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

Question 1: What is the most important professional competency for PANRE certification in endocrinology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 2: A 35-year-old with bipolar I disorder is stable on lithium but develops polyuria and polydipsia. What is the most appropriate next step?

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

Correct answer: Check serum lithium level and renal function

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

Question 3: What is the most common cause of hypercalcemia in the outpatient setting?

Malignancy
Sarcoidosis
Vitamin D toxicity
Primary hyperparathyroidism (Correct answer)

Correct answer: Primary hyperparathyroidism

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

Question 4: At the intensive care unit (ICU), a newborn was being treated for cyanotic episodes and stunted growth. Auscultation reveals a systolic murmur, and an x-ray reveals a heart that resembles a boot. Which diagnosis is more likely?

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

Correct answer: Tetralogy of Fallot

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

Question 5: Which of the following is the first-line pharmacotherapy for panic disorder?

Benzodiazepines
Buspirone
Tricyclic antidepressants
SSRIs (Correct answer)

Correct answer: SSRIs

SSRIs are first-line for panic disorder due to efficacy and favorable side-effect profile.

Question 6: Which lipid abnormality pattern is most associated with metabolic syndrome?

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

Correct answer: Low HDL with elevated triglycerides

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

Question 7: A patient presents with sudden-onset urticaria and angioedema 20 minutes after eating shellfish. Blood pressure is 80/50 mmHg and heart rate is 120 bpm. What is the immediate treatment?

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

Correct answer: Epinephrine 1:1000 IM 0.3mg

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

Question 8: Which HbA1c threshold is used to diagnose diabetes mellitus?

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

Correct answer: ≥ 6.5%

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

Question 9: A 55-year-old male with a history of prostate cancer presents with severe low back pain. Plain radiograph shows mixed lytic and blastic lesions of the lumbar vertebrae. What is the most likely etiology?

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

Correct answer: Metastatic prostate cancer

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

Question 10: A 40-year-old woman presents with a butterfly-shaped facial rash, joint pain, pleuritis, and renal involvement. ANA is positive. Which antibody is most specific for her diagnosis?

Anti-Ro/SSA
Anti-histone
Anti-dsDNA
Anti-Smith (anti-Sm) (Correct answer)

Correct answer: Anti-Smith (anti-Sm)

Anti-Smith (anti-Sm) antibodies are highly specific for SLE, although anti-dsDNA is more commonly ordered; anti-Sm is the most specific single antibody for SLE.

Question 11: A patient on chronic NSAID therapy develops pyuria without bacteriuria and eosinophiluria. What is the most likely diagnosis?

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

Correct answer: Acute interstitial nephritis (AIN)

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

Question 12: A 50-year-old diabetic presents with right lower quadrant pain, fever, and nausea for 2 days. CT shows a perforated appendix with localized abscess. What is the best initial management?

Oral antibiotics and outpatient follow-up
Colonoscopy to evaluate the area
IV antibiotics and interventional radiology drainage (Correct answer)
Emergent appendectomy

Correct answer: IV antibiotics and interventional radiology drainage

A walled-off periappendiceal abscess is best managed initially with IV antibiotics and percutaneous drainage, with interval appendectomy planned later.

Question 13: A 40-year-old non-smoker presents with hemoptysis and bilateral pulmonary infiltrates. Urinalysis shows hematuria and red cell casts. Anti-GBM antibodies are positive. Which diagnosis is most likely?

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

Correct answer: Goodpasture syndrome

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

Question 14: Which of the following does NOT indicate that you have Cushing syndrome?

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

Correct answer: Decreased hair growth

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

Question 15: A 65-year-old male with known BPH presents with inability to void, suprapubic pain, and a palpable bladder. What is the immediate management?

Urethral catheterization (Correct answer)
IV furosemide
Suprapubic catheterization
Tamsulosin and re-evaluate in 48 hours

Correct answer: Urethral catheterization

Acute urinary retention requires immediate bladder decompression; urethral catheterization is the first-line approach when no contraindication exists.

Question 16: A 58-year-old man with type 2 diabetes presents with a painless foot ulcer. ABI is 0.6. Which is the most appropriate next step?

Prescribe compression stockings
Start oral antibiotics and wound care
Refer for vascular surgery evaluation (Correct answer)
Obtain plain X-ray of the foot

Correct answer: Refer for vascular surgery evaluation

An ABI of 0.6 indicates significant peripheral arterial disease, requiring vascular surgery evaluation before wound healing can proceed.

Question 17: A 55-year-old woman with type 2 diabetes has an eGFR of 38 mL/min/1.73m². Which medication should be discontinued?

Metformin (Correct answer)
Insulin glargine
Glipizide
Sitagliptin

Correct answer: Metformin

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

Question 18: Which antibiotic class is the treatment of choice for community-acquired pneumonia in a healthy outpatient adult with no comorbidities?

Fluoroquinolones
Tetracyclines
Macrolides (Correct answer)
Beta-lactams

Correct answer: Macrolides

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

Question 19: A 50-year-old woman presents with polyuria and polydipsia. Serum osmolality is 310 mOsm/kg and urine osmolality is 150 mOsm/kg. After water deprivation, urine osmolality remains low. Desmopressin administration increases urine osmolality to 350 mOsm/kg. What is the diagnosis?

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

Correct answer: Central diabetes insipidus

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

Question 20: In PANRE practice, what is the best approach to quality improvement in gastroenterology?

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

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

Correct answer: Sick sinus syndrome

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

Question 22: A 25-year-old woman has episodes of muscle weakness triggered by rest after exercise and is improved by eating. Potassium level is low during attacks. Diagnosis?

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

Correct answer: Hypokalemic periodic paralysis

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

Question 23: A patient has a urine albumin-to-creatinine ratio (ACR) of 450 mg/g. Per KDIGO staging, what albuminuria category does this represent?

A3 — severely increased (Correct answer)
A1 — normal to mildly increased
A4 — nephrotic range
A2 — moderately increased

Correct answer: A3 — severely increased

Per KDIGO CKD classification, an ACR of 300-3499 mg/g corresponds to A3 (severely increased albuminuria).

Question 24: Which electrocardiographic finding is most suggestive of right heart strain in acute pulmonary embolism?

S1Q3T3 pattern (Correct answer)
ST elevation in leads II, III, and aVF
Left axis deviation with RBBB
Diffuse ST depression with T-wave inversions in V4-V6

Correct answer: S1Q3T3 pattern

The S1Q3T3 pattern (S wave in lead I, Q wave and T-wave inversion in lead III) is classic for acute right heart strain in PE.

Question 25: A 70-year-old man presents with urinary incontinence, gait apraxia, and cognitive decline. MRI shows enlarged ventricles disproportionate to sulcal atrophy. Treatment?

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

Correct answer: Ventriculoperitoneal shunt

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

Question 26: What is the most important professional competency for PANRE certification in emergency medicine?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 27: A traveler returning from Central America presents with bloody diarrhea, fever, and a liver abscess on ultrasound. Which organism is most likely responsible?

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

Correct answer: Entamoeba histolytica

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

Question 28: A 30-year-old presents with 6 months of grandiosity, decreased need for sleep, pressured speech, and impulsive spending, but continues to work. Which diagnosis best fits?

Cyclothymic disorder
Bipolar II disorder, hypomanic episode (Correct answer)
Substance-induced mood disorder
Bipolar I disorder, manic episode

Correct answer: Bipolar II disorder, hypomanic episode

Hypomania lasts ≥4 days, does not cause marked impairment, and does not require hospitalization, distinguishing it from mania.

Question 29: Which feature best differentiates migraine with aura from a TIA?

Presence of headache
Age of the patient
Duration of symptoms
Positive phenomena that march across the visual field (Correct answer)

Correct answer: Positive phenomena that march across the visual field

Migraine aura features positive phenomena (e.g., scintillating scotoma that spreads) and evolves slowly over minutes, while TIA causes negative, abrupt deficits.

Question 30: What role does collaboration play in gastroenterology for PANRE professionals?

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

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

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

Question 31: Which imaging finding is pathognomonic for diffuse axonal injury after traumatic brain injury?

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

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

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

Question 32: A 65-year-old with a history of rheumatoid arthritis presents with progressive dyspnea. PFTs show FVC 62% predicted, DLCO 55% predicted, FEV1/FVC 0.78. HRCT shows ground-glass opacities and reticulation. Which pattern is most likely?

Cryptogenic organizing pneumonia (COP)
Non-specific interstitial pneumonia (NSIP) (Correct answer)
Usual interstitial pneumonia (UIP)
Respiratory bronchiolitis-ILD

Correct answer: Non-specific interstitial pneumonia (NSIP)

NSIP is the most common ILD pattern associated with connective tissue diseases like rheumatoid arthritis, presenting with ground-glass opacities and reticulation on HRCT.

Question 33: A 6-year-old boy has recurrent hemarthroses and prolonged bleeding after minor trauma. PTT is 68 seconds (normal <35), PT is normal, platelet count is normal, bleeding time is normal. Factor VIII activity is 2%. What is the diagnosis?

