180 Question Advanced PANCE and PANRE Practice Exams

Psoriasis is a chronic skin condition characterized by well-demarcated plaques with silvery scales, commonly located on the elbows, knees, scalp, and lower back. The description of the rash in this patient, particularly the presence of silvery scales and the tendency to bleed when scratched (Auspitz sign), is highly indicative of psoriasis. Psoriasis is an autoimmune condition and can be associated with joint pain in some individuals (psoriatic arthritis). (Review Blueprint Topic: Psoriasis)

Streptococcus pneumonia tends to cause a lobar or segmental consolidation.

Polycystic kidney disease is a kidney disorder passed down through families in which many cysts form in the kidneys, causing them to become enlarged. PKD can also cause cysts in the liver and problems in other organs, such as blood vessels in the brain and heart. The number of cysts as well as the complications they cause help doctors distinguish PKD from the usually harmless "simple" cysts that often form in the kidneys in later years of life.

Nearly every organ system can be affected by cocaine toxicity. Aside from alcohol (and not including tobacco-related illnesses), cocaine is the most common cause of drug-related emergency department (ED) visits in the United States. There are 3 reported phases of acute cocaine toxicity. In fatal cases, the onset and progression are accelerated, with convulsions and death frequently occurring in 2-3 minutes, though sometimes in 30 minutes. Learn More  

Treatment of gastroesophageal reflux disease involves a stepwise approach. The goals are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modification and control of gastric acid secretion through medical therapy with antacids or proton pump inhibitors or surgical treatment with corrective antireflux surgery. Learn More

JONES CRITERIA:   Major criteria:

• Joint (arthritis)
• Obvious (Cardiac)
• Nodule (Rheumatic)
• Erythema marginatum
• Sydenham chorea

Minor criteria:

• Inflammatory cells (leukocytosis)
• Temperature (fever)
• ESR/CRP elevated
• Raised PR interval
• Itself (previous Hx of Rheumatic fever)
• Arthralgia

Penicillin antibiotics are the most common cause of drug allergies. Some people who are allergic to penicillin are also allergic to other closely related antibiotics, including cephalosporins, such as cephalexin, cefprozil, and cefuroxime. Many people who believe that they have an allergy to penicillin do not. They currently may be less sensitive to penicillin than they were in the past. Or they may have had an adverse reaction, such as a side effect, rather than an allergic reaction. A skin test is the best way to find out whether you have a penicillin allergy.

Burn Injury Fluid Resuscitation, Adult (Parkland crystalloid estimate) Total Crystalloid For First 24 Hours = 4 (x ) Weight (x) Percent Nonsuperficial BurnArea Learn More

• Early congenital syphilis occurs within the first 2 years of life.
• Late congenital syphilis emerges in children older than 2 years.

Congenital syphilis is syphilis present in utero and at birth, and occurs when a child is born to a mother with secondary syphilis. Untreated syphilis results in a high risk of a poor outcome of pregnancy, including mulberry molars in the fetus. Syphilis can cause miscarriages, premature births, stillbirths, or death of newborn babies. Some infants with congenital syphilis have symptoms at birth, but most develop symptoms later. Untreated babies can have deformities, delays in development, or seizures along with many other problems such as rash, fever, hepatosplenomegaly, anemia, and jaundice. Sores on infected babies are infectious. Rarely, the symptoms of syphilis go unseen in infants so that they develop the symptoms of late-stage syphilis, including damage to their bones, teeth, eyes, ears, and brain.

A pterygium is an elevated, superficial, external ocular mass that usually forms over the perilimbal conjunctiva and extends onto the corneal surface. Pterygia can vary from small, atrophic quiescent lesions to large, aggressive, rapidly growing fibrovascular lesions that can distort the corneal topography, and, in advanced cases, they can obscure the optical center of the cornea.

Medulloblastoma (seen in the image below) is the most common malignant brain tumor in children, accounting for 10-20% of primary CNS neoplasms and approximately 40% of all posterior fossa tumors. Learn more

Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children, representing nearly one third of all pediatric cancers. Children with acute lymphoblastic leukemia (ALL) often present with signs and symptoms that reflect bone marrow infiltration and/or extramedullary disease. When leukemic blasts replace the bone marrow, patients present with signs of bone marrow failure, including anemia, thrombocytopenia, and neutropenia.  Learn More

Of interest, studies have shown that there is a 10% decrease in relative risk for every 1% reduction in A1c. So, if a patients starts off with an A1c of 10.7 and drops to 8.2, though they are not yet at goal, they have managed to decrease their risk of microvascular complications by about 20%. The closer to normal the A1c, the lower the absolute risk for microvascular complications.

Cholangitis is an infection of the biliary tract with the potential to cause significant morbidity and mortality. Many patients with acute cholangitis respond to antibiotic therapy; however, patients with severe or toxic cholangitis may not respond and may require emergency biliary drainage. Jean M. Charcot recognized this illness in 1877 when he described a triad of fever, jaundice, and right upper quadrant pain. In 1959, Reynolds and Dargon described a more severe form of the illness that included the additional components of septic shock and mental confusion, which is referred to as the Reynolds pentad. Learn More

Chadwick's sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. It is considered an indication of pregnancy, and can be observed as early as 6–8 weeks after conception, and its presence is an early sign of pregnancy. These color changes were discovered in approximately 1836 by French doctor Étienne Joseph Jacquemin (1796-1872), and are named after James Read Chadwick, who drew attention to it in a paper read before the American Gynecological Society in 1886 and published in the following year, wherein he credited Jacquemin for their discovery.

