Correct answer: Vitamin B12

Elevated methylmalonic acid distinguishes B12 deficiency from folate deficiency, since only B12 is required in the MMA metabolic pathway.

Question 45: Which professional attribute is most valued in musculoskeletal within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 46: A 50-year-old presents with progressive hearing loss and a mass behind the ear with pulsatile tinnitus. CT shows a destructive lesion at the jugular foramen. What is the most likely diagnosis?

Acoustic neuroma
Cholesteatoma
Meningioma
Glomus jugulare tumor (Correct answer)

Correct answer: Glomus jugulare tumor

Glomus jugulare tumors are paragangliomas arising from the jugular bulb, presenting with pulsatile tinnitus and lower cranial nerve deficits with jugular foramen destruction on imaging.

Question 47: A 25-year-old man presents with bilateral cryptorchidism corrected at age 4 and now seeks fertility counseling. What is the most appropriate initial test?

Semen analysis (Correct answer)
Testicular biopsy
Scrotal ultrasound
Serum testosterone level

Correct answer: Semen analysis

Semen analysis is the first-line test for evaluating male fertility because it directly assesses sperm count, motility, and morphology.

Question 48: Which urine finding best differentiates nephritic syndrome from nephrotic syndrome?

Oval fat bodies
Waxy casts
RBC casts (Correct answer)
Protein >3.5 g/day

Correct answer: RBC casts

RBC casts indicate glomerular hematuria from inflammation and are the hallmark of nephritic syndrome.

Question 49: A 60-year-old presents with rectal bleeding, mucus discharge, and tenesmus. Digital rectal exam reveals a rectal mass 4 cm from the anal verge. Which is the most appropriate next step?

MRI of the rectum
CEA level and colonoscopy
Flexible sigmoidoscopy with biopsy (Correct answer)
CT scan of the abdomen and pelvis

Correct answer: Flexible sigmoidoscopy with biopsy

Flexible sigmoidoscopy with biopsy is the most appropriate initial step to directly visualize and obtain tissue from a palpable rectal mass for histologic diagnosis.

Question 50: A patient develops hypotension, bradycardia, and diaphoresis minutes after inferior wall STEMI. Which artery is most likely occluded?

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

Correct answer: Right coronary artery

The right coronary artery supplies the inferior wall, SA node, and AV node; its occlusion causes inferior STEMI with bradycardia and hypotension.

Question 51: A 65-year-old man with hypertension and diabetes presents with exertional dyspnea and preserved ejection fraction (60%). BNP is elevated. What is the most likely diagnosis?

Dilated cardiomyopathy
Restrictive cardiomyopathy
Heart failure with preserved ejection fraction (HFpEF) (Correct answer)
Constrictive pericarditis

Correct answer: Heart failure with preserved ejection fraction (HFpEF)

HFpEF is characterized by symptoms of heart failure with EF ≥50%, commonly seen in elderly patients with hypertension and diabetes who have impaired diastolic relaxation.

Question 52: A 30-year-old woman with Hashimoto thyroiditis is euthyroid. She asks about her risk for other autoimmune conditions. Which condition is she at increased risk for?

Cushing disease
Vitiligo and type 1 diabetes (Correct answer)
Hyperaldosteronism
Type 2 diabetes mellitus

Correct answer: Vitiligo and type 1 diabetes

Hashimoto thyroiditis is associated with other organ-specific autoimmune diseases including type 1 DM, vitiligo, and Addison disease.

Question 53: A 35-year-old with Crohn disease develops a new fistula between the bowel and the bladder. What is the most specific symptom of this complication?

Recurrent UTIs only
Feculent vaginal discharge
Persistent hematuria
Pneumaturia (air in the urine) (Correct answer)

Correct answer: Pneumaturia (air in the urine)

Pneumaturia (passage of gas in urine) is the pathognomonic symptom of an enterovesical fistula, caused by a bowel-bladder connection.

Question 54: A 25-year-old man presents with tall stature, long limbs, lens dislocation, and aortic root dilation. Which endocrine/metabolic condition is associated with this phenotype?

Multiple endocrine neoplasia type 1
Homocystinuria (Correct answer)
Klinefelter syndrome
Acromegaly

Correct answer: Homocystinuria

Homocystinuria (enzyme deficiency) causes a Marfanoid habitus with lens dislocation downward and thrombotic risk, distinguishing it from Marfan syndrome.

Question 55: A 25-year-old male has recurrent hemarthroses, a prolonged aPTT, and normal PT. Factor VIII activity is 2%. What is the diagnosis?

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

Correct answer: Hemophilia A

Hemophilia A is caused by factor VIII deficiency, presenting with hemarthroses and a prolonged aPTT with normal PT.

Question 56: A patient has petechiae, mucosal bleeding, and a platelet count of 8,000. PT and aPTT are normal. What is the most likely diagnosis?

Bernard-Soulier syndrome
Thrombotic thrombocytopenic purpura
Immune thrombocytopenic purpura (Correct answer)
DIC

Correct answer: Immune thrombocytopenic purpura

ITP presents with isolated thrombocytopenia and normal coagulation studies, caused by autoantibodies against platelet glycoproteins.

Question 57: A patient exposed to a bat in their bedroom is brought to the ED. The bat was not captured for testing. The patient has no visible bite marks but was asleep. What is the appropriate management?

Administer rabies immune globulin at wound site plus initiate rabies PEP vaccine series (Correct answer)
Culture wound site and start prophylactic amoxicillin-clavulanate
Reassure and discharge — no treatment needed without confirmed bite
Administer rabies vaccine series only (4 doses)

Correct answer: Administer rabies immune globulin at wound site plus initiate rabies PEP vaccine series

Bat exposure in a sleeping person (potential unrecognized bite) is considered a high-risk rabies exposure; post-exposure prophylaxis (RIG + 4-dose vaccine) is indicated.

Question 58: A patient with a humeral shaft fracture develops wrist drop and inability to extend the fingers. Which nerve is most likely injured?

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

Correct answer: Radial nerve

The radial nerve runs in the spiral groove of the humerus and is commonly injured in mid-shaft humeral fractures, causing wrist drop and finger extension weakness.

Question 59: A newborn develops erythematous macules and papules with surrounding flares on the trunk and extremities within 24–48 hours of birth. Wright stain of pustule contents shows eosinophils. What is the diagnosis?

Neonatal herpes simplex
Transient neonatal pustular melanosis
Erythema toxicum neonatorum (Correct answer)
Miliaria rubra

Correct answer: Erythema toxicum neonatorum

Erythema toxicum neonatorum is a benign, self-limiting rash in newborns characterized by eosinophil-filled pustules on Wright stain, requiring no treatment.

Question 60: A 68-year-old woman presents with polyuria, polydipsia, constipation, and confusion. Labs show calcium of 13.8 mg/dL and PTH is elevated. What is the most common cause of this presentation?

Malignancy-associated hypercalcemia
Sarcoidosis
Primary hyperparathyroidism (Correct answer)
Vitamin D toxicity

Correct answer: Primary hyperparathyroidism

Primary hyperparathyroidism is the most common cause of asymptomatic and symptomatic hypercalcemia with elevated PTH, typically due to a parathyroid adenoma.

Question 61: A 32-year-old woman at 38 weeks gestation develops severe headache, BP 165/110, and RUQ pain. Labs show thrombocytopenia, elevated LFTs, and low haptoglobin. What is the diagnosis?

HELLP syndrome (Correct answer)
Preeclampsia without severe features
Gestational hypertension
Acute fatty liver of pregnancy

Correct answer: HELLP syndrome

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant of preeclampsia requiring urgent delivery.

Question 62: A 30-year-old woman at 10 weeks gestation is found to have a complete hydatidiform mole on ultrasound with a 'snowstorm' appearance. After suction curettage, what is the most important follow-up?

Chest CT to rule out metastases
Immediate chemotherapy with methotrexate
Serial serum hCG monitoring until undetectable (Correct answer)
Repeat ultrasound in 4 weeks

Correct answer: Serial serum hCG monitoring until undetectable

Serial serum hCG monitoring is mandatory after molar evacuation to detect persistent gestational trophoblastic neoplasia, which occurs in ~15-20% of complete moles.

Question 63: A 65-year-old male with a history of NSAID use presents with a duodenal ulcer. Which of the following locations is most common for duodenal ulcers?

Junction of the pylorus and duodenum
Posterior wall of the duodenal bulb
Anterior wall of the first part of the duodenum (Correct answer)
Second portion of the duodenum

Correct answer: Anterior wall of the first part of the duodenum

The majority of duodenal ulcers occur on the anterior wall of the first part (bulb) of the duodenum, where acid exposure is highest.

Question 64: A newborn fails to pass meconium within 48 hours of birth. Abdominal X-ray shows a distended colon with a transition zone. Rectal biopsy confirms absence of ganglion cells. What is the diagnosis?

Anal stenosis
Meconium ileus
Imperforate anus
Hirschsprung disease (Correct answer)

Correct answer: Hirschsprung disease

Hirschsprung disease is caused by absence of enteric ganglion cells (neural crest migration failure) resulting in a functional obstruction and failure to pass meconium.

Question 65: A 19-year-old male presents with multiple firm, flesh-colored, umbilicated papules in the groin and inner thighs after sexual contact. What is the causative agent?

Molluscum contagiosum virus (poxvirus) (Correct answer)
Treponema pallidum
Herpes simplex virus type 2
Human papillomavirus

Correct answer: Molluscum contagiosum virus (poxvirus)

Molluscum contagiosum is caused by a poxvirus and presents with firm, umbilicated, flesh-colored papules; genital involvement in adults is sexually transmitted.

Question 66: A 34-year-old woman presents with weight gain, cold intolerance, constipation, and dry skin. TSH is 18 mIU/L and free T4 is low. Anti-TPO antibodies are positive. What is the most likely diagnosis?

Graves disease
Iodine deficiency hypothyroidism
Subacute thyroiditis
Hashimoto thyroiditis (Correct answer)

Correct answer: Hashimoto thyroiditis

Hashimoto thyroiditis (autoimmune) is the most common cause of primary hypothyroidism in the US, characterized by elevated TSH, low T4, and positive anti-TPO antibodies.

Question 67: A 68-year-old nursing home resident develops sudden onset high fever, myalgias, headache, and dry cough during influenza season. Rapid influenza test is positive. Which antiviral is most appropriate if started within 48 hours?

Zanamivir 10 mg inhaled BID × 5 days
Oseltamivir 75 mg PO BID × 5 days (Correct answer)
Amantadine 100 mg PO BID × 5 days
Baloxavir 40 mg PO single dose

Correct answer: Oseltamivir 75 mg PO BID × 5 days

Oseltamivir (Tamiflu) 75 mg PO BID for 5 days is the preferred neuraminidase inhibitor for influenza treatment in most clinical settings due to oral administration and proven efficacy.

Question 68: A 40-year-old presents with unilateral progressive sensorineural hearing loss, high-frequency tinnitus, and unsteadiness. MRI with gadolinium shows an enhancing cerebellopontine angle mass. What is the most likely diagnosis?

Meningioma
Epidermoid cyst
Facial nerve hemangioma
Vestibular schwannoma (acoustic neuroma) (Correct answer)

Correct answer: Vestibular schwannoma (acoustic neuroma)

Vestibular schwannoma arises from the Schwann cells of CN VIII at the internal auditory canal, presenting with unilateral sensorineural hearing loss, tinnitus, and imbalance.

Question 69: Which acid-base disorder is most commonly seen in end-stage renal disease?

Respiratory acidosis
Normal anion gap metabolic acidosis
High anion gap metabolic acidosis (Correct answer)
Metabolic alkalosis

Correct answer: High anion gap metabolic acidosis

Inability to excrete acid and regenerate bicarbonate in ESRD leads to high anion gap metabolic acidosis from accumulation of organic acids.

Question 70: A 62-year-old has fatigue, back pain, hypercalcemia, anemia, and a serum M-protein spike on SPEP. What is the most likely diagnosis?

Waldenstrom macroglobulinemia
Metastatic prostate cancer
Chronic lymphocytic leukemia
Multiple myeloma (Correct answer)

Correct answer: Multiple myeloma

Multiple myeloma presents with the CRAB criteria (hypercalcemia, renal failure, anemia, bone lesions) plus an M-protein spike.

Question 71: A 55-year-old presents with flank pain, gross hematuria, and a palpable mass. CT reveals a solid renal mass. What is the most likely diagnosis?

Renal cell carcinoma (Correct answer)
Angiomyolipoma
Transitional cell carcinoma
Nephroblastoma

Correct answer: Renal cell carcinoma

Renal cell carcinoma classically presents with the triad of hematuria, flank pain, and a palpable mass in adults.

Question 72: A 35-year-old woman has had a rash on her legs for the previous three weeks. No known infectious contacts exist. Her bladder infection was treated with trimethoprim-sulfamethoxazole a month ago. A generalized rash is visible on the shins, left medial ankle, and right medial calf during physical examination. Tender, diffuse, and returning to the same spots, the rash is. A couple of the lesions show bruise-like characteristics. Which of the subsequent diagnoses is most likely?

Lichen planus
Nummular eczema
Erythema nodosum (Correct answer)
Erythema multiforme

Correct answer: Erythema nodosum

The combination of red, tender nodules on the anterior lower legs (erythema nodosum), bilateral hilar adenopathy on chest X-ray, iritis, and systemic symptoms like malaise, dyspnea, and low-grade fever is highly characteristic of sarcoidosis. Erythema nodosum is a common cutaneous manifestation of sarcoidosis, a multisystem granulomatous disease.

Question 73: A patient with CKD has a serum potassium of 6.4 mEq/L and peaked T-waves on ECG. What is the first intervention?

Insulin with dextrose
Sodium bicarbonate
Sodium polystyrene sulfonate
IV calcium gluconate (Correct answer)

Correct answer: IV calcium gluconate

IV calcium gluconate immediately stabilizes the cardiac membrane when ECG changes are present in hyperkalemia.

Question 74: A 52-year-old has splenomegaly, WBC of 85,000 with basophilia, and a Philadelphia chromosome on cytogenetics. What is the diagnosis?

Acute myeloid leukemia
Polycythemia vera
Myelofibrosis
Chronic myelogenous leukemia (Correct answer)

Correct answer: Chronic myelogenous leukemia

CML is characterized by the BCR-ABL fusion gene (Philadelphia chromosome t(9;22)) and presents with leukocytosis, basophilia, and splenomegaly.

Question 75: A 45-year-old male is found to have a BP of 155/95 mmHg on three separate occasions. He also has diabetes and proteinuria. What is the most appropriate antihypertensive?

Lisinopril (Correct answer)
Hydrochlorothiazide
Metoprolol
Amlodipine

Correct answer: Lisinopril

ACE inhibitors like lisinopril are first-line in diabetic patients with hypertension and proteinuria due to their renoprotective effects.