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

Correct answer: Hemophilia A

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

Question 34: A 32-year-old woman presents with alternating constipation and diarrhea, bloating, and abdominal cramping relieved by defecation. No alarm features are present. What is the most likely diagnosis?

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

Correct answer: Irritable bowel syndrome

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

Question 35: Which of the following methods of transmission of hepatitis C is most frequent?

Blood (Correct answer)
Feces
Sex
Breastfeeding

Correct answer: Blood

The most frequent method of transmission for hepatitis C is through blood-to-blood contact. This primarily occurs through sharing contaminated needles for injection drug use, but also historically through blood transfusions before widespread screening. While sexual transmission is possible, it is much less efficient than blood-borne routes, and fecal-oral transmission is not a route for Hepatitis C.

Question 36: A 30-year-old presents with pancytopenia: Hgb 7.1, WBC 1,800, platelets 28,000. Bone marrow biopsy shows a hypocellular marrow with >70% fat cells. No splenomegaly. What is the most appropriate treatment for severe aplastic anemia in a patient with a matched sibling donor?

Corticosteroids and erythropoietin
Immunosuppression with antithymocyte globulin and cyclosporine
G-CSF therapy alone
Allogeneic hematopoietic stem cell transplantation (Correct answer)

Correct answer: Allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation from a matched sibling donor is the curative treatment of choice for severe aplastic anemia in young patients.

Question 37: A 25-year-old presents with a deep laceration over the MCP joint after punching someone in the mouth. How should this wound be managed?

Close primarily and prescribe antifungals
Irrigate, close primarily, and discharge
Apply a pressure dressing only and reassure
Irrigate, leave open, splint, and prescribe antibiotics covering oral flora (Correct answer)

Correct answer: Irrigate, leave open, splint, and prescribe antibiotics covering oral flora

Fight bites over the MCP joint carry a high risk of septic arthritis from oral flora; the wound must be left open, irrigated, splinted, and treated with antibiotics such as amoxicillin-clavulanate.

Question 38: A veteran with PTSD asks about the most evidence-based non-pharmacological treatment. What should you recommend?

EMDR or prolonged exposure therapy (Correct answer)
Hypnotherapy
Mindfulness-based stress reduction alone
Supportive counseling

Correct answer: EMDR or prolonged exposure therapy

Trauma-focused CBT (including prolonged exposure) and EMDR have the strongest evidence for PTSD.

Question 39: A 22-year-old Black male with sickle cell disease presents with severe bone pain in his legs and back for 12 hours. Temperature is 37.2°C, SpO2 is 97%. What is the most appropriate immediate management?

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

Correct answer: IV morphine and IV fluids

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

Question 40: What is the most important professional competency for PANRE certification in psychiatry?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 41: A patient with hypothyroidism is started on levothyroxine. How soon should TSH be rechecked to assess adequacy of dosing?

6-8 weeks (Correct answer)
4-6 weeks
1-2 weeks
3-6 months

Correct answer: 6-8 weeks

TSH should be rechecked 6-8 weeks after initiating or changing the dose of levothyroxine, as TSH requires this time to reach a new steady state.

Question 42: A 28-year-old female non-smoker presents with recurrent pneumothoraces and dyspnea. HRCT shows bilateral diffuse thin-walled cysts. She is taking oral contraceptives. What is the most likely diagnosis?

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

Correct answer: Lymphangioleiomyomatosis (LAM)

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

Question 43: A 45-year-old with HIV presents with focal seizures and a ring-enhancing lesion on MRI. The most likely diagnosis is:

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

Correct answer: Toxoplasma encephalitis

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

Question 44: A 52-year-old farmer presents with acute onset fever, myalgia, and bilateral pulmonary infiltrates 4-6 hours after working in a dusty barn. Symptoms resolve within 24 hours without treatment. What is the most likely diagnosis?

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

Correct answer: Organic dust toxic syndrome

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

Question 45: In PANRE practice, what is the best approach to quality improvement in obstetrics and gynecology?

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 46: A 70-year-old man with BPH is started on tamsulosin. He develops dizziness after standing. Which mechanism explains this side effect?

Alpha-1 receptor blockade causing venous pooling (Correct answer)
Beta-1 receptor blockade reducing heart rate
Anticholinergic effects reducing preload
Inhibition of PDE5 causing vasodilation

Correct answer: Alpha-1 receptor blockade causing venous pooling

Tamsulosin is an alpha-1 adrenergic blocker; blockade of vascular alpha-1 receptors causes vasodilation and orthostatic hypotension.

Question 47: A patient with recurrent genital herpes wants suppressive therapy to reduce outbreaks. Which regimen is appropriate?

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

Correct answer: Valacyclovir 500 mg daily

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

Question 48: What is the preferred first-line agent for uncomplicated urinary tract infections in otherwise healthy adult women in the United States?

Amoxicillin
Trimethoprim-sulfamethoxazole
Nitrofurantoin (Correct answer)
Ciprofloxacin

Correct answer: Nitrofurantoin

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

Question 49: A 70-year-old woman presents with large, tense bullae on the flexural surfaces. Direct immunofluorescence shows linear IgG and C3 deposits at the dermal-epidermal junction. What is the diagnosis?

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

Correct answer: Bullous pemphigoid

Bullous pemphigoid is characterized by tense bullae (subepidermal blistering) with linear IgG and C3 deposits at the BMZ on DIF, targeting BP180 and BP230 antigens.

Question 50: A 25-year-old woman presents with 7 weeks of amenorrhea, left lower quadrant pain, and vaginal spotting. Serum hCG is 2,200 mIU/mL and transvaginal ultrasound shows no intrauterine gestational sac. She is hemodynamically stable. What is the most appropriate management?

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

Correct answer: Methotrexate 50 mg/m² IM

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

Question 51: A newborn develops jaundice within the first 24 hours of life. Mother is blood type O negative, baby is A positive. Which condition is most likely?

Biliary atresia
ABO hemolytic disease of the newborn (Correct answer)
Crigler-Najjar syndrome
Physiologic jaundice

Correct answer: ABO hemolytic disease of the newborn

Jaundice appearing within 24 hours is pathologic; ABO incompatibility with O-negative mother and A-positive infant causes hemolytic disease of the newborn.

Question 52: What is the most important professional competency for PANRE certification in obstetrics and gynecology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 53: An adult patient presents with erythema migrans (bull's-eye rash) after hiking in Connecticut. What is the most appropriate treatment?

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

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

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

Question 54: A 45-year-old male presents with chronic cough, wheezing, and nasal polyps. He develops severe bronchospasm after taking ibuprofen for knee pain. What syndrome does he have?

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

Correct answer: Aspirin-exacerbated respiratory disease (AERD)

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

Question 55: A 35-year-old woman has recurrent mucosal bleeding, easy bruising, and prolonged bleeding after dental extraction. PTT is mildly prolonged, PT is normal, platelet count is 210,000/μL. What is the most likely diagnosis?

Hemophilia A
Von Willebrand disease (Correct answer)
Bernard-Soulier syndrome
Immune thrombocytopenic purpura

Correct answer: Von Willebrand disease

Von Willebrand disease is the most common inherited bleeding disorder, presenting with mucosal and skin bleeding, a normal platelet count, and a mildly prolonged PTT due to VWF's role in stabilizing factor VIII.

Question 56: A patient with CKD has a serum potassium of 6.4 mEq/L with peaked T-waves on EKG. What is the FIRST priority treatment?

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

Correct answer: Calcium gluconate IV

IV calcium gluconate is given first in hyperkalemia with EKG changes to stabilize the cardiac membrane and prevent fatal arrhythmias.

Question 57: Which professional attribute is most valued in emergency medicine within the PANRE 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 58: Which antiepileptic drug is contraindicated in pregnancy due to highest risk of neural tube defects?

Valproate (Correct answer)
Lamotrigine
Oxcarbazepine
Levetiracetam

Correct answer: Valproate

Valproate inhibits folate metabolism and is associated with a 1–2% risk of neural tube defects and multiple other congenital abnormalities, making it contraindicated in pregnancy when possible.

Question 59: A 50-year-old man with type 2 diabetes presents with velvety, hyperpigmented skin in the axillae and posterior neck. Which condition is most associated with this finding?

Acanthosis nigricans (Correct answer)
Terra firma-forme dermatosis
Erythrasma
Confluent and reticulated papillomatosis

Correct answer: Acanthosis nigricans

Acanthosis nigricans is strongly associated with insulin resistance and type 2 diabetes, presenting as velvety hyperpigmentation in body folds.

Question 60: A patient presents 24 hours after an ankle sprain with significant swelling and inability to bear weight. The Ottawa Ankle Rules indicate X-ray is needed when there is tenderness at which location?

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

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

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

Question 61: A 45-year-old woman presents with fatigue, weight gain, constipation, and cold intolerance. TSH is 12 mIU/L and free T4 is low. Which medication is the standard of care?