Question 76: A 19-year-old male athlete collapses during a basketball game. He is resuscitated from ventricular fibrillation. ECG shows ST elevation in V1-V2 with a right bundle branch block pattern. What is the most likely diagnosis?

Hypertrophic cardiomyopathy
Long QT syndrome
Brugada syndrome (Correct answer)
Arrhythmogenic right ventricular cardiomyopathy

Correct answer: Brugada syndrome

Brugada syndrome presents with the characteristic coved-type ST elevation in V1-V2 with RBBB pattern and is a cause of sudden cardiac death in young individuals.

Question 77: Which approach best demonstrates mastery of dermatology in PANCE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 78: A 60-year-old man presents with symmetric morning stiffness lasting over 1 hour, swelling of MCPs and PIPs, and positive anti-CCP antibodies. What is the first-line DMARD therapy?

Methotrexate (Correct answer)
Hydroxychloroquine
Sulfasalazine
Leflunomide

Correct answer: Methotrexate

Methotrexate is the anchor DMARD for rheumatoid arthritis due to its efficacy, tolerability, and long track record.

Question 79: A 31-year-old man and his partner have been trying to conceive for 18 months. Semen analysis shows count 8 million/mL, motility 25%, normal morphology 3%. Which condition should be excluded first?

Retrograde ejaculation
Congenital absence of vas deferens
Klinefelter syndrome
Varicocele (Correct answer)

Correct answer: Varicocele

Varicocele is the most common correctable cause of male infertility and should be the first diagnosis excluded with scrotal ultrasound and physical exam.

Question 80: What is the best practice for maintaining cardiovascular system performance over time?

Upgrade all equipment annually
Outsource all maintenance
Wait for failures before acting
Implement scheduled preventive maintenance (Correct answer)

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 81: A 32-year-old woman presents with pleuritic chest pain, malar rash, oral ulcers, and arthralgias. Lab work shows anti-dsDNA antibodies and low complement (C3/C4). What is the most likely diagnosis?

Rheumatoid arthritis
Sjogren's syndrome
Systemic lupus erythematosus (SLE) (Correct answer)
Mixed connective tissue disease

Correct answer: Systemic lupus erythematosus (SLE)

SLE is characterized by malar rash, oral ulcers, serositis (pleuritis), arthritis, and positive anti-dsDNA with low complement levels.

Question 82: A 70-year-old male presents with bilateral leg cramping when walking that is relieved by leaning forward or sitting. MRI shows narrowing of the lumbar spinal canal. What is the diagnosis?

L4 disc herniation
Lumbar spinal stenosis (Correct answer)
Deep vein thrombosis
Peripheral arterial disease

Correct answer: Lumbar spinal stenosis

Lumbar spinal stenosis causes neurogenic claudication with pain relieved by flexion (leaning forward), distinguishing it from vascular claudication which improves with rest alone.

Question 83: Which of the following best distinguishes Crohn disease from ulcerative colitis on endoscopy?

Skip lesions with cobblestone appearance (Correct answer)
Presence of pseudopolyps
Involvement limited to the colon
Continuous mucosal involvement from the rectum

Correct answer: Skip lesions with cobblestone appearance

Crohn disease classically shows discontinuous skip lesions, transmural inflammation, and cobblestone mucosa due to deep fissuring ulcers, unlike UC's continuous mucosal disease.

Question 84: In PANCE certification, what does redundancy in system design primarily provide?

Simplified maintenance
Increased complexity
Lower initial cost
Fault tolerance and high availability (Correct answer)

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 85: A 10-year-old develops cola-colored urine and periorbital edema 2 weeks after a strep throat infection. What is the diagnosis?

Focal segmental glomerulosclerosis
Minimal change disease
IgA nephropathy
Poststreptococcal glomerulonephritis (Correct answer)

Correct answer: Poststreptococcal glomerulonephritis

Poststreptococcal GN typically follows strep pharyngitis by 1–3 weeks and presents with hematuria and edema.

Question 86: A 60-year-old patient who recently completed a 10-day course of antibiotics for a respiratory infection develops profuse watery diarrhea. Stool testing reveals the causative toxin. Which antibiotic is the preferred first-line treatment for mild-to-moderate disease?

Fidaxomicin 200 mg PO BID × 10 days
Vancomycin 125 mg PO QID × 10 days (Correct answer)
Rifaximin 550 mg PO TID × 14 days
Metronidazole 500 mg PO TID × 10 days

Correct answer: Vancomycin 125 mg PO QID × 10 days

Oral vancomycin 125 mg QID for 10 days is now the preferred first-line treatment for mild-to-moderate Clostridioides difficile infection per current IDSA guidelines.

Question 87: When examining a patient who has known benign prostatic hyperplasia, what would you anticipate finding?

Fever and elevated white blood cell count (WBC)
Hard, nodular prostate with digital rectal exam
Rubbery prostate with digital rectal exam (Correct answer)
Patient report of painful urination

Correct answer: Rubbery prostate with digital rectal exam

Benign prostatic hyperplasia (BPH) involves a non-cancerous enlargement of the prostate gland. During a digital rectal exam (DRE), a prostate affected by BPH typically feels symmetrically enlarged, smooth, and rubbery. A hard, nodular prostate would be a more concerning finding, suggestive of prostate cancer.

Question 88: A 68-year-old woman presents with tense bullae on an erythematous base on her trunk and proximal extremities. Direct immunofluorescence shows linear IgG and C3 at the dermal-epidermal junction. What is the diagnosis?

Bullous pemphigoid (Correct answer)
Linear IgA bullous dermatosis
Pemphigus vulgaris
Dermatitis herpetiformis

Correct answer: Bullous pemphigoid

Bullous pemphigoid features tense bullae (not flaccid), linear IgG/C3 at the BMZ on DIF, and anti-BP180/BP230 antibodies targeting hemidesmosomes.

Question 89: You come across a patient who has a history of optic neuritis. What test should be ordered in order to rule out any more severe comorbid conditions?

Reticulocyte count
Lumbar puncture
Magnetic resonance imaging (MRI) (Correct answer)
HIV

Correct answer: Magnetic resonance imaging (MRI)

Optic neuritis, especially in a young adult, is a common initial manifestation of multiple sclerosis (MS), a severe demyelinating condition affecting the central nervous system. Magnetic resonance imaging (MRI) of the brain and orbits is the most appropriate test to identify characteristic demyelinating lesions, which are crucial for diagnosing or ruling out MS and guiding further management.

Question 90: A 65-year-old presents with progressive hoarseness of 8 weeks duration and a 15 lb weight loss. Laryngoscopy shows an ulcerated lesion of the true vocal cord with cord fixation. What staging feature does cord fixation indicate?

T4 disease — cartilage invasion
T3 disease — fixed cord (Correct answer)
T1 disease — limited to true cord
T2 disease — extension to supraglottis

Correct answer: T3 disease — fixed cord

Vocal cord fixation in laryngeal cancer indicates T3 disease regardless of tumor size, reflecting deep invasion of the paraglottic space or cricoarytenoid joint.

Question 91: In PANCE certification, what does redundancy in system design primarily provide?

Fault tolerance and high availability (Correct answer)
Increased complexity
Lower initial cost
Simplified maintenance

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 92: A 60-year-old woman with atrial fibrillation has a CHA₂DS₂-VASc score of 4. She has no contraindications. Which anticoagulation is preferred?

Warfarin with target INR 2-3
Direct oral anticoagulant (DOAC) (Correct answer)
Clopidogrel
Aspirin 325 mg daily

Correct answer: Direct oral anticoagulant (DOAC)

DOACs are preferred over warfarin for non-valvular atrial fibrillation due to superior efficacy, safety, and convenience without routine INR monitoring.

Question 93: A patient is found to have a Horner syndrome (ptosis, miosis, anhidrosis) on the right side. Which of the following is the most concerning etiology?

Benign Raeder syndrome
Cluster headache
Migraine with aura
Carotid artery dissection (Correct answer)

Correct answer: Carotid artery dissection

Carotid artery dissection can interrupt the sympathetic fibers traveling along the carotid sheath and is a life-threatening cause of Horner syndrome requiring urgent imaging.

Question 94: A 35-year-old woman develops sudden-onset severe headache and is found to have markedly elevated blood pressure (240/130 mmHg) with papilledema. Which agent should be avoided?

Nitroprusside IV (Correct answer)
Hydralazine IV
Labetalol IV
Nicardipine IV

Correct answer: Nitroprusside IV

Nitroprusside is metabolized to cyanide and can increase intracranial pressure, making it problematic in hypertensive emergency with neurologic involvement.

Question 95: A 2-year-old presents with sudden onset of choking followed by persistent unilateral wheezing and decreased breath sounds on the right. The child is now afebrile and in no respiratory distress. Chest X-ray shows right-sided hyperinflation. What is the next step?

Rigid bronchoscopy for foreign body removal (Correct answer)
Chest CT scan
Antibiotic therapy for pneumonia
Bronchodilator treatment and observation

Correct answer: Rigid bronchoscopy for foreign body removal

Aspirated foreign body in the airway presents with unilateral air trapping and requires rigid bronchoscopy for definitive removal under controlled conditions.

Question 96: A 28-year-old man presents with scaly, hypopigmented macules on his trunk that become more prominent after sun exposure. KOH preparation shows 'spaghetti and meatballs' hyphae. What organism is responsible?

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

Correct answer: Malassezia furfur

Tinea versicolor is caused by Malassezia furfur, a lipophilic yeast that produces the classic 'spaghetti and meatballs' pattern on KOH prep.

Question 97: A patient with a pulmonary embolism develops hypotension (BP 80/50) and RV dilation on echo. She has no contraindications to thrombolytics. Which statement best describes the appropriate management?

Systemic thrombolysis with alteplase (Correct answer)
Catheter-directed thrombolysis only
Surgical embolectomy as first-line
Anticoagulation with unfractionated heparin alone

Correct answer: Systemic thrombolysis with alteplase

Massive PE with hemodynamic compromise and no contraindications is the primary indication for systemic thrombolysis with alteplase.

Question 98: A 25-year-old male presents with fever, headache, photophobia, and nuchal rigidity. CSF analysis shows WBC 1,200 cells/µL (predominantly neutrophils), glucose 30 mg/dL (serum glucose 90 mg/dL), and protein 180 mg/dL. What is the most likely causative organism in this age group?

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

Correct answer: Neisseria meningitidis

Neisseria meningitidis is the most common cause of bacterial meningitis in adolescents and young adults (15–24 years), particularly in college dormitory settings.

Question 99: What is the most important professional competency for PANCE certification in gastrointestinal?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 100: What is the primary consideration when implementing changes to reproductive system?

Personal convenience
Vendor preference
Speed of implementation
Impact assessment and change management (Correct answer)

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 101: A 70-year-old woman presents with confusion, fever, and flank pain. Urinalysis shows pyuria and bacteriuria. Blood cultures are positive. She has a penicillin allergy (rash). Which antibiotic is most appropriate for gram-negative bacteremia?

Vancomycin 15 mg/kg IV
Clindamycin 900 mg IV
Ampicillin-sulbactam IV
Ciprofloxacin 400 mg IV (Correct answer)

Correct answer: Ciprofloxacin 400 mg IV

Ciprofloxacin IV is an appropriate alternative for gram-negative bacteremia (urosepsis) in patients with penicillin allergy, as fluoroquinolones cover common urinary gram-negative pathogens.

Question 102: A 35-year-old with HIV (CD4 count 60 cells/μL) presents with fever, dry cough, and bilateral interstitial infiltrates. LDH is markedly elevated. Methenamine silver stain of BAL fluid shows cysts. What is the first-line treatment?

Fluconazole
Voriconazole
Trimethoprim-sulfamethoxazole (TMP-SMX) (Correct answer)
Caspofungin

Correct answer: Trimethoprim-sulfamethoxazole (TMP-SMX)

TMP-SMX is the first-line treatment for Pneumocystis jirovecii pneumonia (PCP), which presents with interstitial infiltrates and elevated LDH in severely immunocompromised patients.

Question 103: A 68-year-old man presents with sudden onset of left-sided weakness and slurred speech that resolved completely within 45 minutes. MRI shows no infarct. What is the most appropriate next step?

Start aspirin and statin, arrange outpatient follow-up in 1 week
Order CT head without contrast only
Discharge with carotid ultrasound scheduled in 2 weeks
Admit for urgent evaluation and stroke risk stratification (Correct answer)

Correct answer: Admit for urgent evaluation and stroke risk stratification

TIA carries high early stroke risk; urgent inpatient or rapid outpatient evaluation within 24 hours with ABCD2 scoring, imaging, and cardiac monitoring is indicated.

Question 104: Which of the following best differentiates central from obstructive sleep apnea on polysomnography?

Oxygen desaturation to less than 88%
More than 5 events per hour of sleep
Absence of respiratory effort during apneic episodes (Correct answer)
Apnea duration longer than 10 seconds

Correct answer: Absence of respiratory effort during apneic episodes

Central sleep apnea is defined by cessation of both airflow and respiratory effort, whereas obstructive events have persistent thoracoabdominal effort.

Question 105: Which peripheral blood smear finding is most diagnostic of microangiopathic hemolytic anemia?

Target cells
Spherocytes
Bite cells
Schistocytes (Correct answer)

Correct answer: Schistocytes

Schistocytes (fragmented RBCs) form when red cells are mechanically sheared by fibrin strands or damaged endothelium in microangiopathic conditions.

Question 106: A 55-year-old man presents with dark, velvety thickening of the skin in the axillae and posterior neck. He also reports 20 lb weight loss over 2 months. What is the most important next step?

Start topical retinoids
Perform skin biopsy
Evaluate for underlying malignancy (Correct answer)
Test for insulin resistance

Correct answer: Evaluate for underlying malignancy

Acanthosis nigricans with rapid onset and weight loss suggests malignant acanthosis nigricans, most commonly associated with GI adenocarcinoma.

Question 107: A 60-year-old diabetic male presents with severe left-sided otalgia, purulent otorrhea, and granulation tissue visible in the external auditory canal. He has facial nerve palsy. CT shows cortical bone erosion at the skull base. What is the most likely organism?

Staphylococcus aureus
Pseudomonas aeruginosa (Correct answer)
Aspergillus niger
Streptococcus pneumoniae

Correct answer: Pseudomonas aeruginosa

Malignant (necrotizing) external otitis in diabetics is almost exclusively caused by Pseudomonas aeruginosa; facial nerve palsy indicates skull base osteomyelitis requiring prolonged IV antipseudomonal therapy.

Question 108: A patient presents with a painless penile ulcer with clean base and raised indurated edges. Dark-field microscopy of the lesion reveals spirochetes. Which antibiotic is first-line treatment?

Ceftriaxone 500 mg IM single dose
Azithromycin 1 g PO single dose
Doxycycline 100 mg PO BID × 14 days
Penicillin G benzathine 2.4 million units IM single dose (Correct answer)

Correct answer: Penicillin G benzathine 2.4 million units IM single dose

Primary syphilis caused by Treponema pallidum is treated with a single IM dose of penicillin G benzathine 2.4 million units.

Question 109: A 6-year-old presents with 5 days of fever, purulent nasal discharge, and periorbital edema. CT scan shows opacification of the ethmoid sinuses and a subperiosteal abscess along the medial orbital wall. What is the most appropriate management?

Oral amoxicillin-clavulanate and close follow-up
Topical nasal decongestants and systemic steroids
IV antibiotics and urgent surgical drainage (Correct answer)
IV antibiotics alone without surgery

Correct answer: IV antibiotics and urgent surgical drainage

Subperiosteal orbital abscess secondary to ethmoid sinusitis requires IV antibiotics plus urgent surgical drainage to prevent optic nerve compression and vision loss.

Question 110: A 45-year-old with silicosis develops a new cavitary upper lobe lesion. Which organism is most likely responsible?

Pseudomonas aeruginosa
Mycobacterium tuberculosis (Correct answer)
Aspergillus fumigatus
Streptococcus pneumoniae

Correct answer: Mycobacterium tuberculosis

Silicosis dramatically increases susceptibility to tuberculosis, which preferentially causes upper lobe cavitary lesions.

Question 111: A 47-year-old man has been pushing his lawn mower for the past three weeks while experiencing chest pain. He states he has never been treated for similar symptoms and has no problems presently. He smoked one pack each day for twenty years until giving it up seven years ago. Physical examination results are typical. Electrocardiograms don't reveal any anomalies. Which of the following first diagnostic tests is most appropriate?

Echocardiography
Exercise stress test (Correct answer)
Coronary arteriography
24-Hour ambulatory cardiac monitoring

Correct answer: Exercise stress test

The patient's exertional chest pain, occurring while pushing a lawn mower, is highly suggestive of stable angina, even with a normal resting EKG. An exercise stress test is the most appropriate initial diagnostic test to evaluate for exercise-induced myocardial ischemia. It helps determine if the heart receives enough blood flow during physical activity, which might not be evident at rest.

Question 112: A 72-year-old man with heart failure has a BNP of 1,200 pg/mL. His ejection fraction is 30%. Which diuretic combination is preferred for decongestion?

Furosemide plus metolazone (Correct answer)
Spironolactone alone
Furosemide alone
Hydrochlorothiazide alone

Correct answer: Furosemide plus metolazone

Furosemide plus metolazone provides sequential nephron blockade, overcoming diuretic resistance common in advanced heart failure with low GFR.

Question 113: A 55-year-old man presents with low back pain radiating down the posterior leg to the foot, worsened by sitting and relieved by standing. Straight leg raise is positive at 40°. What is the most likely diagnosis?

Piriformis syndrome
Lumbar spinal stenosis
Cauda equina syndrome
L4-L5 disc herniation (Correct answer)

Correct answer: L4-L5 disc herniation

A positive straight leg raise test at less than 45° is highly sensitive for lumbar disc herniation causing nerve root compression and radiculopathy.

Question 114: A 35-year-old female presents with diffuse musculoskeletal pain for 6 months, fatigue, non-restorative sleep, and 14 tender points. Labs including ANA and ESR are normal. What is the diagnosis?

Fibromyalgia (Correct answer)
Rheumatoid arthritis
Systemic lupus erythematosus
Polymyalgia rheumatica

Correct answer: Fibromyalgia

Fibromyalgia is characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and multiple tender points with normal laboratory findings.

Question 115: What is the fundamental principle behind neurologic system in the PANCE domain?

Following a single vendor solution
Balancing performance, reliability, and efficiency (Correct answer)
Cost minimization at all costs
Using the newest technology exclusively

Correct answer: Balancing performance, reliability, and efficiency

Effective technical design requires balancing performance requirements with reliability needs and operational efficiency.

Question 116: A 29-year-old pregnant woman at 28 weeks is found to have Rh-negative blood type. Her partner is Rh-positive. What is the correct management?

Administer Rh immunoglobulin only postpartum
No treatment needed until delivery
Check maternal antibody titers monthly and treat if positive
Administer Rh immunoglobulin at 28 weeks and within 72 hours postpartum if infant is Rh-positive (Correct answer)

Correct answer: Administer Rh immunoglobulin at 28 weeks and within 72 hours postpartum if infant is Rh-positive

Standard protocol is Rh immunoglobulin at 28 weeks gestation and again within 72 hours of delivery if the neonate is Rh-positive to prevent isoimmunization.

Question 117: A 60-year-old man presents with gynecomastia, small firm testes, and infertility. Karyotype reveals 47,XXY. Which hormone pattern is expected?

Elevated testosterone, low FSH
Elevated FSH and LH, low testosterone (Correct answer)
Low FSH and LH, low testosterone
Normal FSH and LH, normal testosterone

Correct answer: Elevated FSH and LH, low testosterone

Klinefelter syndrome causes primary testicular failure with elevated gonadotropins (FSH, LH) due to absent feedback, and low testosterone.

Question 118: What is the value of continuing education in musculoskeletal for PANCE professionals?

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

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

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

Question 119: A 28-year-old sexually active woman presents with dysuria, mucopurulent cervical discharge, and cervical motion tenderness. Nucleic acid amplification test is positive for Chlamydia trachomatis. Which additional organism must empirically be treated simultaneously?

Trichomonas vaginalis
Neisseria gonorrhoeae (Correct answer)
Mycoplasma genitalium
Gardnerella vaginalis

Correct answer: Neisseria gonorrhoeae

Pelvic inflammatory disease (PID) treatment must cover both Chlamydia trachomatis and Neisseria gonorrhoeae empirically due to frequent co-infection.

Question 120: A 70-year-old farmer presents with a pearly, rolled-edge nodule with telangiectasias on his nose that occasionally bleeds. What is the first-line treatment?

Punch biopsy and observe
Topical imiquimod
Mohs micrographic surgery (Correct answer)
Cryotherapy

Correct answer: Mohs micrographic surgery

Basal cell carcinoma on high-risk areas like the nose is best treated with Mohs surgery to achieve clear margins while sparing maximal tissue.

Question 121: A 68-year-old woman presents with progressive proximal muscle weakness, difficulty rising from a chair, and a heliotrope rash. CK is markedly elevated. What is the diagnosis?

Myasthenia gravis
Polymyalgia rheumatica
Dermatomyositis (Correct answer)
Multiple sclerosis

Correct answer: Dermatomyositis

Dermatomyositis presents with proximal muscle weakness, elevated CK, and characteristic skin findings including the heliotrope rash.

Question 122: Which finding on osmotic fragility testing is most characteristic of hereditary spherocytosis?

Decreased osmotic fragility
Increased osmotic fragility (Correct answer)
Target cells with low fragility
Normal fragility with normal MCHC

Correct answer: Increased osmotic fragility

Spherocytes lack the normal biconcave disc shape, causing increased osmotic fragility as they lyse more easily in hypotonic solutions.

Question 123: A 70-year-old woman with osteoporosis fractures her vertebra after minor trauma. DEXA scan shows T-score of -2.8. Which medication reduces both vertebral and hip fracture risk?

Raloxifene
Calcitonin
Alendronate (Correct answer)
Calcium supplementation alone

Correct answer: Alendronate

Bisphosphonates like alendronate reduce both vertebral and non-vertebral (including hip) fracture risk and are first-line treatment for osteoporosis.

Question 124: A 55-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows grade 1 endometrioid adenocarcinoma. Which is the most significant risk factor she likely has?

BRCA2 mutation
Chronic pelvic inflammatory disease
Unopposed estrogen exposure (Correct answer)
Prior tamoxifen use

Correct answer: Unopposed estrogen exposure

Unopposed estrogen exposure (obesity, anovulation, exogenous estrogen without progesterone) is the most common risk factor for type I endometrioid endometrial carcinoma.

Question 125: A 45-year-old man has prolonged QT on EKG (QTc 510 ms) and is prescribed an antibiotic. Which is SAFEST to use?

Moxifloxacin
Azithromycin
Erythromycin
Amoxicillin (Correct answer)

Correct answer: Amoxicillin

Amoxicillin does not prolong the QT interval, making it safe in patients with prolonged QTc, unlike macrolides and fluoroquinolones.

Question 126: A 35-year-old woman has episodes of sudden muscle weakness triggered by laughter. She also reports excessive daytime sleepiness. What is the most likely diagnosis?

Epilepsy
Multiple sclerosis
Narcolepsy with cataplexy (Correct answer)
Hypokalemic periodic paralysis

Correct answer: Narcolepsy with cataplexy

Narcolepsy with cataplexy presents with excessive daytime sleepiness and sudden loss of muscle tone triggered by strong emotions.

Question 127: Which medication must be held when GFR falls below 30 mL/min due to risk of lactic acidosis?

Atorvastatin
Amlodipine
Metformin (Correct answer)
Lisinopril

Correct answer: Metformin

Metformin accumulates in severe CKD and inhibits hepatic mitochondrial respiration, causing life-threatening lactic acidosis.

Question 128: In PANCE practice, what is the best approach to quality improvement in dermatology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 129: A 48-year-old woman with a history of breast cancer presents with severe back pain and new bilateral leg weakness with bowel/bladder incontinence. What is the most urgent next step?

Lumbar X-ray
Empiric corticosteroids and discharge
Outpatient MRI in 2 weeks
Emergency MRI of the spine and neurosurgical consult (Correct answer)

Correct answer: Emergency MRI of the spine and neurosurgical consult

Malignant spinal cord compression is a surgical emergency requiring immediate MRI and neurosurgical evaluation to prevent permanent neurological deficits.

Question 130: 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?

Perform exercise stress testing
Administer sublingual nitroglycerin and discharge
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 131: A 35-year-old runner presents with pain at the inferior pole of the patella that worsens with jumping. No effusion is present. What is the most likely diagnosis?

Osgood-Schlatter disease
Prepatellar bursitis
Patellar tendinopathy (Correct answer)
Patellofemoral syndrome

Correct answer: Patellar tendinopathy

Patellar tendinopathy (jumper's knee) presents with focal tenderness at the inferior patellar pole, exacerbated by jumping and resisted knee extension.

Question 132: Which laboratory finding is most consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?

Serum sodium 130 mEq/L, urine osmolality 80 mOsm/kg, urine sodium 10 mEq/L
Serum sodium 125 mEq/L, urine osmolality 60 mOsm/kg, urine sodium 5 mEq/L
Serum sodium 132 mEq/L, urine osmolality 100 mOsm/kg, urine sodium 8 mEq/L
Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L (Correct answer)

Correct answer: Serum sodium 128 mEq/L, urine osmolality 550 mOsm/kg, urine sodium 45 mEq/L

SIADH features hyponatremia with inappropriately concentrated urine (>100 mOsm/kg) and high urine sodium (>20 mEq/L).

Question 133: A 10-year-old with recurrent otitis media now has a white pearly mass visible through the tympanic membrane with a foul-smelling discharge. CT shows erosion of the ossicles. What is the diagnosis?

Glomus tympanicum
Cholesteatoma (Correct answer)
Adenoid hypertrophy
Tympanosclerosis

Correct answer: Cholesteatoma

Cholesteatoma is a destructive accumulation of keratinizing squamous epithelium in the middle ear that erodes ossicles and can extend intracranially; surgical removal is required.

Question 134: What role does collaboration play in eent for PANCE professionals?

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

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

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

Question 135: A 26-year-old woman with no prenatal care delivers a term infant. The neonate develops purulent conjunctivitis at 5 days of life. Gram stain shows intracellular gram-negative diplococci. What is the treatment?

Topical ciprofloxacin drops
Topical erythromycin ointment
Oral azithromycin
IV ceftriaxone (Correct answer)

Correct answer: IV ceftriaxone

Neonatal gonococcal ophthalmia (caused by N. gonorrhoeae presenting at 2-5 days) requires IV ceftriaxone because topical therapy alone is insufficient for this serious infection.

Question 136: A patient presents with confusion, asterixis, and jaundice. Labs show elevated ammonia, PT, and bilirubin. What is the primary mechanism of the encephalopathy?

Thiamine deficiency
Cerebral hypoperfusion from low albumin
Accumulation of ammonia causing cerebral edema (Correct answer)
Hypoglycemia from liver failure

Correct answer: Accumulation of ammonia causing cerebral edema

Hepatic encephalopathy results primarily from elevated ammonia, which crosses the blood-brain barrier and causes astrocyte swelling and cerebral dysfunction.

Question 137: Which documentation is essential when working with pulmonary system in PANCE?

General descriptions without specifics
Detailed technical specifications and as-built diagrams (Correct answer)
Marketing materials
Only verbal notes

Correct answer: Detailed technical specifications and as-built diagrams

Detailed technical specifications and as-built diagrams provide the accurate reference information needed for maintenance and troubleshooting.

Question 138: A 28-year-old white male in generally good health has had dull testicular pain for the past two weeks. He denies penile discharge, and the scrotum is non-erythematous, he is negative for sexually transmitted infections. Which do you believe?

Hydrocele
Spermatocele
Testicular cancer (Correct answer)
Epididymitis

Correct answer: Testicular cancer

In a young male, persistent dull testicular pain without signs of infection (no discharge, non-erythematous scrotum, negative STIs) should raise suspicion for testicular cancer. While other conditions can cause testicular pain, testicular cancer often presents with a painless mass or a dull ache/heaviness, making it a crucial diagnosis to rule out promptly in this demographic.

Question 139: A neonate born at 32 weeks develops respiratory distress immediately after birth with grunting, flaring, and retractions. CXR shows diffuse ground-glass opacities. What is the pathophysiology?

Surfactant deficiency (Correct answer)
Transient tachypnea of the newborn
Congenital pneumonia
Meconium aspiration

Correct answer: Surfactant deficiency

Respiratory distress syndrome (RDS) in premature neonates results from surfactant deficiency, causing diffuse atelectasis and ground-glass appearance on CXR.

Question 140: A 25-year-old male presents with urethral discharge and dysuria. Gram stain shows gram-negative intracellular diplococci. Which antibiotic regimen is currently recommended by CDC guidelines?

Azithromycin 1g orally single dose
Ceftriaxone 500mg IM single dose plus doxycycline 100mg twice daily for 7 days (Correct answer)
Ciprofloxacin 500mg orally single dose
Doxycycline 100mg twice daily for 7 days

Correct answer: Ceftriaxone 500mg IM single dose plus doxycycline 100mg twice daily for 7 days

Current CDC guidelines recommend ceftriaxone 500 mg IM (or 1g if weight ≥150 kg) plus doxycycline (if chlamydia not excluded) for uncomplicated gonorrhea.

Question 141: What is the best practice for maintaining pulmonary system performance over time?