Methimazole
Liothyronine
Propylthiouracil
Levothyroxine (Correct answer)

Correct answer: Levothyroxine

Levothyroxine (synthetic T4) is the standard treatment for primary hypothyroidism due to its consistent potency, long half-life, and predictable peripheral conversion to T3.

Question 62: A patient presents with vesicular rash on the forehead, tip of the nose, and periorbital swelling. What is the most urgent complication to rule out?

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

Correct answer: Herpes zoster ophthalmicus

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

Question 63: A 30-year-old male presents with bilateral ankle swelling, eye redness, and dysuria following an episode of Chlamydia trachomatis infection. What is the classic triad of his condition?

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

Correct answer: Arthritis, conjunctivitis, urethritis

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

Question 64: A 38-year-old man presents with severe epigastric pain radiating to the back, nausea, and vomiting. He denies alcohol use. Lipase is 4× normal and triglycerides are 1,800 mg/dL. What is the cause of his pancreatitis?

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

Correct answer: Hypertriglyceridemia-induced pancreatitis

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

Question 65: A 5-year-old boy presents with a limp and hip pain. X-ray shows flattening and increased density of the femoral head. What is the diagnosis?

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

Correct answer: Legg-Calvé-Perthes disease

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

Question 66: A patient with type 1 diabetes presents with blood glucose of 650 mg/dL, pH 7.20, bicarbonate 12 mEq/L, and large ketones. What is the hallmark of diabetic ketoacidosis that distinguishes it from hyperglycemic hyperosmolar state?

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

Correct answer: Significant ketonemia and anion gap metabolic acidosis

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

Question 67: Which condition is characterized by at least 2 years of fluctuating hypomanic and depressive symptoms that do not meet criteria for full bipolar episodes?

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

Correct answer: Cyclothymic disorder

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

Question 68: A 5-year-old child develops multiple 2–5 mm umbilicated, flesh-colored papules on the trunk and extremities without surrounding inflammation. The child is otherwise healthy. What is the treatment of choice?

Watchful waiting (self-limited) (Correct answer)
Oral acyclovir for 5 days
Cryotherapy immediately
Topical imiquimod 5% daily

Correct answer: Watchful waiting (self-limited)

Molluscum contagiosum in immunocompetent children is self-limited, typically resolving in 6–18 months, and watchful waiting is the preferred management to avoid painful procedures.

Question 69: What is the most important professional competency for PANRE certification in gastroenterology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 70: A 58-year-old man presents with new-onset ascites. Paracentesis shows SAAG of 1.5 g/dL. Which condition is most consistent with this result?

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

Correct answer: Portal hypertension

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

Question 71: In PANRE practice, what is the best approach to quality improvement in neurology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 72: A patient presents with altered mental status, fever of 40°C, muscle rigidity, and autonomic instability after starting a new antipsychotic. What is the diagnosis?

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

Correct answer: Neuroleptic malignant syndrome

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

Question 73: A patient presents with flank pain, hematuria, and nausea. CT shows a 4 mm ureteral stone. What is the most appropriate initial management?

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

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

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

Question 74: A 65-year-old male with a known history of gout is found to have chalky white deposits over his Achilles tendon and ear helices. What are these deposits called?

Rheumatoid nodules
Tophi (Correct answer)
Heberden nodes
Bouchard nodes

Correct answer: Tophi

Tophi are deposits of monosodium urate crystals that form in chronic tophaceous gout, commonly at pressure points and cooler areas like the ear helix.

Question 75: Which test is used to diagnose carpal tunnel syndrome at the bedside?

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

Correct answer: Phalen test and Tinel sign

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

Question 76: A 60-year-old male smoker presents with hemoptysis and a central cavitary lung mass on CT. Biopsy shows large cells with abundant cytoplasm and no glandular or squamous features. What is the most likely cell type?

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

Correct answer: Large cell carcinoma

Large cell carcinoma is an undifferentiated NSCLC that lacks features of adenocarcinoma, squamous cell, or small cell carcinoma on histology and is often centrally located.

Question 77: A 60-year-old woman on bisphosphonate therapy for osteoporosis has a 'drug holiday' recommended after 5 years. Which bisphosphonate characteristic makes this most appropriate?

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

Correct answer: Prolonged skeletal retention and residual effect after discontinuation

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

Question 78: What is the value of continuing education in gastroenterology for PANRE professionals?

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

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

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

Question 79: A patient on warfarin for atrial fibrillation has an INR of 8.5 with no active bleeding. What is the most appropriate management?

Hold warfarin and administer oral vitamin K 2.5 mg (Correct answer)
Administer IV vitamin K 10 mg
Administer fresh frozen plasma
Continue warfarin and recheck INR in 24 hours

Correct answer: Hold warfarin and administer oral vitamin K 2.5 mg

For INR >8 without bleeding, holding warfarin and giving low-dose oral vitamin K is the recommended approach.

Question 80: A 30-year-old presents with spontaneous pneumothorax on the right side with 25% lung collapse. He is hemodynamically stable. What is the most appropriate management?

Immediate needle decompression
Large-bore chest tube
Small-bore chest tube or aspiration (Correct answer)
Observation with supplemental oxygen

Correct answer: Small-bore chest tube or aspiration

A primary spontaneous pneumothorax with >20% collapse in a stable patient is typically managed with small-bore chest tube or needle aspiration.

Question 81: A patient presents with ataxia, nystagmus, and ophthalmoplegia. What is the immediate priority treatment?

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

Correct answer: Thiamine (vitamin B1) administration

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

Question 82: A patient on an ACE inhibitor is found to have bilateral renal artery stenosis. Which lab change is most expected after starting the ACE inhibitor?

Decreased serum potassium
Decreased urine protein
Increased serum creatinine (Correct answer)
Decreased serum creatinine

Correct answer: Increased serum creatinine

ACE inhibitors block efferent arteriolar vasoconstriction, causing a significant drop in GFR and a rise in creatinine in bilateral renal artery stenosis.

Question 83: What is the most important professional competency for PANRE certification in dermatology?

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

Levothyroxine (Correct answer)
Radioactive iodine ablation
Methimazole
Propylthiouracil

Correct answer: Levothyroxine

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

Question 85: A 6-year-old presents with wheezing, accessory muscle use, and an O2 saturation of 88%. After two doses of nebulized albuterol and one dose of ipratropium, the patient's condition is unchanged. What should be added?

IV or oral corticosteroids and consider IV magnesium sulfate (Correct answer)
Heliox alone
IV aminophylline
Intubate immediately

Correct answer: IV or oral corticosteroids and consider IV magnesium sulfate

Severe acute asthma unresponsive to bronchodilators requires systemic corticosteroids and IV magnesium sulfate, which acts as a bronchodilator.

Question 86: What is the value of continuing education in obstetrics and gynecology for PANRE professionals?

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

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

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

Question 87: A 45-year-old man presents with diarrhea, flushing, and wheezing. Urine 5-HIAA levels are elevated. CT abdomen shows a liver mass. What is the most likely primary tumor location?

Stomach
Small intestine (Correct answer)
Colon
Pancreas

Correct answer: Small intestine

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

Question 88: A 50-year-old male with alcohol use disorder has a last drink 36 hours ago and now has tremors, diaphoresis, and a seizure. What is the most appropriate pharmacotherapy?

Phenytoin
Lorazepam (Correct answer)
Haloperidol
Carbamazepine

Correct answer: Lorazepam

Benzodiazepines (lorazepam) are first-line for alcohol withdrawal seizures due to cross-tolerance with GABA receptors.

Question 89: In PANRE practice, what is the best approach to quality improvement in psychiatry?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 90: A 31-year-old G1P0 at 39 weeks has a Bishop score of 4. She is being considered for labor induction. Which agent is appropriate for cervical ripening?

Oxytocin IV infusion
Castor oil
Misoprostol or dinoprostone (Correct answer)
Amniotomy alone

Correct answer: Misoprostol or dinoprostone

An unfavorable cervix (Bishop score <6) requires cervical ripening with prostaglandins such as misoprostol or dinoprostone before or alongside induction.

Question 91: A 65-year-old man with COPD is noted to have a hematocrit of 56%. Which mechanism best explains this finding?

Polycythemia vera with JAK2 mutation
Decreased erythropoietin from renal artery stenosis
Dehydration causing hemoconcentration
Secondary polycythemia from chronic hypoxemia (Correct answer)

Correct answer: Secondary polycythemia from chronic hypoxemia

Chronic hypoxemia in COPD stimulates erythropoietin release, causing secondary polycythemia as a compensatory response.

Question 92: Which special test is used to evaluate for rotator cuff impingement?

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

Correct answer: Neer impingement sign

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

Question 93: A 30-year-old woman develops a butterfly-shaped rash across her cheeks and nasal bridge that spares the nasolabial folds. Which test is most specific for confirming systemic lupus erythematosus?