Implement scheduled preventive maintenance (Correct answer)
Upgrade all equipment annually
Outsource all maintenance
Wait for failures before acting

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 142: A 25-year-old woman with MVP presents with palpitations. Holter monitor shows frequent PVCs. She is anxious about her condition. First-line treatment is:

Beta-blocker (Correct answer)
Catheter ablation
Flecainide
Amiodarone

Correct answer: Beta-blocker

Beta-blockers are first-line for symptomatic PVCs in MVP as they suppress ectopy, reduce anxiety-triggered adrenergic activity, and have a favorable safety profile.

Question 143: A 22-year-old presents with a 3-day history of painful vesicles on the auricle, ear canal pain, and ipsilateral facial droop. She also notes decreased taste on the anterior tongue. What is the diagnosis?

Malignant otitis externa
Otitis externa with nerve compression
Bell's palsy
Herpes zoster oticus (Ramsay Hunt syndrome) (Correct answer)

Correct answer: Herpes zoster oticus (Ramsay Hunt syndrome)

Ramsay Hunt syndrome is herpes zoster reactivation in the geniculate ganglion causing otalgia, auricular vesicles, facial palsy, and loss of taste in the anterior two-thirds of the tongue.

Question 144: A 55-year-old smoker presents with progressive dyspnea and a barrel chest. Spirometry shows FEV1/FVC ratio of 0.60. Which pathophysiologic mechanism best explains his air trapping?

Alveolar wall thickening reducing diffusion capacity
Bronchial smooth muscle hypertrophy
Mucus gland hyperplasia obstructing large airways
Loss of elastic recoil causing dynamic airway collapse (Correct answer)

Correct answer: Loss of elastic recoil causing dynamic airway collapse

In emphysema, destruction of alveolar walls reduces elastic recoil, causing dynamic small airway collapse during expiration and air trapping.

Question 145: A patient presents with sudden-onset tearing chest pain radiating to the back. CT angiography confirms a Stanford Type B aortic dissection. Initial management should include:

Emergency surgical repair
IV labetalol and nicardipine (Correct answer)
Thrombolytic therapy
Emergent pericardiocentesis

Correct answer: IV labetalol and nicardipine

Uncomplicated Type B dissections (descending aorta) are managed medically with IV beta-blockers to reduce heart rate and blood pressure, limiting propagation.

Question 146: In PANCE certification, what does redundancy in system design primarily provide?

Fault tolerance and high availability (Correct answer)
Lower initial cost
Increased complexity
Simplified maintenance

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Question 147: A 70-year-old hypertensive patient presents with sudden unilateral vision loss that lasted 10 minutes and resolved completely. Fundoscopic exam is normal. What is this episode called and what is the first-line imaging study?

Migraine equivalent; MRI of the brain
Optic neuritis; MRI of the brain
Central retinal artery occlusion; CT angiography
Amaurosis fugax; carotid duplex ultrasound (Correct answer)

Correct answer: Amaurosis fugax; carotid duplex ultrasound

Amaurosis fugax (transient monocular blindness from carotid emboli) requires urgent carotid duplex ultrasound to evaluate for significant ipsilateral carotid stenosis.

Question 148: A 60-year-old presents with recurrent hemoptysis, and CT shows a central endobronchial lesion. Biopsy reveals squamous cell carcinoma. Which paraneoplastic syndrome is most associated with this tumor type?

Cushing syndrome from ectopic ACTH
Hypercalcemia due to PTHrP secretion (Correct answer)
Eaton-Lambert syndrome
SIADH causing hyponatremia

Correct answer: Hypercalcemia due to PTHrP secretion

Squamous cell carcinoma of the lung is the most common cause of hypercalcemia of malignancy via PTHrP secretion.

Question 149: A 14-year-old male presents with knee pain and a tender tibial tubercle that is worse with activity. No joint effusion. What is the diagnosis?

Osgood-Schlatter disease (Correct answer)
Legg-Calvé-Perthes disease
Patellar tendinopathy
Slipped capital femoral epiphysis

Correct answer: Osgood-Schlatter disease

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle in adolescents during growth spurts, presenting with localized tenderness and swelling.

Question 150: A 40-year-old African American woman presents with bilateral hilar lymphadenopathy, uveitis, and erythema nodosum. Serum ACE level is elevated. What is the most likely diagnosis?

Lymphoma
Histoplasmosis
Sarcoidosis (Correct answer)
Tuberculosis

Correct answer: Sarcoidosis

The triad of bilateral hilar lymphadenopathy, uveitis, and erythema nodosum with elevated ACE is classic for sarcoidosis, which has higher prevalence in African Americans.

Question 151: A 26-year-old woman at 32 weeks gestation develops sudden onset severe headache, visual disturbances, and BP 158/106 mmHg. Urinalysis shows 3+ proteinuria. Which complication must be urgently assessed?

HELLP syndrome (Correct answer)
Gestational hypertension
Eclampsia
Chronic hypertension with superimposed preeclampsia

Correct answer: HELLP syndrome

The combination of preeclampsia symptoms with severe features warrants urgent CBC, LFTs, and LDH to rule out HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).

Question 152: A newborn has ambiguous genitalia, hyponatremia, hyperkalemia, and low cortisol. 17-hydroxyprogesterone is markedly elevated. What is the most likely diagnosis?

Adrenal adenoma
Primary hyperaldosteronism
Congenital adrenal hyperplasia due to 21-hydroxylase deficiency (Correct answer)
Congenital hypothyroidism

Correct answer: Congenital adrenal hyperplasia due to 21-hydroxylase deficiency

21-hydroxylase deficiency is the most common form of CAH, causing cortisol and aldosterone deficiency with androgen excess and markedly elevated 17-OHP.

Question 153: A 40-year-old HIV-positive patient (CD4 count 80 cells/μL) presents with headache, fever, and altered mental status. CSF India ink preparation shows encapsulated organisms. What is the treatment?

Fluconazole monotherapy
Ceftriaxone plus vancomycin
Acyclovir IV
Liposomal amphotericin B plus flucytosine (Correct answer)

Correct answer: Liposomal amphotericin B plus flucytosine

Cryptococcal meningitis is treated with induction using liposomal amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole consolidation.

Question 154: In PANCE practice, what is the best approach to quality improvement in musculoskeletal?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 155: A 32-year-old woman develops gestational diabetes at 28 weeks. Her fasting glucose is 105 mg/dL. After failing medical nutrition therapy, what is the preferred pharmacologic treatment during pregnancy?

Metformin
Glipizide
Empagliflozin
Insulin (Correct answer)

Correct answer: Insulin

Insulin is the preferred medication for gestational diabetes when dietary modification fails, as it does not cross the placenta in significant amounts.

Question 156: A construction worker presents with pain and crepitus of the shoulder with overhead activities. Neer and Hawkins-Kennedy tests are positive. What is the most likely diagnosis?

Subacromial impingement syndrome (Correct answer)
Bicipital tendinopathy
AC joint separation
Glenohumeral instability

Correct answer: Subacromial impingement syndrome

Subacromial impingement presents with positive Neer and Hawkins-Kennedy signs, pain with overhead activity, and crepitus due to compression of the rotator cuff beneath the acromion.

Question 157: A 25-year-old with cystic fibrosis has chronic Pseudomonas aeruginosa colonization. Which inhaled antibiotic is approved for chronic suppressive therapy in this setting?

Inhaled azithromycin
Inhaled amphotericin B
Inhaled tobramycin (Correct answer)
Inhaled ciprofloxacin oral solution

Correct answer: Inhaled tobramycin

Inhaled tobramycin (TOBI) is FDA-approved for chronic suppressive therapy of P. aeruginosa in cystic fibrosis patients aged 6 years and older.

Question 158: A 55-year-old presents with a painless neck mass. Fine-needle aspiration shows squamous cell carcinoma. He has a 40 pack-year smoking history and drinks alcohol daily. Nasopharyngoscopy reveals an asymmetric, ulcerated lesion in the pyriform sinus. What is the most likely primary site?

Supraglottic larynx
Oropharynx (tonsil)
Hypopharynx (pyriform sinus) (Correct answer)
Nasopharynx

Correct answer: Hypopharynx (pyriform sinus)

Pyriform sinus carcinoma of the hypopharynx commonly presents as a painless neck mass from nodal metastasis, given the rich lymphatic drainage and late local symptoms.

Question 159: A patient develops oliguria and elevated creatinine after aminoglycoside therapy. Urinalysis shows muddy brown granular casts. What is the diagnosis?

Acute tubular necrosis (Correct answer)
Acute interstitial nephritis
Prerenal azotemia
Contrast nephropathy

Correct answer: Acute tubular necrosis

Aminoglycoside nephrotoxicity causes direct tubular injury, producing the classic muddy brown granular casts of ATN.

Question 160: A 40-year-old woman presents with right upper quadrant pain after fatty meals, fever of 38.8°C, and jaundice. What is the most likely diagnosis?

Ascending cholangitis (Correct answer)
Hepatitis A
Acute cholecystitis
Choledocholithiasis

Correct answer: Ascending cholangitis

Charcot's triad of RUQ pain, fever, and jaundice is pathognomonic for ascending cholangitis caused by biliary obstruction and infection.

Question 161: A 55-year-old man presents with claudication. Doppler shows ABI of 0.72 at rest, dropping to 0.45 post-exercise. What is the first-line treatment?

Supervised exercise therapy and cilostazol (Correct answer)
Warfarin anticoagulation
Compression stockings
Immediate revascularization

Correct answer: Supervised exercise therapy and cilostazol

Supervised exercise rehabilitation plus cilostazol (a phosphodiesterase inhibitor) is first-line for claudication from PAD, improving walking distance and quality of life.

Question 162: A 30-year-old woman presents with bilateral proptosis, lid retraction, and a stare. Thyroid-stimulating hormone is suppressed and free T4 is elevated. What finding on extraocular muscle testing is most characteristic of her orbital condition?

Limitation of abduction (medial rectus palsy)
Limitation of elevation (inferior rectus restriction) (Correct answer)
Limitation of adduction (lateral rectus restriction)
Complete ophthalmoplegia

Correct answer: Limitation of elevation (inferior rectus restriction)

Thyroid eye disease (Graves' orbitopathy) most commonly affects the inferior rectus muscle, causing restriction of elevation and hypotropia.

Question 163: What is the primary consideration when implementing changes to endocrine system?

Impact assessment and change management (Correct answer)
Personal convenience
Speed of implementation
Vendor preference

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 164: On lumbar puncture in bacterial meningitis, which CSF finding best distinguishes it from viral meningitis?

Lymphocytic pleocytosis
Xanthochromia
Elevated opening pressure
Glucose < 45 mg/dL with elevated protein (Correct answer)

Correct answer: Glucose < 45 mg/dL with elevated protein

Bacterial meningitis characteristically shows low CSF glucose (< 45 mg/dL or CSF:serum ratio < 0.4) and markedly elevated protein, unlike viral meningitis.

Question 165: A 38-year-old woman is diagnosed with BRCA1 mutation. She has completed childbearing. Which risk-reduction strategy has the greatest absolute reduction in ovarian cancer risk?

Risk-reducing bilateral salpingo-oophorectomy (Correct answer)
Prophylactic tamoxifen
Annual pelvic ultrasound and CA-125 screening
Oral contraceptive use for 5 years

Correct answer: Risk-reducing bilateral salpingo-oophorectomy

Risk-reducing bilateral salpingo-oophorectomy reduces ovarian cancer risk by >95% in BRCA1 carriers and is the most effective prevention strategy.

Question 166: A patient with suspected TB has a positive QuantiFERON-Gold test but a negative tuberculin skin test. Which situation best explains this discordant result?

HIV-induced anergy causing false-negative IGRA
Prior BCG vaccination causing false-positive TST but not IGRA (Correct answer)
Prior BCG vaccination causing false-negative TST
Active TB disease

Correct answer: Prior BCG vaccination causing false-positive TST but not IGRA

BCG vaccination causes false-positive TST reactions but does not affect IGRA results, which are BCG-unaffected because they use ESAT-6 and CFP-10 antigens absent from BCG.

Question 167: A patient develops worsening hypoxemia 48 hours after an aspiration event. CXR shows bilateral infiltrates with no evidence of cardiogenic edema. PaO2/FiO2 ratio is 150. How is this classified?

Mild ARDS
Acute lung injury (ALI)
Severe ARDS (Correct answer)
Moderate ARDS

Correct answer: Severe ARDS

Per Berlin definition, severe ARDS is defined by a PaO2/FiO2 ratio ≤100 mmHg with PEEP ≥5 cmH2O; PaO2/FiO2 of 150 classifies as moderate (100-200).

Question 168: A 55-year-old man with small cell lung cancer develops ascending weakness and areflexia two weeks after chemotherapy. Anti-Hu antibodies are detected. This is an example of:

Paraneoplastic encephalomyelitis/sensory neuronopathy (Correct answer)
Lambert-Eaton myasthenic syndrome
Direct tumor invasion of the spinal cord
Chemotherapy-induced peripheral neuropathy

Correct answer: Paraneoplastic encephalomyelitis/sensory neuronopathy

Anti-Hu antibodies are associated with paraneoplastic sensory neuronopathy/encephalomyelitis, an immune-mediated syndrome triggered by SCLC.

Question 169: A patient with known Addison disease presents with severe hypotension and vomiting after a flu illness. Which is the most critical immediate treatment?

Oral fludrocortisone
Oral prednisone
IV dextrose only
IV hydrocortisone and saline (Correct answer)

Correct answer: IV hydrocortisone and saline

Adrenal crisis requires immediate IV hydrocortisone and aggressive IV fluid resuscitation with normal saline.

Question 170: A 48-year-old male presents with sudden severe 'thunderclap' headache described as the worst of his life. CT head is negative. What is the next most appropriate step?

Order ESR and CRP for temporal arteritis
Discharge with sumatriptan for migraine
Perform MRI brain with gadolinium
Perform lumbar puncture to detect xanthochromia (Correct answer)

Correct answer: Perform lumbar puncture to detect xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture detecting xanthochromia is required to exclude SAH when CT is negative.

Question 171: A 45-year-old woman presents with acute onset of right upper quadrant pain, fever, and jaundice. Her labs show elevated total bilirubin, alkaline phosphatase, and WBC of 18,000. What is the most likely diagnosis?

Ascending cholangitis (Correct answer)
Acute hepatitis
Pancreatitis
Acute cholecystitis

Correct answer: Ascending cholangitis

Charcot's triad (RUQ pain, fever, jaundice) is classic for ascending cholangitis, indicating biliary obstruction with infection.

Question 172: A 25-year-old presents with recurrent abdominal pain, diarrhea, and mouth sores. Labs show elevated ESR and CRP. Colonoscopy shows ileitis with skip lesions. What extraintestinal manifestation is most commonly associated with this condition?

Pyoderma gangrenosum
Primary sclerosing cholangitis
Erythema nodosum (Correct answer)
Ankylosing spondylitis

Correct answer: Erythema nodosum

Erythema nodosum (tender red nodules on the shins) is the most common extraintestinal skin manifestation of both Crohn disease and ulcerative colitis.

Question 173: Which electrolyte abnormality is most characteristic of primary hyperaldosteronism (Conn syndrome)?

Hypokalemia and hypertension (Correct answer)
Hyperkalemia and hypernatremia
Hyponatremia and hypotension
Hyperkalemia and hypotension

Correct answer: Hypokalemia and hypertension

Excess aldosterone causes sodium retention and potassium wasting, producing hypokalemia with hypertension.

Question 174: A previously healthy 15-month-old kid develops anxiety, starts sobbing uncontrollably, and drools a lot. He had been calmly playing with his toys just moments ago. Pulse rate is 84/min, temperature is 36.7°C (98.1°F), and respirations are 18/min. The posterior pharynx is faintly injected but otherwise clear upon physical examination. Auscultation and percussion reveal no obstruction in the lungs. Chest X-ray study results are normal. He becomes quieter after an hour, but he still drools a lot. Which of the following is the ideal course of action?

Administration of syrup of ipecac
Barium swallow x-ray study
Esophagogastroduodenoscopy (Correct answer)
Insertion of a nasogastric tube

Correct answer: Esophagogastroduodenoscopy

The sudden onset of anxiety, uncontrollable crying, and profuse drooling in a previously healthy child, especially with normal respiratory findings, strongly suggests an esophageal foreign body. The persistent drooling indicates an obstruction or irritation preventing normal swallowing. An esophagogastroduodenoscopy (EGD) is the definitive procedure to both diagnose and remove an esophageal foreign body.

Question 175: A 55-year-old woman on long-term corticosteroids develops a vertebral compression fracture. Which medication should be co-prescribed to prevent glucocorticoid-induced osteoporosis?

Raloxifene
Bisphosphonate plus calcium and vitamin D (Correct answer)
Calcium and vitamin D alone
Teriparatide alone

Correct answer: Bisphosphonate plus calcium and vitamin D

Glucocorticoid-induced osteoporosis is prevented and treated with bisphosphonate therapy plus calcium and vitamin D supplementation for patients on chronic steroids.

Question 176: A 22-year-old college student presents with fever, severe headache, photophobia, and a non-blanching petechial rash. What is the most immediate treatment?

Administer IV ceftriaxone immediately without delay (Correct answer)
Start oral doxycycline empirically
Perform lumbar puncture before starting antibiotics
Obtain blood cultures, then administer IV ceftriaxone

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 177: A 28-year-old woman presents with optic neuritis and a prior episode of transverse myelitis. MRI shows periventricular white matter lesions disseminated in time and space. Which treatment reduces long-term disability?

Plasmapheresis every 6 months
Prednisone taper alone
Disease-modifying therapy (e.g., interferon beta or natalizumab) (Correct answer)
IV methylprednisolone indefinitely

Correct answer: Disease-modifying therapy (e.g., interferon beta or natalizumab)

Disease-modifying therapies reduce relapse rate and MRI lesion burden in relapsing-remitting MS; IV steroids treat acute attacks but do not alter long-term disease course.

Question 178: What is the primary consideration when implementing changes to neurologic system?

Vendor preference
Impact assessment and change management (Correct answer)
Speed of implementation
Personal convenience

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 179: Which test is most appropriate for diagnosing Clostridioides difficile infection?

Colonoscopy showing pseudomembranes
PCR for C. difficile toxin genes (Correct answer)
Stool Gram stain
Stool culture for C. difficile

Correct answer: PCR for C. difficile toxin genes

Nucleic acid amplification tests (NAAT/PCR) for C. difficile toxin genes are the most sensitive and specific initial diagnostic test for C. diff infection.

Question 180: A 35-year-old presents with episodic peptic ulcers refractory to PPI therapy and diarrhea. Fasting serum gastrin is 1,200 pg/mL. What is the most likely diagnosis?

Autoimmune gastritis
H. pylori gastritis
Zollinger-Ellison syndrome (Correct answer)
VIPoma

Correct answer: Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is caused by a gastrin-secreting tumor (gastrinoma), leading to massively elevated gastrin, multiple refractory peptic ulcers, and diarrhea.

Question 181: A 16-year-old obese male presents with left hip and knee pain and a limp. The hip is held in external rotation. What is the most likely diagnosis?

Slipped capital femoral epiphysis (Correct answer)
Transient synovitis
Septic arthritis
Legg-Calvé-Perthes disease

Correct answer: Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) occurs in obese adolescent males, presenting with hip/knee pain and obligate external rotation of the hip; urgent surgical pinning is required.

Question 182: A 50-year-old male with psoriasis presents with sausage digits, asymmetric joint pain, and nail pitting. RF is negative. Which pattern of joint involvement is described?

Monoarticular arthritis
Symmetric polyarthritis
Axial-only disease
Dactylitis (Correct answer)

Correct answer: Dactylitis

Dactylitis (sausage digits) is a hallmark of psoriatic arthritis, caused by inflammation of the entire digit including flexor tendons and joint synovium.

Question 183: Which cranial nerve is responsible for the corneal reflex afferent limb?

CN VI
CN III
CN VII
CN V (ophthalmic branch) (Correct answer)

Correct answer: CN V (ophthalmic branch)

The afferent limb of the corneal reflex is mediated by CN V1 (ophthalmic branch of trigeminal nerve); the efferent limb is CN VII (facial nerve).

Question 184: Which documentation is essential when working with endocrine system in PANCE?

Only verbal notes
Marketing materials
General descriptions without specifics
Detailed technical specifications and as-built diagrams (Correct answer)

Correct answer: Detailed technical specifications and as-built diagrams

Detailed technical specifications and as-built diagrams provide the accurate reference information needed for maintenance and troubleshooting.

Question 185: What is the first-line treatment for newly diagnosed warm autoimmune hemolytic anemia?

Rituximab
Splenectomy
Corticosteroids (Correct answer)
Intravenous immunoglobulin

Correct answer: Corticosteroids

Corticosteroids suppress autoantibody production and are the initial treatment of choice for warm AIHA.

Question 186: A 60-year-old woman presents with proximal muscle weakness affecting her hips and shoulders, difficulty rising from a chair, and elevated CK and aldolase. ANA and anti-Jo-1 are positive. What is the diagnosis?

Polymyalgia rheumatica
Myasthenia gravis
Polymyositis (Correct answer)
Fibromyalgia

Correct answer: Polymyositis

Polymyositis presents with proximal muscle weakness, elevated muscle enzymes (CK, aldolase), and positive anti-Jo-1 antibodies in an inflammatory myopathy.

Question 187: A patient on long-term PPI therapy is most at risk for deficiency in which micronutrient?

Magnesium
Vitamin B12
All of the above (Correct answer)
Iron

Correct answer: All of the above

Long-term PPI use impairs absorption of magnesium, vitamin B12 (requires acid for release from food), and iron, making all three deficiencies relevant.

Question 188: A 63-year-old woman with known CAD presents 30 minutes after onset of crushing chest pain. EKG shows 3 mm ST elevation in leads II, III, aVF. Door-to-balloon time capability is 45 minutes. Best treatment?

Thrombolytics (tPA)
Urgent CABG
Primary percutaneous coronary intervention (PCI) (Correct answer)
Heparin drip alone

Correct answer: Primary percutaneous coronary intervention (PCI)

Primary PCI is the preferred reperfusion strategy for STEMI when door-to-balloon time is ≤90 minutes, offering superior outcomes over thrombolytics.

Question 189: A 28-year-old presents with bloody diarrhea, tenesmus, and proctitis. Colonoscopy shows continuous mucosal inflammation starting from the rectum. Which diagnosis is most consistent?

Crohn disease
Ischemic colitis
Infectious colitis
Ulcerative colitis (Correct answer)

Correct answer: Ulcerative colitis

Ulcerative colitis characteristically starts in the rectum with continuous mucosal involvement, causing bloody diarrhea and tenesmus.

Question 190: A 65-year-old woman presents with bilateral shoulder and hip girdle aching, morning stiffness over 1 hour, and ESR of 85 mm/hr. Muscle strength is normal. What is the first-line treatment?

Physical therapy alone
Low-dose prednisone (Correct answer)
NSAIDs alone
Methotrexate

Correct answer: Low-dose prednisone

Polymyalgia rheumatica responds dramatically to low-dose prednisone (15-20 mg/day), which is both diagnostic and therapeutic; strength is preserved unlike in myositis.

Question 191: What is the primary consideration when implementing changes to pulmonary system?

Vendor preference
Speed of implementation
Personal convenience
Impact assessment and change management (Correct answer)

Correct answer: Impact assessment and change management

Impact assessment and proper change management ensure that modifications do not introduce unexpected problems or service disruptions.

Question 192: What is the first-line noninvasive screening test for suspected renal artery stenosis?

Conventional arteriography
MR angiography
Renal artery duplex ultrasound (Correct answer)
CT angiography

Correct answer: Renal artery duplex ultrasound

Renal artery duplex ultrasound is the preferred initial screening modality as it avoids contrast and radiation while assessing renal artery flow.

Question 193: A 70-year-old male presents with insidious onset dyspnea and a dry cough over 18 months. HRCT shows honeycombing with basal predominance. Pulmonary function tests reveal a restrictive pattern. Which diagnosis is most likely?

Nonspecific interstitial pneumonia (NSIP)
Idiopathic pulmonary fibrosis (IPF) (Correct answer)
Cryptogenic organizing pneumonia (COP)
Hypersensitivity pneumonitis

Correct answer: Idiopathic pulmonary fibrosis (IPF)

IPF classically presents in older males with progressive dyspnea, basal honeycombing on HRCT, and a restrictive PFT pattern with no identifiable cause.

Question 194: A 30-year-old presents with recurrent episodes of severe unilateral eye pain, redness, and halos around lights. Each episode lasts 2-3 hours and resolves spontaneously. IOP during an attack is 45 mmHg. What is the treatment of choice for long-term prevention?

Trabeculectomy
Laser peripheral iridotomy (Correct answer)
Topical timolol daily
Systemic acetazolamide indefinitely

Correct answer: Laser peripheral iridotomy

Laser peripheral iridotomy creates an opening in the iris to relieve pupillary block and prevent recurrent acute angle-closure glaucoma attacks.

Question 195: A 40-year-old woman presents with heat intolerance, weight loss, tremor, and TSH <0.01 mIU/L with elevated free T4. Radioiodine uptake is diffusely increased. What is the preferred long-term treatment option in a non-pregnant patient?

IV methimazole
Thyroidectomy only
Propranolol alone
Radioactive iodine (RAI) ablation (Correct answer)

Correct answer: Radioactive iodine (RAI) ablation

RAI ablation is the preferred definitive treatment for Graves disease in non-pregnant adults in the US.

Question 196: A 45-year-old presents with chronic bilateral rhinorrhea, nasal congestion, and excessive sneezing, worst in spring. Nasal smear shows eosinophils. Skin-prick testing is positive for grass and tree pollens. What is first-line pharmacotherapy?

Leukotriene receptor antagonists
Oral antihistamines alone
Intranasal corticosteroids (Correct answer)
Oral decongestants

Correct answer: Intranasal corticosteroids

Intranasal corticosteroids are the most effective first-line treatment for moderate-to-severe allergic rhinitis, superior to antihistamines for nasal congestion and overall symptom control.

Question 197: A 22-year-old college student presents with fever, pharyngitis, cervical lymphadenopathy, and marked fatigue. A peripheral blood smear shows atypical lymphocytes. Heterophile antibody test is positive. Which complication should be avoided during recovery?

Contact sports (Correct answer)
Swimming in chlorinated pools
Prolonged sun exposure
Eating spicy foods

Correct answer: Contact sports

Infectious mononucleosis (EBV) can cause splenomegaly, making contact sports dangerous due to risk of splenic rupture, which is the most serious complication.

Question 198: Which professional attribute is most valued in eent within the PANCE field?

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

Correct answer: Accountability and commitment to standards

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

Question 199: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?

Complete blood count only
Thyroid function tests
Serum creatinine
Liver function tests (Correct answer)

Correct answer: Liver function tests

Valproic acid can cause hepatotoxicity (particularly in children < 2 years) and pancreatitis; LFTs and amylase/lipase should be monitored.

Question 200: A patient with end-stage renal disease on dialysis develops hypotension with distended neck veins and muffled heart sounds. CXR shows enlarged cardiac silhouette. Immediate management is:

Pericardiocentesis (Correct answer)
IV furosemide
Emergent dialysis
IV fluid bolus

Correct answer: Pericardiocentesis

Beck's triad (hypotension, JVD, muffled heart sounds) indicates cardiac tamponade, which requires immediate pericardiocentesis to relieve life-threatening pericardial pressure.

Question 201: A 40-year-old immunocompromised patient presents with painful vesicular lesions along a unilateral dermatomal distribution on the chest. Which antiviral, started within 72 hours of rash onset, is the treatment of choice?

Famciclovir 500 mg PO TID × 7 days
Acyclovir 800 mg PO 5 times daily × 7–10 days
Oseltamivir 75 mg BID × 5 days
Valacyclovir 1000 mg PO TID × 7 days (Correct answer)

Correct answer: Valacyclovir 1000 mg PO TID × 7 days

Valacyclovir 1000 mg TID for 7 days is preferred over acyclovir for herpes zoster (shingles) due to better bioavailability and simpler dosing schedule.

Question 202: Which approach is recommended for troubleshooting neurologic system issues?

Wait for the problem to resolve itself
Replace all components simultaneously
Rely solely on past experience
Use systematic isolation and testing methods (Correct answer)

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 203: A 48-year-old man with poorly controlled type 2 diabetes develops painless loss of vision in one eye. Fundoscopy shows neovascularization. What is the most appropriate next step?

Immediate insulin titration only
Start ACE inhibitor
Prescribe corrective lenses
Urgent ophthalmology referral for laser photocoagulation (Correct answer)

Correct answer: Urgent ophthalmology referral for laser photocoagulation

Proliferative diabetic retinopathy with neovascularization requires urgent ophthalmology referral for pan-retinal photocoagulation.

Question 204: A 35-year-old HIV-positive patient with a CD4 count of 50 cells/µL presents with headache, altered mental status, and a positive India ink stain of the CSF. Which medication is first-line induction therapy?

Amphotericin B plus flucytosine (Correct answer)
Fluconazole
Caspofungin
Voriconazole

Correct answer: Amphotericin B plus flucytosine

Amphotericin B plus flucytosine is the standard induction therapy for cryptococcal meningitis in HIV-positive patients, providing fungicidal activity.

Question 205: A 28-year-old woman presents with cyclic pelvic pain, dyspareunia, and infertility. Laparoscopy reveals powder-burn lesions on the peritoneum. Which mechanism best explains her infertility?