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

Correct answer: Anti-dsDNA

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

Question 94: A 25-year-old woman presents with watery diarrhea (8-10 stools/day) and mild cramping. She recently completed a course of clindamycin. Stool testing is positive for C. difficile toxin. What is the first-line treatment?

Metronidazole
Fecal microbiota transplant
Fidaxomicin
Vancomycin (oral) (Correct answer)

Correct answer: Vancomycin (oral)

Current IDSA/ACG guidelines recommend oral vancomycin as the first-line treatment for initial C. difficile infection, having replaced metronidazole as first-line therapy.

Question 95: A 68-year-old man with a 40 pack-year history presents with a 2.5 cm solitary pulmonary nodule. PET scan shows no FDG uptake. What is the most appropriate next step?

CT surveillance at 3-month intervals (Correct answer)
Surgical resection
CT-guided biopsy immediately
Bronchoscopy

Correct answer: CT surveillance at 3-month intervals

A solid pulmonary nodule ≥6 mm in a high-risk patient with no PET activity warrants serial CT surveillance per Fleischner Society guidelines rather than immediate biopsy.

Question 96: Which approach best demonstrates mastery of obstetrics and gynecology in PANRE practice?

Following procedures without understanding
Relying entirely on technology
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 97: A 70-year-old man with a history of NSAID use presents with epigastric pain and melena. Endoscopy reveals a duodenal ulcer with a visible vessel. What is the endoscopic treatment of choice?

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

Correct answer: Hemoclip or thermal coagulation plus epinephrine injection

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

Question 98: Which medication is FDA-approved for the treatment of bulimia nervosa?

Fluoxetine (Correct answer)
Topiramate
Sertraline
Bupropion

Correct answer: Fluoxetine

Fluoxetine 60 mg/day is the only FDA-approved medication for bulimia nervosa.

Question 99: A 62-year-old male with a history of chronic liver disease presents with confusion, asterixis, and elevated ammonia. Which medication is first-line to reduce ammonia production in the gut?

Metronidazole
Lactulose (Correct answer)
Rifaximin
Neomycin

Correct answer: Lactulose

Lactulose is first-line for hepatic encephalopathy; it acidifies the colon, trapping ammonia as ammonium (NH4+) and promoting its excretion.

Question 100: A 60-year-old male presents with progressive low back pain radiating to both legs with walking, relieved by sitting or bending forward. What is the most likely diagnosis?

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

Correct answer: Spinal stenosis

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

Question 101: Which fetal heart rate pattern is most concerning for uteroplacental insufficiency during labor?

Variable decelerations
Accelerations
Early decelerations
Late decelerations (Correct answer)

Correct answer: Late decelerations

Late decelerations—nadir after the peak of a contraction—reflect uteroplacental insufficiency and fetal hypoxemia.

Question 102: A 40-year-old woman with known Crohn's disease presents with right lower quadrant pain, fever, and a palpable mass. Which complication should be suspected?

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

Correct answer: Intra-abdominal abscess

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

Question 103: What is the value of continuing education in neurology for PANRE professionals?

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

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

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

Question 104: A patient has a positive Lachman test but negative McMurray test. Which structure is most likely injured?

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

Correct answer: Anterior cruciate ligament

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

Question 105: A patient has a positive direct Coombs test, elevated indirect bilirubin, low haptoglobin, and reticulocytosis. Peripheral smear shows spherocytes. Splenomegaly is present. What condition is most consistent with these findings?

Microangiopathic hemolytic anemia
Autoimmune hemolytic anemia (Correct answer)
Hereditary spherocytosis
Paroxysmal nocturnal hemoglobinuria

Correct answer: Autoimmune hemolytic anemia

Autoimmune hemolytic anemia (AIHA) is confirmed by a positive direct Coombs (DAT) test, which detects IgG or complement on RBC surfaces, causing extravascular hemolysis with spherocyte formation.

Question 106: A 25-year-old football player sustains a direct blow to his knee and develops immediate hemarthrosis. Which structure is most likely ruptured?

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

Correct answer: Anterior cruciate ligament

Immediate hemarthrosis following a knee injury is most commonly caused by ACL tear due to rupture of branches of the middle geniculate artery.

Question 107: A 40-year-old man has central obesity, moon facies, and purple striae. His 24-hour urine free cortisol is elevated. What is the next best step?

CT of the adrenal glands
Low-dose dexamethasone suppression test (Correct answer)
MRI of the pituitary
High-dose dexamethasone suppression test

Correct answer: Low-dose dexamethasone suppression test

After confirming hypercortisolism with elevated urine free cortisol, a low-dose dexamethasone suppression test helps confirm the diagnosis of Cushing syndrome before localization.

Question 108: Which clinical finding best differentiates upper motor neuron (UMN) lesion from lower motor neuron (LMN) lesion?

Hyperreflexia with spasticity (Correct answer)
Muscle atrophy
Decreased tone
Fasciculations

Correct answer: Hyperreflexia with spasticity

UMN lesions produce hyperreflexia, spasticity, and Babinski sign due to loss of descending inhibition; LMN lesions cause hyporeflexia, flaccidity, and atrophy.

Question 109: A 35-year-old female presents with wrist pain. Finkelstein test is positive. What tendons are involved?

Extensor carpi ulnaris
Extensor digitorum communis
Abductor pollicis longus and extensor pollicis brevis (Correct answer)
Flexor carpi radialis

Correct answer: Abductor pollicis longus and extensor pollicis brevis

De Quervain tenosynovitis affects the abductor pollicis longus and extensor pollicis brevis tendons in the first dorsal compartment, confirmed by the Finkelstein test.

Question 110: Which of the following is the most common cause of acute pancreatitis in the United States?

Gallstones (Correct answer)
Medications
Hypertriglyceridemia
Alcohol use

Correct answer: Gallstones

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

Question 111: Which of the following is the most sensitive and specific test for diagnosing H. pylori infection in a patient who cannot undergo endoscopy?

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

Correct answer: Urea breath test

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

Question 112: A 55-year-old male presents with lateral elbow pain worsened by resisted wrist extension. What is the most likely diagnosis?

Olecranon bursitis
Cubital tunnel syndrome
Medial epicondylitis
Lateral epicondylitis (Correct answer)

Correct answer: Lateral epicondylitis

Lateral epicondylitis (tennis elbow) causes pain at the lateral epicondyle worsened by resisted wrist extension due to extensor carpi radialis brevis tendinopathy.

Question 113: A 62-year-old man with hypertension develops sudden left-sided weakness and slurred speech that resolves completely in 45 minutes. Workup includes ECG showing atrial fibrillation. Best long-term stroke prevention strategy?

Aspirin alone
Carotid endarterectomy
Clopidogrel plus aspirin
Anticoagulation with a DOAC (Correct answer)

Correct answer: Anticoagulation with a DOAC

Atrial fibrillation-related TIA requires anticoagulation (preferably a DOAC) to prevent cardioembolic stroke; antiplatelet therapy is insufficient for this indication.

Question 114: A patient with HIV has a CD4 count of 175 cells/µL. Which opportunistic infection prophylaxis must be initiated?

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

Correct answer: TMP-SMX for Pneumocystis jirovecii pneumonia

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

Question 115: A 72-year-old woman on warfarin presents with painless bright red blood per rectum. Colonoscopy shows bleeding diverticula in the sigmoid colon. What is the most appropriate initial management?

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

Correct answer: Endoscopic hemostasis (clips or coagulation)

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

Question 116: Which finding is most consistent with primary hyperaldosteronism (Conn syndrome)?

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

Correct answer: Hypokalemia with hypertension

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

Question 117: Which ventilator parameter should be prioritized when managing ARDS to prevent ventilator-induced lung injury (VILI)?

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

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

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

Question 118: A patient presents with sharp pleuritic chest pain, friction rub, and diffuse ST elevation with PR depression on EKG. What is the diagnosis?

Acute pericarditis (Correct answer)
Aortic dissection
STEMI
Pulmonary embolism

Correct answer: Acute pericarditis

Diffuse ST elevation with PR depression and friction rub are hallmark features of acute pericarditis.

Question 119: Which approach best demonstrates mastery of orthopedics in PANRE practice?

Relying entirely on technology
Applying principles to novel situations with sound judgment (Correct answer)
Following procedures without understanding
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 120: Which finding best differentiates delirium from dementia?

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

Correct answer: Acute fluctuating course

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

Question 121: A patient with schizophrenia on olanzapine gains 20 lbs over 6 months and develops fasting glucose of 126 mg/dL. What is the most appropriate next step?

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

Correct answer: Switch to aripiprazole or ziprasidone

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

Question 122: A 24-year-old presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. CA-125 is mildly elevated. What is the gold standard for diagnosis?

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

Correct answer: Diagnostic laparoscopy

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

Question 123: A 25-year-old presents with grouped vesicles on an erythematous base in a dermatomal distribution on the right thorax with pain preceding the rash by 3 days. Which antiviral should be initiated?