Autoimmune destruction of oocytes
Anovulation due to elevated prolactin
Distorted pelvic anatomy and inflammatory cytokines impairing implantation (Correct answer)
Cervical stenosis blocking sperm entry

Correct answer: Distorted pelvic anatomy and inflammatory cytokines impairing implantation

Endometriosis causes infertility through distorted pelvic anatomy, peritoneal inflammation, and cytokine-mediated impairment of fertilization and implantation.

Question 206: A patient with sickle cell disease presents with acute bone pain, fever, and dactylitis. What is the most appropriate initial management?

Emergent exchange transfusion
Hydroxyurea initiation
IV fluids, oxygen, and analgesics (Correct answer)
Bone marrow transplant referral

Correct answer: IV fluids, oxygen, and analgesics

Acute vaso-occlusive crisis is managed with IV hydration, supplemental oxygen, and adequate analgesia.

Question 207: A 55-year-old woman presents with bilateral knee pain worsened by climbing stairs and improved with rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Rheumatoid arthritis
Gout
Osteoarthritis (Correct answer)
Pseudogout

Correct answer: Osteoarthritis

Osteoarthritis presents with pain worsened by activity, relieved by rest, and X-ray findings of joint space narrowing, subchondral sclerosis, and osteophytes.

Question 208: A 24-year-old woman on combined oral contraceptives for 3 years presents for a routine visit. Which absolute contraindication should prompt you to discontinue her OCP?

Mild migraines without aura
History of migraine with aura (Correct answer)
Irregular menstrual cycles
Family history of ovarian cancer

Correct answer: History of migraine with aura

Migraine with aura is an absolute contraindication to combined estrogen-containing contraceptives due to increased risk of ischemic stroke.

Question 209: An 8-year-old boy presents with a limp and hip pain radiating to the knee for 2 months. X-ray shows flattening and sclerosis of the femoral head. What is the diagnosis?

Transient synovitis
Legg-Calvé-Perthes disease (Correct answer)
Slipped capital femoral epiphysis
Septic arthritis

Correct answer: Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is avascular necrosis of the femoral head in children aged 4-10, presenting with chronic hip pain, limp, and X-ray changes of femoral head collapse.

Question 210: A 40-year-old diver presents with right ear pain and conductive hearing loss after a dive to 30 meters. Otoscopy shows a hemotympanum. What is the diagnosis?

Otitis media
Barotrauma (ear squeeze) (Correct answer)
Perilymphatic fistula
Otitis externa

Correct answer: Barotrauma (ear squeeze)

Middle ear barotrauma occurs when pressure cannot equalize across the tympanic membrane during descent, causing hemorrhage into the middle ear (hemotympanum).

Question 211: A 25-year-old woman presents with fever, bilateral joint pain (wrists, knees), skin lesions (pustules on erythematous base), and tenosynovitis of the right hand. Cervical cultures are positive. What is the most appropriate treatment?

Ceftriaxone 1 g IV/IM daily × 7 days (Correct answer)
Penicillin V 500 mg PO QID × 10 days
Azithromycin 1 g PO single dose
Doxycycline 100 mg PO BID × 7 days

Correct answer: Ceftriaxone 1 g IV/IM daily × 7 days

Disseminated gonococcal infection (DGI) causing septic arthritis-dermatitis syndrome is treated with ceftriaxone 1 g IV/IM daily for 7 days.

Question 212: A patient presents with perifollicular hemorrhages, bleeding gums, and corkscrew hairs. CBC is normal. Which deficiency is responsible?

Vitamin B12
Vitamin C (Correct answer)
Vitamin K
Vitamin D

Correct answer: Vitamin C

Vitamin C deficiency (scurvy) impairs collagen synthesis, causing perifollicular hemorrhage, gingival bleeding, and corkscrew hairs.

Question 213: A 30-year-old woman with known asthma presents to the ED with severe bronchospasm unresponsive to two doses of albuterol. Which medication is most appropriate next?

Oral prednisone 40 mg
IV magnesium sulfate (Correct answer)
IV aminophylline
Inhaled ipratropium bromide

Correct answer: IV magnesium sulfate

IV magnesium sulfate relaxes bronchial smooth muscle and is indicated for severe acute asthma refractory to initial bronchodilator therapy.

Question 214: A 22-year-old presents with sudden onset unilateral chest pain and dyspnea. He is tall and thin with no prior medical history. CXR shows a 25% pneumothorax. What is the appropriate management?

Observation with supplemental oxygen
Needle decompression followed by chest tube
Surgical pleurodesis
Simple aspiration or small-bore chest tube (Correct answer)

Correct answer: Simple aspiration or small-bore chest tube

A primary spontaneous pneumothorax >20% in a symptomatic patient warrants simple aspiration or small-bore chest tube; observation is reserved for <20% with minimal symptoms.

Question 215: A 45-year-old woman presents with weight gain, cold intolerance, and constipation. TSH is 12 mIU/L and free T4 is low. Which medication is first-line treatment?

Propylthiouracil
Methimazole
Levothyroxine (Correct answer)
Radioactive iodine

Correct answer: Levothyroxine

Levothyroxine (synthetic T4) is the first-line treatment for hypothyroidism.

Question 216: A 30-year-old IV drug user presents with fever, new holosystolic murmur at the right sternal border, and multiple septic pulmonary emboli on CT scan. Which organism is most commonly responsible for right-sided endocarditis in IV drug users?

Streptococcus viridans
Staphylococcus aureus (Correct answer)
Enterococcus faecalis
Staphylococcus epidermidis

Correct answer: Staphylococcus aureus

Staphylococcus aureus is the most common cause of right-sided infective endocarditis in IV drug users, typically affecting the tricuspid valve.

Question 217: A 50-year-old presents with symmetric ascending weakness starting in the legs 2 weeks after a GI illness. Deep tendon reflexes are absent. CSF shows elevated protein with normal cell count (albuminocytologic dissociation). What is the diagnosis?

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

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome is an autoimmune demyelinating polyneuropathy characterized by ascending weakness, areflexia, and albuminocytologic dissociation in CSF.

Question 218: A 55-year-old man has a 3-month history of progressive distal lower extremity weakness, areflexia, and glove-and-stocking sensory loss. Nerve conduction studies show reduced amplitudes and slow velocities. What is the most likely diagnosis?

Guillain-Barré syndrome
Amyotrophic lateral sclerosis
Chronic inflammatory demyelinating polyneuropathy (CIDP) (Correct answer)
Multiple sclerosis

Correct answer: Chronic inflammatory demyelinating polyneuropathy (CIDP)

CIDP presents with progressive or relapsing symmetric limb weakness, areflexia, and demyelinating features on nerve conduction studies lasting > 8 weeks.

Question 219: A 25-year-old woman presents with recurrent episodes of severe unilateral headache with photophobia, phonophobia, and nausea lasting 8-12 hours. She has no neurological deficits. What is the best abortive therapy?

Prednisone 60 mg
Sumatriptan 50 mg orally (Correct answer)
Acetaminophen 1000 mg
Ergotamine 2 mg

Correct answer: Sumatriptan 50 mg orally

Triptans (5-HT1B/1D agonists) are first-line abortive therapy for moderate-to-severe migraines, providing targeted relief by causing vasoconstriction and blocking pain pathways.

Question 220: A 19-year-old male presents with a painless testicular mass. Serum AFP is markedly elevated. Which tumor type is most likely?

Embryonal carcinoma
Seminoma
Yolk sac tumor (Correct answer)
Leydig cell tumor

Correct answer: Yolk sac tumor

Yolk sac tumors (endodermal sinus tumors) are the most common testicular tumor in young males and are associated with markedly elevated AFP.

Question 221: A 45-year-old woman presents with menorrhagia and pelvic pressure. Uterus is 14-week size on exam. Ultrasound shows multiple intramural masses. What is the most appropriate first-line pharmacologic treatment?

Danazol
GnRH agonist indefinitely
Combined oral contraceptives
Levonorgestrel IUD (Correct answer)

Correct answer: Levonorgestrel IUD

The levonorgestrel IUD (Mirena) is first-line pharmacologic therapy for fibroid-related menorrhagia, reducing bleeding by up to 90%.

Question 222: A 60-year-old man on lithium for 15 years presents with polyuria and polydipsia. Urine osmolality remains low after water deprivation but increases after desmopressin. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

Response to desmopressin indicates central (not nephrogenic) DI; lithium can cause nephrogenic DI, but response to ADH analog points to central.

Question 223: A 28-year-old male presents with a painless scrotal swelling. Urethral culture is positive for an intracellular gram-negative diplococci. He also complains of urethral discharge. Which is the recommended dual therapy per current CDC guidelines?

Ciprofloxacin 500 mg PO + doxycycline 100 mg PO BID × 7 days
Ceftriaxone 250 mg IM + azithromycin 1 g PO
Penicillin G 4.8 million units IM + probenecid
Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days (Correct answer)

Correct answer: Ceftriaxone 500 mg IM + doxycycline 100 mg PO BID × 7 days

Current CDC guidelines recommend ceftriaxone 500 mg IM (single dose) plus doxycycline 100 mg BID × 7 days for uncomplicated gonorrhea to cover co-infection with chlamydia.

Question 224: A 45-year-old patient presents with sudden painless vision loss in one eye described as a 'curtain coming down.' Fundoscopic exam reveals a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

Central retinal vein occlusion
Vitreous hemorrhage
Central retinal artery occlusion (Correct answer)
Retinal detachment

Correct answer: Central retinal artery occlusion

Central retinal artery occlusion presents with sudden painless monocular vision loss, pale retina with cherry-red macula due to ischemia from loss of blood supply.

Question 225: A 55-year-old diabetic presents with fever, crepitus, and rapidly spreading necrosis of the scrotum and perineum. CT shows subcutaneous gas. What is the immediate management priority?

Start IV vancomycin and piperacillin-tazobactam and observe for 24 hours
Emergent surgical debridement plus broad-spectrum IV antibiotics (Correct answer)
Hyperbaric oxygen therapy as definitive treatment
Culture the wound and start targeted antibiotic monotherapy

Correct answer: Emergent surgical debridement plus broad-spectrum IV antibiotics

Fournier's gangrene (necrotizing fasciitis of the perineum) requires immediate surgical debridement as the cornerstone of treatment, combined with broad-spectrum IV antibiotics; delay increases mortality significantly.

Question 226: A 45-year-old man presents with fatigue, splenomegaly, and a WBC of 120,000/µL with a left shift. Cytogenetics reveal the Philadelphia chromosome t(9;22). What is the first-line treatment?

Hydroxyurea
Interferon-alpha
Imatinib (Gleevec) (Correct answer)
Allogeneic stem cell transplant

Correct answer: Imatinib (Gleevec)

Imatinib, a BCR-ABL tyrosine kinase inhibitor, is first-line therapy for chronic myeloid leukemia (CML) harboring the Philadelphia chromosome.

Question 227: A 72-year-old man has a PSA of 18 ng/mL. Prostate biopsy shows Gleason score 4+4=8 in 8 of 12 cores. Bone scan shows no metastases. Which treatment is most appropriate?

Radical prostatectomy or radiation with androgen deprivation therapy (Correct answer)
Active surveillance
Androgen deprivation therapy alone
Observation with PSA monitoring

Correct answer: Radical prostatectomy or radiation with androgen deprivation therapy

High-risk localized prostate cancer (Gleason ≥8, PSA >20, or clinical T3) requires definitive local therapy (surgery or radiation) combined with androgen deprivation therapy.

Question 228: Which murmur is best heard at the left sternal border and increases with inspiration?

Mitral stenosis
Aortic regurgitation
Tricuspid regurgitation (Correct answer)
Pulmonic stenosis

Correct answer: Tricuspid regurgitation

Tricuspid regurgitation is heard at the left lower sternal border and increases with inspiration (Carvallo's sign) due to increased venous return.

Question 229: A 55-year-old woman with COPD and a 60-pack-year history presents with hemoptysis and a 3 cm spiculated pulmonary nodule on CXR. What is the most appropriate next step?

PET scan
Repeat CXR in 6 months
CT scan of the chest with contrast (Correct answer)
CT-guided biopsy immediately

Correct answer: CT scan of the chest with contrast

A CT scan of the chest is the next step to characterize the nodule's features (size, density, borders) and guide further management including biopsy or PET scan.

Question 230: A patient with polycythemia vera reports intense itching that occurs specifically after showering. What explains this symptom?

Iron deficiency secondary to venesection
Uremic pruritus from secondary erythrocytosis
Histamine release from basophils and mast cells triggered by water (Correct answer)
Dry skin from hyperviscosity

Correct answer: Histamine release from basophils and mast cells triggered by water

Aquagenic pruritus in PV is caused by histamine release from increased basophils and mast cells upon water contact.

Question 231: A 30-year-old woman has recurrent episodes of vertigo lasting 20–30 minutes associated with tinnitus and low-frequency hearing loss. The most likely diagnosis is:

Vestibular neuritis
Benign paroxysmal positional vertigo
Ménière disease (Correct answer)
Acoustic neuroma

Correct answer: Ménière disease

Ménière disease presents with episodic vertigo (20 min–12 hr), fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness.

Question 232: What is the fundamental principle behind cardiovascular system in the PANCE domain?

Cost minimization at all costs
Balancing performance, reliability, and efficiency (Correct answer)
Following a single vendor solution
Using the newest technology exclusively

Correct answer: Balancing performance, reliability, and efficiency

Effective technical design requires balancing performance requirements with reliability needs and operational efficiency.

Question 233: A 35-year-old male presents with recurrent episodes of severe unilateral periorbital pain lasting 45-90 minutes, associated with ipsilateral lacrimation and nasal congestion. What is the most likely diagnosis?

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

Correct answer: Cluster headache

Cluster headaches are severe unilateral periorbital headaches with autonomic features (lacrimation, rhinorrhea) lasting 15-180 minutes.

Question 234: A 32-year-old hiker presents 3 weeks after returning from New England with a bull's-eye rash (erythema migrans), fever, and arthralgias. What is the most appropriate treatment?

Amoxicillin 500 mg PO TID × 21 days
Azithromycin 500 mg PO daily × 7 days
Ceftriaxone 2 g IV daily × 14 days
Doxycycline 100 mg PO BID × 14–21 days (Correct answer)

Correct answer: Doxycycline 100 mg PO BID × 14–21 days

Doxycycline is the first-line treatment for early Lyme disease (erythema migrans stage) in adults, given for 14–21 days.

Question 235: A 19-year-old male presents with fever, night sweats, and weight loss. Exam reveals painless cervical lymphadenopathy. Biopsy shows Reed-Sternberg cells. What is the diagnosis?

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

Correct answer: Hodgkin lymphoma

Reed-Sternberg cells ('owl eye' nuclei) are pathognomonic for Hodgkin lymphoma, which presents with painless lymphadenopathy and B symptoms.

Question 236: A 55-year-old man undergoes thyroidectomy. Postoperatively he develops perioral numbness and carpopedal spasm. Which sign would you elicit?

Cullen sign
Rovsing sign
Chvostek sign (Correct answer)
Kernig sign

Correct answer: Chvostek sign

Chvostek sign (facial twitch on tapping the facial nerve) indicates hypocalcemia from hypoparathyroidism after thyroidectomy.

Question 237: Which approach is recommended for troubleshooting reproductive system issues?

Wait for the problem to resolve itself
Replace all components simultaneously
Rely solely on past experience
Use systematic isolation and testing methods (Correct answer)

Correct answer: Use systematic isolation and testing methods

Systematic isolation and testing methodically narrows down the root cause, making troubleshooting efficient and accurate.

Question 238: Which finding on chest X-ray is most characteristic of a tension pneumothorax?

Unilateral pleural effusion without mediastinal shift
Contralateral tracheal deviation with ipsilateral lung collapse (Correct answer)
Bilateral diffuse infiltrates
Ipsilateral tracheal deviation with complete opacification

Correct answer: Contralateral tracheal deviation with ipsilateral lung collapse

Tension pneumothorax causes mediastinal shift away from the affected side due to positive pressure buildup, displacing the trachea contralaterally.

Question 239: A 55-year-old diabetic patient presents with a painless foot ulcer over the plantar surface of the first metatarsal head. Pulses are intact. What is the primary etiology?

Osteomyelitis
Peripheral arterial disease
Venous insufficiency
Peripheral neuropathy (Correct answer)

Correct answer: Peripheral neuropathy

Neuropathic ulcers in diabetics occur at pressure points (plantar metatarsal heads) due to loss of protective sensation from peripheral neuropathy.

Question 240: A 22-year-old sexually active woman has a positive urine hCG. Transvaginal ultrasound shows no intrauterine gestational sac, and serum hCG is 2,400 mIU/mL. What is the most appropriate next step?

Administer methotrexate immediately
Diagnostic laparoscopy
Perform dilation and curettage
Repeat hCG in 48 hours (Correct answer)

Correct answer: Repeat hCG in 48 hours

With hCG below the discriminatory zone (~3,000 mIU/mL), no intrauterine sac is expected; repeat hCG in 48 hours assesses rise pattern to distinguish ectopic from early intrauterine pregnancy.

Question 241: 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?

Teriparatide injection
Estrogen replacement therapy
Oral bisphosphonate (e.g., alendronate) (Correct answer)
Calcitonin nasal spray

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 242: A patient on mechanical ventilation has high peak airway pressures but normal plateau pressures. Which condition best explains this finding?

ARDS
Pulmonary fibrosis
Auto-PEEP
Kinked endotracheal tube (Correct answer)

Correct answer: Kinked endotracheal tube

High peak with normal plateau pressure indicates increased airway resistance (not decreased compliance), classically caused by a kinked or partially obstructed ETT.

Question 243: A patient with nephrotic syndrome has 4+ proteinuria and lipiduria. Which urinalysis finding is most characteristic?

WBC casts
Oval fat bodies (Correct answer)
Granular casts
RBC casts

Correct answer: Oval fat bodies

Oval fat bodies are characteristic of nephrotic syndrome due to lipiduria from massive glomerular protein loss.

Question 244: Which of the following is the gold standard for diagnosing esophageal motility disorders such as achalasia?

Upper endoscopy
Barium swallow esophagram
CT scan of the chest
Esophageal manometry (Correct answer)

Correct answer: Esophageal manometry

Esophageal manometry is the definitive test for diagnosing achalasia, showing absence of peristalsis and failure of the LES to relax.

Question 245: Which approach best demonstrates mastery of musculoskeletal in PANCE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 246: What is the best practice for maintaining endocrine system performance over time?

Implement scheduled preventive maintenance (Correct answer)
Wait for failures before acting
Upgrade all equipment annually
Outsource all maintenance

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 247: A 35-year-old woman has episodic hypertension, headache, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines. Which imaging is most appropriate next?

Nuclear stress test
Ultrasound of the thyroid
Chest X-ray
CT or MRI of the abdomen/pelvis (Correct answer)

Correct answer: CT or MRI of the abdomen/pelvis

CT or MRI of the abdomen/pelvis is used to localize pheochromocytoma after biochemical confirmation.

Question 248: A 50-year-old returns from a trip to sub-Saharan Africa with fever, chills, and rigors occurring every 48 hours. Blood smear reveals ring-form trophozoites with appliqué (accolé) positioning and no Schüffner's dots. Which Plasmodium species is most likely responsible?

Plasmodium malariae
Plasmodium vivax
Plasmodium falciparum (Correct answer)
Plasmodium ovale

Correct answer: Plasmodium falciparum

Plasmodium falciparum shows ring-form trophozoites with appliqué positioning, multiple rings per RBC, and no Schüffner's dots — and is the most dangerous species causing severe malaria.

Question 249: A 45-year-old woman is brought in after a witnessed tonic-clonic seizure. She takes no medications. Blood glucose is 45 mg/dL. After dextrose administration, the seizure does not recur. What is the most appropriate next step?

Admit for 24-hour video EEG monitoring
Start long-term antiepileptic drug therapy
Treat underlying hypoglycemia cause; no antiepileptic drug needed (Correct answer)
Perform emergent MRI brain

Correct answer: Treat underlying hypoglycemia cause; no antiepileptic drug needed

A provoked seizure secondary to an identifiable metabolic cause (hypoglycemia) does not require antiepileptic drug therapy; correction of the underlying cause is sufficient.

Question 250: A 58-year-old man with peripheral artery disease has an ankle-brachial index (ABI) of 0.55. He has rest pain. Next best step?

Compression stockings
Start cilostazol and increase walking
Anticoagulation with heparin
Referral for revascularization (Correct answer)

Correct answer: Referral for revascularization

An ABI <0.6 with rest pain indicates critical limb ischemia (CLI), which requires urgent revascularization to prevent limb loss.

Question 251: How does donepezil function when used to treat Alzheimer's disease?

Acetylcholinesterase inhibitor (Correct answer)
Glutamate antagonist
Acetyl/butyryl cholinesterase inhibitor
Cholinesterase and nicotinic receptor stimulation modulator

Correct answer: Acetylcholinesterase inhibitor

Donepezil is an acetylcholinesterase inhibitor. It works by preventing the breakdown of acetylcholine, a neurotransmitter crucial for memory and learning, in the brain. By increasing the availability of acetylcholine, donepezil helps to improve cholinergic function and alleviate some cognitive symptoms associated with Alzheimer's disease.

Question 252: A 55-year-old presents with progressive bilateral sensorineural hearing loss, tinnitus, and episodic vertigo lasting 20 minutes to several hours. Audiometry shows low-frequency hearing loss. What is the most likely diagnosis?

Ménière's disease (Correct answer)
Benign paroxysmal positional vertigo
Acoustic neuroma
Vestibular neuritis

Correct answer: Ménière's disease

Ménière's disease is characterized by the triad of episodic vertigo, fluctuating sensorineural hearing loss (initially low-frequency), and tinnitus due to endolymphatic hydrops.

Question 253: A miner presents with progressive dyspnea and bilateral upper lobe fibrosis on chest X-ray. Biopsy shows collagen nodules with birefringent crystals. What is the diagnosis?

Asbestosis
Coal workers' pneumoconiosis
Berylliosis
Silicosis (Correct answer)

Correct answer: Silicosis

Silicosis presents with bilateral upper lobe nodular fibrosis, and birefringent silica crystals are seen on polarized microscopy of biopsy specimens.

Question 254: 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 255: A 55-year-old man with a history of alcohol use disorder presents with painless jaundice, clay-colored stools, and dark urine. Ultrasound shows dilation of the common bile duct. What is the most likely cause?

Primary sclerosing cholangitis
Pancreatic head carcinoma (Correct answer)
Alcoholic hepatitis
Choledocholithiasis

Correct answer: Pancreatic head carcinoma

Painless obstructive jaundice with dilated CBD in an older patient is the classic presentation of pancreatic head carcinoma compressing the bile duct.

Question 256: Which of the following is the most common cause of Cushing syndrome in clinical practice?

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

Correct answer: Exogenous corticosteroid use

Iatrogenic Cushing syndrome from exogenous glucocorticoid use is the most common cause overall.

Question 257: A patient has microcytic anemia, low serum ferritin, low serum iron, and elevated TIBC. What is the diagnosis?

Sideroblastic anemia
Iron deficiency anemia (Correct answer)
Anemia of chronic disease
Thalassemia minor

Correct answer: Iron deficiency anemia

Low ferritin, low serum iron, and elevated TIBC are the hallmark lab findings of iron deficiency anemia.

Question 258: A 68-year-old presents with gradual bilateral vision loss. Fundoscopic exam reveals drusen deposits and geographic atrophy in the macular region but no hemorrhage or exudate. What type of macular degeneration does this represent?

Dry (atrophic) AMD (Correct answer)
Wet (exudative) AMD
Central serous chorioretinopathy
Diabetic macular edema

Correct answer: Dry (atrophic) AMD

Dry AMD is characterized by drusen and geographic atrophy without neovascularization or hemorrhage; it accounts for 90% of AMD cases and progresses slowly.

Question 259: A 22-year-old female presents with joint pain, a butterfly rash, and oral ulcers. Labs show positive ANA, anti-dsDNA, and low complement levels. What is the most likely diagnosis?

Rheumatoid arthritis
Dermatomyositis
Systemic lupus erythematosus (Correct answer)
Sjögren syndrome

Correct answer: Systemic lupus erythematosus

SLE is confirmed by anti-dsDNA antibodies, low complement, malar rash, arthritis, and oral ulcers meeting ACR criteria.

Question 260: What is the best practice for maintaining reproductive system performance over time?

Implement scheduled preventive maintenance (Correct answer)
Upgrade all equipment annually
Outsource all maintenance
Wait for failures before acting

Correct answer: Implement scheduled preventive maintenance

Scheduled preventive maintenance catches potential issues before they cause failures, maintaining reliability and extending equipment life.

Question 261: A patient with DIC has prolonged PT/aPTT, low fibrinogen, elevated D-dimer, and thrombocytopenia. Which product should be given to correct the fibrinogen level?

Fresh frozen plasma
Cryoprecipitate (Correct answer)
Platelet transfusion
Packed red blood cells

Correct answer: Cryoprecipitate

Cryoprecipitate is rich in fibrinogen, factor VIII, vWF, and factor XIII and is the preferred product to correct hypofibrinogenemia in DIC.

Question 262: A patient with COPD exacerbation has a PaCO2 of 65 mmHg and pH of 7.28 despite controlled oxygen therapy. Which intervention has the strongest evidence for avoiding intubation?

High-flow nasal cannula
Heliox therapy
IV methylxanthines
Non-invasive positive pressure ventilation (NIPPV) (Correct answer)

Correct answer: Non-invasive positive pressure ventilation (NIPPV)

NIPPV (BiPAP) is first-line for hypercapnic respiratory failure in COPD exacerbation, reducing intubation rates and mortality.

Question 263: A 70-year-old man with history of MI 10 years ago presents with a pulsatile abdominal mass. Ultrasound shows infrarenal aortic diameter of 6 cm. What is the recommended management?

Watchful waiting with repeat ultrasound in 1 year
Emergency surgery only if symptomatic
Elective surgical or endovascular repair (Correct answer)
Beta-blocker therapy

Correct answer: Elective surgical or endovascular repair

Abdominal aortic aneurysms ≥5.5 cm in men warrant elective repair due to high rupture risk; endovascular repair (EVAR) is preferred if anatomy allows.

Question 264: A patient with autosomal dominant polycystic kidney disease asks about the most life-threatening extrarenal complication. What is it?

Mitral valve prolapse
Hepatic cysts
Intracranial berry aneurysm (Correct answer)
Pancreatic cysts

Correct answer: Intracranial berry aneurysm

Intracranial berry aneurysms occur in ~10% of ADPKD patients and are the most dangerous extrarenal manifestation due to subarachnoid hemorrhage risk.

Question 265: A 40-year-old lady is undergoing in vitro fertilization procedures with her husband's sperm and eggs that were removed from her body. 15% of attempts at conception will be successful for the patient. The physician assistant learns from reading the patient's records that the patient was unintentionally implanted with a fertilized egg from another couple 24 hours prior. Which of the following is the physician assistant's best line of action?

Inform the donor of the error only if the patient becomes pregnant
Administer emergency contraception
Inform the patient of the error only if she becomes pregnant
Immediately inform the patient of the error (Correct answer)

Correct answer: Immediately inform the patient of the error

This situation involves a serious medical error and a breach of ethical principles, particularly patient autonomy and honesty. The physician assistant has an immediate ethical and legal obligation to inform the patient of the error, regardless of whether she becomes pregnant. This allows the patient to make informed decisions about her care, future, and potential legal recourse, upholding transparency and trust in the medical relationship.

Question 266: A 45-year-old farmer in Ohio presents with fever, chills, and a dry cough after cleaning a chicken coop. Chest X-ray shows hilar lymphadenopathy and diffuse small nodular infiltrates. Urine antigen test is positive. What is the diagnosis?

Histoplasmosis (Correct answer)
Blastomycosis
Coccidioidomycosis
Aspergillosis

Correct answer: Histoplasmosis

Histoplasmosis is endemic in the Ohio and Mississippi River valleys, spread by bird/bat droppings; urine antigen testing is the diagnostic method of choice.

Question 267: A 60-year-old man has sudden severe 'thunderclap' headache reaching peak intensity in seconds. CT head is negative. What is the next best step?

Lumbar puncture to evaluate for xanthochromia (Correct answer)
Discharge with NSAIDs for presumed tension headache
MRI brain with gadolinium
EEG to rule out seizure

Correct answer: Lumbar puncture to evaluate for xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; LP is required to detect xanthochromia or blood in the CSF when CT is negative.

Question 268: A 45-year-old male with ankylosing spondylitis has back pain unresponsive to two NSAIDs after 3 months. What is the next appropriate treatment?

Increase NSAID dose indefinitely
Switch to a TNF inhibitor (Correct answer)
Add hydroxychloroquine
Add methotrexate

Correct answer: Switch to a TNF inhibitor

TNF inhibitors (e.g., adalimumab, etanercept) are the next step in ankylosing spondylitis after failure of NSAIDs, as conventional DMARDs are not effective for axial disease.

Question 269: Which lab pattern is most consistent with prerenal azotemia?

WBC casts with low urine osmolality
BUN:Cr ratio >20:1 with urine sodium <20 mEq/L (Correct answer)
BUN:Cr ratio <10:1 with urine sodium >40 mEq/L
Muddy brown casts with urine sodium >40 mEq/L

Correct answer: BUN:Cr ratio >20:1 with urine sodium <20 mEq/L

Prerenal azotemia shows a BUN:Cr >20:1 and low urine sodium as the kidneys avidly retain sodium to restore perfusion.