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

Correct answer: Valacyclovir 1000mg TID x 7 days

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

Question 124: A 45-year-old woman is found to have a serum LDL of 210 mg/dL with no cardiovascular risk factors. Initial management should include:

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

Correct answer: Lifestyle modification for 3 months, then reassess

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

Question 125: A patient with celiac disease continues to have diarrhea and weight loss despite strict gluten avoidance. What should be the next step in management?

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

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

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

Question 126: A 45-year-old male presents with fatigue and splenomegaly. WBC is 85,000/μL with a left shift. Peripheral smear shows all stages of granulocyte maturation. Cytogenetics reveal the Philadelphia chromosome t(9;22). What is the first-line treatment?

Allogeneic stem cell transplantation
Imatinib (tyrosine kinase inhibitor) (Correct answer)
Interferon-alpha
Hydroxyurea

Correct answer: Imatinib (tyrosine kinase inhibitor)

Chronic myelogenous leukemia (CML) driven by the BCR-ABL fusion from the Philadelphia chromosome is treated with tyrosine kinase inhibitors like imatinib as first-line therapy.

Question 127: What qualities do an indirect inguinal hernia have?

Occurs below inguinal ligament at weak spot of femoral canal
Occurs at umbilical ring through abdominal wall
Protrusion through weak spot of inguinal canal
Congenital protrusion through the inguinal ring into inguinal canal (Correct answer)

Correct answer: Congenital protrusion through the inguinal ring into inguinal canal

An indirect inguinal hernia is characterized by a congenital protrusion through the deep (internal) inguinal ring into the inguinal canal. This occurs when the processus vaginalis, a peritoneal outpouching, fails to close completely after testicular descent, creating a pathway for abdominal contents to herniate. It follows the path of the spermatic cord and can extend into the scrotum.

Question 128: Which formula is currently recommended for estimating GFR in clinical practice?

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

Correct answer: CKD-EPI equation

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

Question 129: A patient presents with a painless genital ulcer with indurated edges. Which organism is responsible?

Haemophilus ducreyi
Neisseria gonorrhoeae
Treponema pallidum (Correct answer)
Chlamydia trachomatis

Correct answer: Treponema pallidum

Primary syphilis is characterized by a painless, indurated genital chancre caused by Treponema pallidum.

Question 130: A 32-year-old woman at 10 weeks gestation presents with nausea, vomiting, vaginal bleeding, and a uterus larger than dates. Beta-hCG is markedly elevated and ultrasound shows a 'snowstorm' pattern. What is the diagnosis?

Complete hydatidiform mole (Correct answer)
Threatened abortion
Choriocarcinoma
Ectopic pregnancy

Correct answer: Complete hydatidiform mole

A snowstorm ultrasound pattern with markedly elevated beta-hCG, uterus larger than dates, and vaginal bleeding is classic for a complete hydatidiform mole.

Question 131: A 34-year-old woman at 28 weeks gestation has a 1-hour glucose challenge test result of 158 mg/dL. A subsequent 3-hour 100g OGTT shows: fasting 92, 1-hr 182, 2-hr 154, 3-hr 138 mg/dL. How many values are abnormal?

One abnormal value — gestational diabetes diagnosed
No abnormal values — no gestational diabetes
Three abnormal values — gestational diabetes diagnosed
Two abnormal values — gestational diabetes diagnosed (Correct answer)

Correct answer: Two abnormal values — gestational diabetes diagnosed

Using Carpenter-Coustan criteria (fasting ≥95, 1-hr ≥180, 2-hr ≥155, 3-hr ≥140), the 1-hr (182) and 2-hr (154) values are abnormal, diagnosing GDM with ≥2 abnormal values.

Question 132: Which of the following is the most appropriate initial treatment for a non-displaced clavicle fracture?

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

Correct answer: Sling immobilization for 4–6 weeks

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

Question 133: A 28-year-old woman develops targetoid lesions (concentric rings) on her palms and oral erosions 10 days after starting trimethoprim-sulfamethoxazole for a UTI. She has no systemic symptoms. What is the diagnosis?

Stevens-Johnson syndrome
Erythema multiforme major
Erythema multiforme minor (Correct answer)
Toxic epidermal necrolysis

Correct answer: Erythema multiforme minor

Erythema multiforme minor presents with typical target lesions on acral surfaces and may involve one mucosal surface without systemic symptoms or significant epidermal detachment.

Question 134: A 62-year-old presents with progressive dyspnea and is found to have bilateral pleural effusions. Echocardiography shows EF of 35%. Thoracentesis reveals protein 2.1 g/dL and LDH 140 U/L. What is the most likely cause?

Malignant pleural effusion
Hepatic hydrothorax
Parapneumonic effusion
Congestive heart failure transudate (Correct answer)

Correct answer: Congestive heart failure transudate

Bilateral effusions with low protein and LDH in the context of reduced EF are consistent with a transudative effusion from congestive heart failure.

Question 135: A patient with Graves disease is treated with methimazole. Which serious adverse effect requires immediate discontinuation?

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

Correct answer: Agranulocytosis

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

Question 136: What role does collaboration play in pulmonology for PANRE professionals?

It is only needed in emergencies
It enhances outcomes through diverse perspectives and shared expertise (Correct answer)
It slows down work unnecessarily
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 137: Which finding on urinalysis is most consistent with nephrotic syndrome?

Massive proteinuria (>3.5 g/day) (Correct answer)
RBC casts
WBC casts
Granular casts

Correct answer: Massive proteinuria (>3.5 g/day)

Nephrotic syndrome is defined by massive proteinuria (>3.5 g/day), which drives the associated hypoalbuminemia, edema, and hyperlipidemia.

Question 138: A patient with Hashimoto thyroiditis is euthyroid. What is the most appropriate management?

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

Correct answer: Monitor TSH periodically

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

Question 139: A 60-year-old female presents with acute onset atrial fibrillation with rapid ventricular response and hypotension (BP 80/50). What is the immediate treatment?

Oral metoprolol for rate control
Synchronized DC cardioversion (Correct answer)
IV diltiazem for rate control
IV amiodarone infusion

Correct answer: Synchronized DC cardioversion

Unstable atrial fibrillation with hemodynamic compromise requires immediate synchronized cardioversion regardless of duration.

Question 140: A patient on warfarin for atrial fibrillation has an INR of 8.5 with no active bleeding. What is the most appropriate management?

Hold warfarin only and recheck in 24 hours (Correct answer)
Hold warfarin and give IV vitamin K
Give prothrombin complex concentrate
Give fresh frozen plasma

Correct answer: Hold warfarin only and recheck in 24 hours

For supratherapeutic INR (>8) without bleeding, holding warfarin and rechecking in 24 hours is appropriate; oral vitamin K may be added per guidelines.

Question 141: An 8-year-old child presents with inspiratory stridor, drooling, and prefers to sit in a tripod position. Temperature is 39.5°C. What is the most likely diagnosis?

Anaphylaxis
Croup
Foreign body aspiration
Epiglottitis (Correct answer)

Correct answer: Epiglottitis

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

Question 142: Which antifungal is first-line for treating oropharyngeal candidiasis in an immunocompromised patient?

Voriconazole
Caspofungin
Amphotericin B
Fluconazole (Correct answer)

Correct answer: Fluconazole

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

Question 143: At what GFR level is hemodialysis typically initiated in symptomatic CKD patients?

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

Correct answer: 10-15 mL/min/1.73m²

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

Question 144: Which professional attribute is most valued in dermatology within the PANRE field?

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

Correct answer: Accountability and commitment to standards

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

Question 145: A patient with ESRD develops pruritis, pericarditis, and encephalopathy. These findings are best explained by which condition?

Hypervolemia
Hyponatremia
Uremic syndrome (Correct answer)
Hyperphosphatemia

Correct answer: Uremic syndrome

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

Question 146: In PANRE practice, what is the best approach to quality improvement in orthopedics?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 147: A 50-year-old obese man with type 2 diabetes has elevated transaminases. Liver biopsy shows steatosis, lobular inflammation, and hepatocyte ballooning. What is the diagnosis?

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

Correct answer: Nonalcoholic steatohepatitis (NASH)

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

Question 148: A 65-year-old male presents with peripheral neuropathy, glossitis, and megaloblastic anemia. Serum B12 is 98 pg/mL. Anti-intrinsic factor antibodies are positive. What is the most likely diagnosis?

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

Correct answer: Pernicious anemia

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

Question 149: A 55-year-old presents with thick, silvery-white scales overlying well-demarcated erythematous plaques on the elbows and knees. Removing a scale produces punctate bleeding (Auspitz sign). What systemic comorbidity should be screened for?

Celiac disease
Inflammatory bowel disease
Psoriatic arthritis (Correct answer)
Primary biliary cholangitis

Correct answer: Psoriatic arthritis

Psoriatic arthritis occurs in up to 30% of patients with psoriasis and should be routinely screened for, as early detection prevents joint destruction.