Question 270: A 3-year-old presents with high fever, drooling, muffled voice, and refusal to open the mouth. Examination shows medial displacement of the tonsil and uvular deviation. What is the most appropriate next step?

Immediate needle aspiration or incision and drainage (Correct answer)
CT scan of the neck with contrast
Throat culture and wait for results
Oral antibiotics and close outpatient follow-up

Correct answer: Immediate needle aspiration or incision and drainage

A peritonsillar abscess with airway compromise requires immediate aspiration or incision and drainage along with IV antibiotics to relieve the abscess.

Question 271: A 35-year-old patient with HIV (CD4 count 150 cells/µL) presents with painless white plaques on the lateral tongue that cannot be scraped off. What is the most likely diagnosis?

Oral hairy leukoplakia (Correct answer)
Lichen planus
Oral candidiasis (thrush)
Aphthous ulcers

Correct answer: Oral hairy leukoplakia

Oral hairy leukoplakia, caused by EBV reactivation, appears as non-removable white plaques on the lateral tongue and is an AIDS-defining condition marker in HIV patients.

Question 272: A 55-year-old woman is found to have a diastolic murmur at the left sternal border that increases with inspiration. What is the most likely diagnosis?

Mitral stenosis
Pulmonary regurgitation (Correct answer)
Tricuspid stenosis
Aortic regurgitation

Correct answer: Pulmonary regurgitation

Pulmonary regurgitation produces a diastolic murmur at the left sternal border that increases with inspiration (Carvallo sign) due to increased right-sided flow.

Question 273: A 22-year-old woman presents with painful genital ulcers, tender inguinal lymphadenopathy, and dysuria. PCR confirms HSV-2 primary infection. What treatment reduces future recurrence frequency?

Single-dose oral famciclovir
Topical cidofovir
Daily oral valacyclovir suppressive therapy (Correct answer)
Topical acyclovir ointment

Correct answer: Daily oral valacyclovir suppressive therapy

Daily suppressive therapy with valacyclovir (or acyclovir) reduces HSV-2 recurrences by approximately 70–80% and decreases viral shedding.

Question 274: What is the fundamental principle behind pulmonary system in the PANCE domain?

Balancing performance, reliability, and efficiency (Correct answer)
Cost minimization at all costs
Following a single vendor solution
Using the newest technology exclusively

Correct answer: Balancing performance, reliability, and efficiency

Effective technical design requires balancing performance requirements with reliability needs and operational efficiency.

Question 275: A 72-year-old woman with osteoporosis is started on alendronate. What is the most important counseling instruction regarding administration?

Take with a full glass of water and remain upright for 30 minutes (Correct answer)
Take with food to improve absorption
Take with calcium supplements simultaneously
Take at bedtime to reduce GI side effects

Correct answer: Take with a full glass of water and remain upright for 30 minutes

Bisphosphonates must be taken with a full glass of water and the patient must remain upright for at least 30 minutes to prevent esophageal irritation.

Question 276: A 15-year-old presents with bilateral nasal polyps. No history of asthma or aspirin sensitivity. A sweat chloride test is ordered. What underlying condition is being screened for?

Cystic fibrosis (Correct answer)
Primary ciliary dyskinesia
Churg-Strauss vasculitis
Allergic rhinitis

Correct answer: Cystic fibrosis

Bilateral nasal polyps in a child or adolescent should prompt evaluation for cystic fibrosis, as nasal polyposis occurs in up to 50% of CF patients.

Question 277: A 23-year-old woman presents with 3 months of secondary amenorrhea, galactorrhea, and headache. MRI shows a 12 mm pituitary mass. What is first-line treatment?

Combined oral contraceptives
Bromocriptine or cabergoline (Correct answer)
Transsphenoidal surgery
Radiation therapy

Correct answer: Bromocriptine or cabergoline

Dopamine agonists (cabergoline preferred over bromocriptine) are first-line treatment for prolactinomas regardless of size, effectively normalizing prolactin and reducing tumor size.

Question 278: A 65-year-old woman on alendronate for 5 years asks about continuing therapy. What is the most serious rare adverse effect associated with long-term bisphosphonate use?

Adrenal suppression
Hypercalcemia
Hypomagnesemia
Atypical femur fracture (Correct answer)

Correct answer: Atypical femur fracture

Long-term bisphosphonate use is associated with atypical subtrochanteric or diaphyseal femur fractures.

Question 279: A 50-year-old man is found to have a serum calcium of 9.0 mg/dL and PTH of 12 pg/mL (low). He complains of muscle cramps and perioral tingling. Which condition is most likely?

Secondary hyperparathyroidism
Familial hypocalciuric hypercalcemia
Primary hyperparathyroidism
Hypoparathyroidism (Correct answer)

Correct answer: Hypoparathyroidism

Low PTH with low-normal calcium and symptoms of hypocalcemia (cramps, tingling) is consistent with hypoparathyroidism.

Question 280: A 45-year-old patient who received a renal transplant 6 months ago presents with fever, dyspnea, and non-productive cough. CT chest shows bilateral ground-glass opacities. BAL with Gomori methenamine silver stain reveals cysts. What is the treatment?

Trimethoprim-sulfamethoxazole (Correct answer)
Amphotericin B
Fluconazole
Caspofungin

Correct answer: Trimethoprim-sulfamethoxazole

Pneumocystis jirovecii pneumonia (PCP) in immunocompromised patients is treated with high-dose trimethoprim-sulfamethoxazole (TMP-SMX) as first-line therapy.

Question 281: Which of the following is the most appropriate initial management for a patient presenting with acute upper GI bleeding and hemodynamic instability?

Oral PPI therapy and observation
Surgical consultation without prior endoscopy
IV fluid resuscitation and blood transfusion, then endoscopy (Correct answer)
Emergent upper endoscopy immediately

Correct answer: IV fluid resuscitation and blood transfusion, then endoscopy

Hemodynamically unstable patients require initial resuscitation with IV fluids and blood products before proceeding to urgent upper endoscopy within 24 hours.

Question 282: A 16-year-old girl presents with severe dysmenorrhea since menarche. Pelvic exam is normal. NSAIDs provide minimal relief. What is the most appropriate next treatment?

Laparoscopy to rule out endometriosis
Opioid analgesics
Combined oral contraceptive pills (Correct answer)
GnRH agonist therapy

Correct answer: Combined oral contraceptive pills

Combined oral contraceptives are second-line therapy for primary dysmenorrhea after NSAIDs fail, suppressing ovulation and reducing prostaglandin-mediated uterine cramping.

Question 283: A 25-year-old woman has an intensely pruritic, vesicular rash on the extensor surfaces of her elbows and knees. IgA deposits are found at the dermal-epidermal junction. What is the associated systemic condition?

Type 1 diabetes mellitus
Crohn disease
Celiac disease (Correct answer)
Systemic lupus erythematosus

Correct answer: Celiac disease

Dermatitis herpetiformis with IgA deposits is strongly associated with celiac disease (gluten-sensitive enteropathy).

Question 284: What is the most important professional competency for PANCE certification in eent?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 285: A neonate develops seizures at 36 hours of life after a prolonged difficult delivery. Brain MRI shows restricted diffusion in watershed zones. What is the most appropriate intervention?

Emergent neurosurgical decompression
High-dose corticosteroids
IV phenobarbital only
Therapeutic hypothermia (whole-body cooling) (Correct answer)

Correct answer: Therapeutic hypothermia (whole-body cooling)

Therapeutic hypothermia (33–34°C for 72 hours) is the standard of care for hypoxic-ischemic encephalopathy in neonates ≥ 36 weeks when initiated within 6 hours of birth.

Question 286: A 66-year-old woman has a blood pressure of 158/96 mmHg at two separate visits. She has a history of type 2 diabetes and microalbuminuria. Which antihypertensive is most appropriate as first-line therapy?

Lisinopril (Correct answer)
Amlodipine
Metoprolol
Hydrochlorothiazide

Correct answer: Lisinopril

ACE inhibitors (e.g., lisinopril) are first-line in diabetic patients with hypertension and microalbuminuria because they provide renoprotection beyond blood pressure lowering.

Question 287: A patient with Parkinson disease develops visual hallucinations after starting a new medication. Which drug is the most likely culprit?

Trihexyphenidyl
Carbidopa-levodopa
Pramipexole (Correct answer)
Amantadine

Correct answer: Pramipexole

Dopamine agonists such as pramipexole are the most common cause of hallucinations in Parkinson disease patients.

Question 288: A 45-year-old man with HIV (CD4 count 80 cells/μL) presents with painless, papular, violaceous lesions on his lower extremities and oral mucosa. What is the causative organism?

Epstein-Barr virus
Human papillomavirus
Cytomegalovirus
Human herpesvirus 8 (HHV-8) (Correct answer)

Correct answer: Human herpesvirus 8 (HHV-8)

Kaposi sarcoma in HIV-infected individuals is caused by HHV-8 (KSHV) and presents as violaceous vascular tumors, particularly at low CD4 counts.

Question 289: A 25-year-old woman has recurrent episodes of unilateral throbbing headache with photophobia, phonophobia, and nausea lasting 12–24 hours. What is the acute treatment of choice?

Opioids
Triptans (e.g., sumatriptan) (Correct answer)
Topiramate
Beta-blockers

Correct answer: Triptans (e.g., sumatriptan)

Triptans are serotonin 5-HT1B/1D receptor agonists and are first-line acute therapy for moderate-to-severe migraine.

Question 290: Which ventilator setting is most important in preventing ventilator-induced lung injury (VILI) in ARDS patients?

PEEP >15 cmH2O
Respiratory rate <12 breaths/min
FiO2 <0.40
Tidal volume 6 mL/kg ideal body weight (Correct answer)

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

Low tidal volume ventilation (6 mL/kg IBW) as established by the ARDSnet trial is the most evidence-based intervention to reduce VILI and mortality.

Question 291: A 5-year-old child presents with high fever, inspiratory stridor, drooling, and sitting in the 'tripod position.' Lateral neck X-ray shows the 'thumbprint sign.' Which organism is the most likely cause?

Parainfluenza virus
Staphylococcus aureus
Moraxella catarrhalis
Haemophilus influenzae type b (Correct answer)

Correct answer: Haemophilus influenzae type b

The 'thumbprint sign' on lateral neck X-ray indicates epiglottic enlargement caused by Haemophilus influenzae type b in unvaccinated children, a life-threatening emergency.

Question 292: Which finding on DEXA scan defines osteoporosis (not osteopenia)?

T-score above -1.0
T-score between -1.0 and -2.5
T-score of -2.5 or below (Correct answer)
Z-score below -2.0

Correct answer: T-score of -2.5 or below

Osteoporosis is defined by a T-score of -2.5 or lower on DEXA scan.

Question 293: On his fingertips, a 26-year-old male has 3 to 4 cm depigmented irregular patches that have been there for the past two months and appear to be becoming bigger. What is probably taking place with this patient?

Loss of skin melanocytes with unclear cause (Correct answer)
Chronic fungal infection with underlying disease
Too much sun exposure
Acute infection with a virus

Correct answer: Loss of skin melanocytes with unclear cause

The description of 3-4 cm depigmented, irregular, and growing patches on the fingertips is characteristic of vitiligo. Vitiligo is an autoimmune condition where the body's immune system attacks and destroys melanocytes, the cells responsible for producing skin pigment. This leads to the appearance of white patches on the skin, and its cause is often unclear but involves autoimmune mechanisms.

Question 294: A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. What is the immediate treatment?

Thiamine before glucose (Correct answer)
Glucose infusion alone
Haloperidol for agitation
Naloxone IV push

Correct answer: Thiamine before glucose

Wernicke encephalopathy requires immediate IV thiamine before glucose, as glucose administration can precipitate or worsen thiamine deficiency.

Question 295: A patient with alcoholic cirrhosis develops tense ascites and acute kidney injury with urine sodium <10 mEq/L and no response to diuretics or albumin. What is the most likely diagnosis?

Prerenal azotemia
Glomerulonephritis
Acute tubular necrosis
Hepatorenal syndrome (Correct answer)

Correct answer: Hepatorenal syndrome

Hepatorenal syndrome is a functional renal failure in cirrhosis with ascites, characterized by very low urine sodium, no response to volume expansion, and exclusion of other causes.

Question 296: A patient with recurrent DVT has a prolonged aPTT that does not correct with a 1:1 mixing study. What is the most likely diagnosis?

Heparin contamination
Antiphospholipid syndrome (Correct answer)
Hemophilia A
Factor VIII deficiency

Correct answer: Antiphospholipid syndrome

Failure to correct on mixing study indicates an inhibitor; lupus anticoagulant in antiphospholipid syndrome is the most common cause.

Question 297: A 75-year-old man has a rough, scaly, erythematous papule on a sun-damaged area of his face. Biopsy shows atypical keratinocytes confined to the epidermis. What is the diagnosis?

Squamous cell carcinoma
Actinic keratosis
Seborrheic keratosis
Bowen disease (Correct answer)

Correct answer: Bowen disease

Bowen disease (SCC in situ) shows full-thickness epidermal atypia without dermal invasion, distinguishing it from invasive SCC; it is treated with topical 5-FU, PDT, or excision.

Question 298: A 35-year-old flight attendant develops sudden-onset pleuritic chest pain and dyspnea after a long flight. CT pulmonary angiography confirms a pulmonary embolism. She has no bleeding risk factors. What is the first-line treatment?

Alteplase thrombolysis
Unfractionated heparin infusion with warfarin bridge
Rivaroxaban (Correct answer)
Inferior vena cava filter placement

Correct answer: Rivaroxaban

Direct oral anticoagulants such as rivaroxaban are now first-line for hemodynamically stable PE due to ease of use and non-inferiority to heparin/warfarin.

Question 299: A 25-year-old presents with painless, progressive bilateral sensorineural hearing loss since age 12. He has no family history of hearing loss. He is found to have hematuria on urinalysis. Renal biopsy shows thinning of the glomerular basement membrane with a split lamina densa. What syndrome is this?

Usher syndrome
Waardenburg syndrome
Alport syndrome (Correct answer)
Pendred syndrome

Correct answer: Alport syndrome

Alport syndrome is an X-linked disorder of type IV collagen causing sensorineural hearing loss and nephritis with characteristic lamina densa splitting on electron microscopy.

Question 300: In PANCE certification, what does redundancy in system design primarily provide?

Increased complexity
Fault tolerance and high availability (Correct answer)
Lower initial cost
Simplified maintenance

Correct answer: Fault tolerance and high availability

Redundancy provides fault tolerance by ensuring that if one component fails, backup components maintain system availability.

Physician Assistant National Certifying Examination (PANCE)

The PANCE is the national certification examination administered by the NCCPA for entry-level physician assistants. It tests medical and surgical knowledge across 14 organ systems plus professional practice, and is required for initial PA licensure in the United States.

300

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300 min

Time Limit

70%

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