Question 150: A 55-year-old man post-CABG develops new-onset fever, pleuritic chest pain, and pericardial rub on day 10. What is the most likely diagnosis?

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

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

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

Question 151: A 17-year-old male complains of hip pain and a limp. X-ray shows the femoral head appearing to 'slip' posterior and inferior off the femoral neck. What is the diagnosis?

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

Correct answer: Slipped capital femoral epiphysis

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

Question 152: Which insulin regimen best mimics physiologic insulin secretion in type 1 diabetes?

Once-daily NPH insulin
Basal-bolus regimen with glargine plus rapid-acting insulin (Correct answer)
Twice-daily premixed 70/30 insulin
Sliding scale regular insulin only

Correct answer: Basal-bolus regimen with glargine plus rapid-acting insulin

A basal-bolus regimen using long-acting insulin (e.g., glargine) for basal needs and rapid-acting insulin at meals best approximates normal pancreatic insulin secretion.

Question 153: A patient reports that her neighbor has been poisoning her food for the past year. She is otherwise functional, with no hallucinations or disorganized speech. What is the most likely diagnosis?

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

Correct answer: Delusional disorder, persecutory type

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

Question 154: Which test is most sensitive for detecting early Alzheimer disease when clinical diagnosis is uncertain?

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

Correct answer: CSF tau/amyloid ratio

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

Question 155: A 26-year-old male presents with painless cervical lymphadenopathy, night sweats, fever, and weight loss. Biopsy of a lymph node reveals Reed-Sternberg cells. CT shows mediastinal involvement. What is the most likely diagnosis?

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

Correct answer: Hodgkin lymphoma

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

Question 156: What role does collaboration play in orthopedics for PANRE professionals?

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

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

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

Question 157: A 62-year-old man presents with grouped, crusted vesicles in the L3 dermatomal distribution 2 weeks after resolution of his acute zoster rash. He reports burning pain 8/10 in the same area. What is this complication called?

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

Correct answer: Post-herpetic neuralgia

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

Question 158: Which of the following is an absolute contraindication to thrombolytic therapy in acute ischemic stroke?

Recent intracranial surgery within 3 months (Correct answer)
Mild stroke with NIHSS score of 4
Blood glucose of 60 mg/dL
Age over 80 years

Correct answer: Recent intracranial surgery within 3 months

Recent intracranial surgery, head trauma, or prior stroke within 3 months is an absolute contraindication to IV tPA because of the risk of catastrophic hemorrhage.

Question 159: Which of the following is the safest antidepressant choice during pregnancy when treatment is necessary?

Paroxetine
Sertraline (Correct answer)
Phenelzine
Nortriptyline

Correct answer: Sertraline

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

Question 160: A 60-year-old man with a history of alcohol use presents with acute pancreatitis. His lipase is 1,200 U/L and CT shows peripancreatic fat stranding but no necrosis. What is the Revised Atlanta Classification severity?

Mild acute pancreatitis (Correct answer)
Severe acute pancreatitis
Moderately severe acute pancreatitis
Critical acute pancreatitis

Correct answer: Mild acute pancreatitis

Mild acute pancreatitis has no organ failure and no local or systemic complications, resolving within the first week.

Question 161: Which GLP-1 receptor agonist is approved for weight management in non-diabetic obese patients?

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

Correct answer: Semaglutide (2.4 mg subcutaneous weekly)

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

Question 162: Which approach best demonstrates mastery of endocrinology in PANRE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 163: Which organism is the most common cause of septic arthritis in adults under 30 years old?

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

Correct answer: Neisseria gonorrhoeae

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

Question 164: A 35-year-old man presents with a new 7 mm pigmented lesion with asymmetry, irregular borders, two colors (brown and black), and recent size change. The ABCDE criteria suggest malignancy. What is the next best step?

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

Correct answer: Excisional biopsy with 1–3 mm margins

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

Question 165: What is the most common cause of acute kidney injury (AKI) in hospitalized patients?

Contrast nephropathy
Acute interstitial nephritis
Prerenal azotemia (Correct answer)
Obstructive uropathy

Correct answer: Prerenal azotemia

Prerenal azotemia due to volume depletion, hypotension, or reduced cardiac output is the most common cause of AKI in hospitalized patients.

Question 166: A patient on warfarin for atrial fibrillation has an INR of 9.2 with active major bleeding. Which intervention is most appropriate?

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

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

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

Question 167: Which of the following best describes the mechanism of action of lactulose in hepatic encephalopathy?

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

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

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

Question 168: A 55-year-old woman presents with fatigue, arthralgias, and elevated transaminases (AST/ALT 3× ULN). ANA titer is 1:320 and anti-smooth muscle antibody is positive. Liver biopsy shows interface hepatitis. What is the diagnosis?

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

Correct answer: Autoimmune hepatitis

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

Question 169: A patient on long-term lithium therapy develops polyuria and polydipsia. What endocrine complication should be suspected?

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

Correct answer: Nephrogenic diabetes insipidus

Lithium causes nephrogenic diabetes insipidus by impairing the kidney's response to ADH, typically presenting with polyuria, polydipsia, and dilute urine.

Question 170: What is the value of continuing education in dermatology for PANRE professionals?

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

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

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

Question 171: A 55-year-old with chronic cough undergoes bronchoscopy revealing endobronchial lesion. Biopsy shows small cells with high nuclear-to-cytoplasm ratio and crush artifact. Which treatment is most appropriate?

Radiation therapy alone
Targeted therapy with EGFR inhibitor
Surgical lobectomy
Chemotherapy with etoposide and platinum (Correct answer)

Correct answer: Chemotherapy with etoposide and platinum

Small cell lung cancer is managed with platinum-based chemotherapy (etoposide + cisplatin/carboplatin) as it is highly sensitive to chemotherapy but rarely curable surgically.

Question 172: In PANRE practice, what is the best approach to quality improvement in dermatology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 173: A 68-year-old man undergoes colonoscopy and is found to have a 25 mm pedunculated polyp in the transverse colon. Pathology shows invasive adenocarcinoma confined to the stalk with clear margins. What is the most appropriate next step?

Radiation therapy
No additional surgery if resection margins are clear and no high-risk features (Correct answer)
Immediate right hemicolectomy
Repeat colonoscopy in 3 months

Correct answer: No additional surgery if resection margins are clear and no high-risk features

Pedunculated polyps with invasive cancer at clear margins, no lymphovascular invasion, and well-differentiated histology can be managed endoscopically without surgery.

Question 174: A 28-year-old woman at 10 weeks gestation presents with severe nausea, vomiting, and weight loss of 8 pounds. Urine shows ketonuria. What is the diagnosis?

Cholecystitis
Appendicitis
Hyperemesis gravidarum (Correct answer)
Gastroenteritis

Correct answer: Hyperemesis gravidarum

Hyperemesis gravidarum is defined by intractable vomiting in pregnancy causing dehydration, ketonuria, and weight loss exceeding 5% of pre-pregnancy weight.

Question 175: Which medication class is first-line for reducing proteinuria and slowing progression of diabetic nephropathy?

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

Correct answer: ACE inhibitors or ARBs

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

Question 176: A 33-year-old woman at 16 weeks gestation has a serum alpha-fetoprotein (AFP) of 3.2 MOM. What is the most appropriate next step?

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

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

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

Question 177: A 50-year-old diabetic male presents with painless swelling, deformity, and instability of the ankle without history of trauma. Radiographs show joint destruction, fragmentation, and new bone formation. What is the most likely diagnosis?

Osteonecrosis
Septic arthritis
Osteoarthritis
Charcot arthropathy (Correct answer)

Correct answer: Charcot arthropathy

Charcot arthropathy (neuropathic joint) occurs in patients with peripheral neuropathy, causing progressive joint destruction due to loss of protective sensation.

Question 178: Which approach best demonstrates mastery of cardiology in PANRE practice?

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

Correct answer: Applying principles to novel situations with sound judgment

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

Question 179: A 16-year-old male presents with knee pain after playing basketball. Examination reveals tenderness at the tibial tuberosity. X-ray shows soft tissue swelling with irregular ossification. What is the diagnosis?

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

Correct answer: Osgood-Schlatter disease

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

Question 180: A 68-year-old man presents with acute onset painless monocular vision loss described as a 'curtain coming down.' Fundoscopic exam shows a pale retina with a cherry-red spot. What is the diagnosis?

Acute angle-closure glaucoma
Retinal detachment
Central retinal artery occlusion (Correct answer)
Central retinal vein occlusion

Correct answer: Central retinal artery occlusion

A pale retina with a cherry-red spot at the macula is pathognomonic of central retinal artery occlusion, an ophthalmic emergency.

Question 181: A 50-year-old man with long-standing GERD undergoes surveillance endoscopy revealing Barrett's esophagus with high-grade dysplasia. What is the recommended management?

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

Correct answer: Endoscopic eradication therapy (radiofrequency ablation)

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

Question 182: Which antibiotic is the drug of choice for Rocky Mountain Spotted Fever in all age groups, including children?

Azithromycin
Doxycycline (Correct answer)
Ciprofloxacin
Amoxicillin

Correct answer: Doxycycline

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

Question 183: A patient with suspected pheochromocytoma should be screened using which initial test?

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

Correct answer: 24-hour urine catecholamines and metanephrines

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

Question 184: A 35-year-old woman with PCOS is anovulatory and desires conception. After lifestyle modification fails, what is the first-line pharmacologic ovulation induction agent?

Clomiphene citrate
Gonadotropins
Metformin
Letrozole (Correct answer)

Correct answer: Letrozole

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

Question 185: A 72-year-old woman on warfarin for atrial fibrillation is started on fluconazole. What is the expected effect?

Decreased INR due to vitamin K competition
Increased INR due to CYP2C9 inhibition (Correct answer)
Decreased INR due to CYP2C9 induction
No change in INR

Correct answer: Increased INR due to CYP2C9 inhibition

Fluconazole inhibits CYP2C9, which metabolizes warfarin's S-enantiomer, leading to elevated INR and bleeding risk.

Question 186: Which lab finding is most characteristic of primary biliary cholangitis (PBC)?

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

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

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

Question 187: CSF analysis shows neutrophilic pleocytosis, elevated protein, and markedly decreased glucose. What is the most likely diagnosis?

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

Correct answer: Bacterial meningitis

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

Question 188: A patient on lithium for 10 years presents with coarse tremor, ataxia, and confusion. His lithium level is 2.4 mEq/L. What is the priority intervention?

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

Correct answer: Hemodialysis

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

Question 189: Which urinalysis finding is pathognomonic for acute tubular necrosis (ATN)?

White blood cell casts
Red blood cell casts
Fatty casts
Granular (muddy brown) casts (Correct answer)

Correct answer: Granular (muddy brown) casts

Granular 'muddy brown' casts result from sloughed tubular epithelial cells and are pathognomonic for acute tubular necrosis.

Question 190: A child develops fever, malaise, and a bright red 'slapped cheek' rash followed by a lacy reticular rash on the trunk. What is the causative agent?

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

Correct answer: Parvovirus B19

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

Question 191: A 44-year-old man presents with jaundice, pruritus, and an elevated alkaline phosphatase. MRCP shows multifocal strictures of both intrahepatic and extrahepatic bile ducts with a 'beaded' appearance. What is the most likely diagnosis?

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

Correct answer: Primary sclerosing cholangitis

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

Question 192: Which finding on nerve conduction studies best distinguishes demyelinating neuropathy from axonal neuropathy?

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

Correct answer: Slowed conduction velocity with conduction block

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

Question 193: A 62-year-old woman presents with a pelvic organ prolapse bulging beyond the introitus, bladder symptoms, and significant quality-of-life impairment. She fails pessary management. What is the most appropriate next step?

Surgical repair (Correct answer)
Topical estrogen and reassurance
Pelvic floor physical therapy alone
Anticholinergic medication

Correct answer: Surgical repair

Symptomatic prolapse that fails conservative management (pessary, pelvic PT) with significant quality-of-life impact is an indication for surgical repair.

Question 194: Which test best distinguishes central (secondary) diabetes insipidus from nephrogenic diabetes insipidus?

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

Correct answer: Response to desmopressin (DDAVP) administration

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

Question 195: Which approach best demonstrates mastery of pulmonology in PANRE practice?

Following procedures without understanding
Relying entirely on technology
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 196: What is the most common cause of community-acquired bacterial meningitis in adults in the United States?

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

Correct answer: Streptococcus pneumoniae

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

Question 197: Which approach best demonstrates mastery of gastroenterology in PANRE practice?

Relying entirely on technology
Applying principles to novel situations with sound judgment (Correct answer)
Following procedures without understanding
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 198: What role does collaboration play in psychiatry for PANRE professionals?

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

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

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

Question 199: A 40-year-old male construction worker presents with pain in the first metatarsophalangeal joint after 3 days of high-purine diet and alcohol use. Joint aspiration reveals negatively birefringent, needle-shaped crystals. What is the treatment?

Indomethacin
Probenecid
Allopurinol
Colchicine or NSAIDs (Correct answer)

Correct answer: Colchicine or NSAIDs

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

Question 200: A patient with schizophrenia on haloperidol develops sustained muscle contractions of the neck. Which medication should be given immediately?

Benztropine
Propranolol
Diphenhydramine IV (Correct answer)
Lorazepam

Correct answer: Diphenhydramine IV

Acute dystonic reactions respond rapidly to IV diphenhydramine or IM benztropine; IV diphenhydramine acts fastest.

Question 201: Which approach best demonstrates mastery of psychiatry in PANRE 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 202: A 24-year-old African American male develops hemolytic anemia and hemoglobinuria after being prescribed dapsone for dermatitis herpetiformis. Peripheral smear shows Heinz bodies. What is the underlying defect?

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

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

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

Question 203: What is the most important professional competency for PANRE certification in orthopedics?

Ability to work alone exclusively
Memorization of all reference materials
Speed of task completion
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 204: A 28-year-old woman presents with bloody diarrhea, tenesmus, and urgency. Colonoscopy shows continuous mucosal inflammation starting from the rectum. Biopsy shows crypt abscesses. What is the diagnosis?

Crohn's colitis
Ischemic colitis
Infectious colitis
Ulcerative colitis (Correct answer)

Correct answer: Ulcerative colitis

Continuous inflammation starting from the rectum with crypt abscesses on biopsy is the hallmark presentation of ulcerative colitis.

Question 205: A 55-year-old man with a 30-pack-year smoking history presents with hemoptysis and a coin lesion on chest X-ray. PET scan shows no uptake. What is the next best step?

Surgical resection without biopsy
Repeat chest X-ray in 6 months
Bronchoscopy with BAL
CT-guided needle biopsy (Correct answer)

Correct answer: CT-guided needle biopsy

A solitary pulmonary nodule in a high-risk smoker with no PET activity requires tissue diagnosis; CT-guided needle biopsy is the most direct approach.

Question 206: Which of the following diuretics inhibits chloride reabsorption in the ascending loop of Henie while treating hypertension?

Triamterene
Spironolactone
Furosemide (Correct answer)
Acetazolamide

Correct answer: Furosemide

Furosemide is a loop diuretic that primarily acts on the thick ascending limb of the loop of Henle. It inhibits the Na+/K+/2Cl- cotransporter, which is responsible for reabsorbing chloride, sodium, and potassium ions. By blocking this transporter, furosemide prevents chloride reabsorption, leading to increased excretion of these electrolytes and water, making it effective in treating hypertension and edema.

Question 207: What role does collaboration play in neurology for PANRE 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 208: A patient with stable angina is intolerant of beta-blockers and nitrates. Which agent is an appropriate alternative for angina prophylaxis?

Ranolazine
Either B or C (Correct answer)
Aspirin 325 mg daily
Ivabradine (if sinus rhythm and HR >70)

Correct answer: Either B or C

Both ranolazine (reduces late Na current, improving diastolic relaxation) and ivabradine (If channel blocker reducing HR) are approved alternatives for angina when first-line agents are not tolerated.

Question 209: A 40-year-old woman has menorrhagia and a uterus enlarged to 12 weeks size with multiple fibroids. She has completed childbearing. She wants a definitive solution. What is the most appropriate option?

Endometrial ablation
Hysterectomy (Correct answer)
Uterine fibroid embolization
GnRH agonist therapy

Correct answer: Hysterectomy

Hysterectomy is the definitive treatment for symptomatic uterine fibroids in a woman who has completed childbearing and wants no further pregnancies.

Question 210: What is the most important professional competency for PANRE certification in cardiology?

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

Correct answer: Deep knowledge combined with practical application skills

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

Question 211: A patient receiving unfractionated heparin for 8 days develops a platelet count drop from 230,000 to 65,000/μL and a new arterial thrombosis. What is the most appropriate next step?

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

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

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

Question 212: A 58-year-old male with known COPD presents with increasing dyspnea, pursed-lip breathing, and SpO2 of 82% on room air. His PCO2 is 68 mmHg. What is the preferred initial ventilatory support?

Immediate endotracheal intubation
High-flow oxygen via non-rebreather mask
Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
Nasal cannula at 2 L/min only

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

BiPAP reduces the work of breathing in COPD exacerbation and has been shown to decrease intubation rates and mortality compared to standard oxygen therapy.

Question 213: What is the causative organism of pertussis (whooping cough)?

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

Correct answer: Bordetella pertussis

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

Question 214: A 55-year-old presents with sudden-onset tearing chest pain radiating to the back. BP is 180/100 in the right arm and 140/80 in the left arm. CT angiography is ordered. What is the most likely diagnosis?

Type A aortic dissection (Correct answer)
Pulmonary embolism
Boerhaave syndrome
Myocardial infarction

Correct answer: Type A aortic dissection

Tearing chest pain with inter-arm blood pressure differential strongly suggests aortic dissection; Type A involves the ascending aorta and requires emergent surgery.

Question 215: Which professional attribute is most valued in neurology within the PANRE field?

Prioritizing personal convenience
Avoiding challenging situations
Accountability and commitment to standards (Correct answer)
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 216: Which professional attribute is most valued in endocrinology within the PANRE field?

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

Correct answer: Accountability and commitment to standards

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

Question 217: A 25-year-old presents with fever, headache, and a rash that began on the wrists and ankles and spread centrally after a tick exposure. What is the most likely diagnosis?

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

Correct answer: Rocky Mountain Spotted Fever

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

Question 218: Which vaccine is routinely recommended for all healthcare workers due to occupational exposure risk?

Hepatitis B (Correct answer)
Hepatitis A
HPV
Pneumococcal

Correct answer: Hepatitis B

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

Question 219: Which electrolyte abnormality is most commonly associated with hypomagnesemia?

Hypernatremia
Hypokalemia (Correct answer)
Hyperkalemia
Hypercalcemia

Correct answer: Hypokalemia

Hypomagnesemia frequently causes refractory hypokalemia because magnesium is required for proper potassium reabsorption in the kidney; replace magnesium first.

Question 220: In PANRE practice, what is the best approach to quality improvement in endocrinology?

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

Correct answer: Use data-driven methods with measurable outcomes

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

Question 221: Which of the following drugs increased insulin release from pancreatic beta cells, hence lowering plasma glucose levels?

Pioglitazone
Glyburide (Correct answer)
Metformin
Acarbose

Correct answer: Glyburide

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

Question 222: A patient on isoniazid therapy develops peripheral neuropathy. Which supplement is deficient?

Folate
Vitamin B12
Vitamin B6 (pyridoxine) (Correct answer)
Vitamin D

Correct answer: Vitamin B6 (pyridoxine)

Isoniazid competitively inhibits pyridoxine (B6) metabolism, causing a sensory-predominant peripheral neuropathy that is prevented by B6 supplementation.

Question 223: A patient on clozapine develops a WBC of 2,800/mm³. What is the correct action?

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

Correct answer: Discontinue clozapine immediately

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

Question 224: A 45-year-old woman presents with episodic hypertension, headache, diaphoresis, and palpitations. Which initial test is most appropriate?

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

Correct answer: 24-hour urine catecholamines and metanephrines

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

Question 225: A patient with suspected pulmonary embolism has a Wells score of 6. D-dimer is elevated. What is the best next diagnostic step?

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

Correct answer: Obtain CT pulmonary angiography (CTPA)

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

Question 226: A 45-year-old patient with immune thrombocytopenic purpura (ITP) has a platelet count of 8,000/μL and is actively bleeding from the gums. Which is the most appropriate initial management?

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

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

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

Question 227: A 55-year-old with a history of small cell lung cancer presents with proximal muscle weakness, reduced reflexes that improve with repeated stimulation, and autonomic dysfunction. Diagnosis?

Lambert-Eaton myasthenic syndrome (Correct answer)
Polymyositis
Myasthenia gravis
Eaton-Lambert syndrome due to ALS

Correct answer: Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome is a paraneoplastic disorder most associated with small cell lung cancer; reflexes and strength paradoxically improve with repetitive activity.

Question 228: Per current CDC guidelines, uncomplicated gonorrhea in an adult weighing less than 150 kg is treated with which single-dose regimen?

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

Correct answer: Ceftriaxone 500 mg IM once

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

Question 229: A 35-year-old woman notes symmetric hyperpigmented patches on her cheeks and upper lip that worsen during summer and pregnancy. She is on oral contraceptives. What is the recommended first-line treatment?

Laser therapy with Q-switched Nd:YAG
Topical tretinoin 0.1% alone
Chemical peel with TCA 25%
Topical hydroquinone 4% + sun protection (Correct answer)

Correct answer: Topical hydroquinone 4% + sun protection

Hydroquinone 4% combined with strict photoprotection is first-line for melasma; the triple combination (hydroquinone + tretinoin + mild corticosteroid) is more effective for resistant cases.

Question 230: A 48-year-old woman presents with hot flashes, night sweats, and irregular menses for 14 months. FSH is 58 mIU/mL. She denies a history of VTE or breast cancer. What is the most effective treatment for her vasomotor symptoms?

Clonidine
Menopausal hormone therapy (Correct answer)
Venlafaxine
Black cohosh

Correct answer: Menopausal hormone therapy

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

Question 231: A post-surgical ICU patient develops DIC. Labs show: PT prolonged, PTT prolonged, fibrinogen 80 mg/dL, D-dimer markedly elevated, platelet count 42,000/μL, and schistocytes on smear. What is the most critical initial management step?

Administer heparin to prevent further clotting
Platelet transfusion alone
Treat the underlying cause and replace clotting factors with FFP and cryoprecipitate (Correct answer)
Administer tranexamic acid immediately

Correct answer: Treat the underlying cause and replace clotting factors with FFP and cryoprecipitate

DIC treatment centers on addressing the precipitating cause while supporting coagulation with FFP (for clotting factors) and cryoprecipitate (for fibrinogen) and platelets as needed.

Question 232: Oseltamivir for influenza is most effective when started within how many hours of symptom onset?

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

Correct answer: 48 hours

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

Question 233: A 32-year-old woman presents with recurrent unprovoked DVTs. Labs show a prolonged aPTT that does not correct on mixing study. Which condition is most likely?

Antithrombin III deficiency
Antiphospholipid syndrome (Correct answer)
Factor V Leiden mutation
Protein C deficiency

Correct answer: Antiphospholipid syndrome

A prolonged aPTT that fails to correct on mixing study suggests an inhibitor (antibody), most consistent with lupus anticoagulant in antiphospholipid syndrome.

Question 234: A patient with chronic liver disease develops sudden onset abdominal pain, fever, and ascitic fluid PMN count >250 cells/mm³. What is the empiric antibiotic of choice?

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

Correct answer: Cefotaxime or ceftriaxone

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

Question 235: A patient describes feeling detached from their own body and mind, as if they are an outside observer, for several weeks. Which condition best describes this?

Derealization disorder
Depersonalization/derealization disorder (Correct answer)
Dissociative amnesia
Schizotypal personality disorder

Correct answer: Depersonalization/derealization disorder

Persistent depersonalization (detachment from self) with intact reality testing defines depersonalization/derealization disorder.

Question 236: A 60-year-old woman with a history of breast cancer presents with hypercalcemia, constipation, polyuria, and confusion. Calcium is 13.5 mg/dL. What is the first treatment?

Furosemide
IV bisphosphonates
Calcitonin
IV normal saline hydration (Correct answer)

Correct answer: IV normal saline hydration

IV normal saline is the first-line treatment for hypercalcemia to restore volume depletion and promote renal calcium excretion.

Question 237: A patient presents with acute adrenal crisis. What is the immediate treatment?

Fludrocortisone 0.1 mg orally
IV dexamethasone 4 mg followed by IV fluids
IV hydrocortisone 100 mg plus aggressive IV normal saline (Correct answer)
Oral hydrocortisone 20 mg

Correct answer: IV hydrocortisone 100 mg plus aggressive IV normal saline

Adrenal crisis requires immediate IV hydrocortisone 100 mg (stress dose) and aggressive IV saline resuscitation; dexamethasone can be used if cortisol stimulation test is needed first.

Question 238: Which of the following symptoms is NOT part of the DSM-5 criteria for major neurocognitive disorder (dementia)?

Cognitive deficits that interfere with daily independence
Decline from prior level of functioning
Impairment in one or more cognitive domains
Acute onset over hours (Correct answer)

Correct answer: Acute onset over hours

Acute onset suggests delirium, not dementia; major NCD requires gradual onset and progressive decline.

Question 239: A 22-year-old presents with perioral tingling, carpopedal spasm, and a positive Trousseau's sign after hyperventilating due to anxiety. What is the most likely electrolyte abnormality?

Hypomagnesemia
Hyperkalemia
Hypocalcemia (Correct answer)
Hypernatremia

Correct answer: Hypocalcemia

Hyperventilation causes respiratory alkalosis, which increases protein binding of calcium, leading to symptomatic hypocalcemia with tetany and a positive Trousseau's sign.

Question 240: A 28-year-old presents with 2 weeks of depressed mood, insomnia, poor concentration, and passive suicidal ideation after a romantic breakup. She denies psychosis. What is the diagnosis?

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

Correct answer: Major depressive episode

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

Question 241: A 55-year-old male presents with dysphagia to solids only that has progressively worsened over 6 months along with a 15-pound weight loss. Which diagnosis is most concerning?

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

Correct answer: Esophageal carcinoma

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

Physician Assistant National Recertifying Examination (PANRE)

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

240

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240 min

Time Limit

70%

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