To gain an understanding of pediatric third-degree acquired atrioventricular (AV) block (AVB), one must first understand the concepts behind AV blocks. In general, AV block refers to a conduction delay or interruption of the impulses generated in the atrium before they reach the ventricles. AV block may be transient or permanent, and the anatomic level at which it occurs varies. These features determine the clinical significance of this condition, which may range from minimal to severely symptomatic, including Stokes-Adams syncope, congestive heart failure, or sudden death.

Allopurinol blocks xanthine oxidase and thus reduces the generation of uric acid. Approximately 3-10% of patients taking allopurinol develop symptoms of intolerance, such as dyspepsia, headache, diarrhea, or pruritic maculopapular rash.

Plasma renin activity (PRA), also known as the renin (active) assay or random plasma renin, is a measure of the activity of the plasma enzyme renin, which plays a major role in the body's regulation of blood pressure, thirst, and urine output. PRA is sometimes measured, specially in case of certain diseases which present with hypertension or hypotension. This is not recommended as a baseline test for our patient above.

Dizziness and vertigo are common clinical complaints. Vertigo is caused by a disturbed vestibular system and is subdivided into peripheral vertigo (due to failure of the end organs) or central vertigo (due to failure of the vestibular nerves or central connections to the brainstem and cerebellum).

In almost all patients in whom stones form, an increase in fluid intake and, therefore, an increase in urine output is recommended. This is likely the single most important aspect of stone prophylaxis. Patients with recurrent nephrolithiasis traditionally have been instructed to drink 8 glasses of fluid daily to maintain adequate hydration and decrease chance of urinary supersaturation with stone-forming salts. The goal is a total urine volume in 24 hours in excess of 2 liters. The only other general dietary guidelines are to avoid excessive salt and protein intake. Moderation of calcium and oxalate intake is also reasonable, but great care must be taken not to indiscriminately instruct the patient to reduce calcium intake. Dietary calcium should not be restricted beyond normal unless specifically indicated based on 24-hour urinalysis findings. Urinary calcium levels are normal in many patients with calcium stones. Reducing dietary calcium in these patients may actually worsen their stone disease, because more oxalate is absorbed from the GI tract in the absence of sufficient intestinal calcium to bind with it. This results in a net increase in oxalate absorption and hyperoxaluria, which tends to increase new kidney stone formation in patients with calcium oxalate calculi. An empiric restriction of dietary calcium may also adversely affect bone mineralization and may have osteoporosis implications, especially in women. This practice should be condemned unless indicated based on a metabolic evaluation. As a rule, dietary calcium should be restricted to 600-800 mg/d in patients with diet-responsive hypercalciuria who form calcium stones. This is roughly equivalent to a single high-calcium or dairy meal per day. Learn More

Typical antipsychotics (e.g., haloperidol, chlorpromazine, fluphenazine) can produce extrapyramidal symptoms (EPS) via blockade of dopamine (D2) receptors in the nigrostriatum. Symptoms can include akinesia, bradykinesia, mask-like facial expression, tremor, cogwheel rigidity, and postural abnormalities. Tardive dyskinesia may also occur.

Down syndrome is by far the most common and best known chromosomal disorder in humans and the most common cause of intellectual disability. It is primarily caused by trisomy of chromosome 21, which gives rise to multiple systemic complications as part of the syndrome. However, not all defects occur in each patient; there is a wide range of phenotypic variation.

Pericardial effusion is the presence of an abnormal amount of fluid and/or an abnormal character to fluid in the pericardial space. It can be caused by a variety of local and systemic disorders, or it may be idiopathic.

Blastomycosis is a common infection among dogs in endemic areas. It may serve as an indicator of human disease because of the shared environment. Blastomycosis is reported in other animals, including the horse, cow, cat, bat, and lion. Chest radiograph from a patient with pulmonary blastomycosis demonstrates multiple nodular lesions, some of which are cavitating, in the left lower lobe. Cavitation occurs in 15-20% of patients with blastomycosis.

Multifocal atrial tachycardia (MAT) is a cardiac arrhythmia caused by multiple sites of competing atrial activity. It is characterized by an irregular atrial rate greater than 100 beats per minute (bpm). Atrial activity is well organized, with at least 3 morphologically distinct P waves, irregular P-P intervals, and an isoelectric baseline between the P waves. Learn More

Fetal warfarin syndrome (Dysmorphism due to warfarin, Warfarin embryopathy ) is a condition associated with the administration of Warfarin during pregnancy. Associated conditions include hypoplasia of nasal bridge, laryngomalacia, pectus carinatum, congenital heart defects, ventriculomegaly, agenesis of the corpus callosum, stippled epiphyses, telebrachydactyly, and growth retardation. It is also known as "DiSala syndrome". The symptoms are as follows:

• Nasal hypoplasia
• Depressed nasal bridge
• Deep groove between the nostril and nasal tip
• Stippling of uncalcified epiphyses during the first year
• Mild hypoplasia of nails
• Shortened fingers
• Low birth weight
• Significant mental retardation
• Seizures
• Reduced muscle tone
• Widely spaced nipples
• Deafness
• Feeding difficulty
• Failure to thrive

Argyll Robertson pupils (“AR pupils” or colloquially as"Prostitute's Pupil") are bilateral small pupils that reduce in size when the patient focuses on a near object (they “accommodate”), but do not constrict when exposed to bright light (they do not “react” to light). They are a highly specific sign of neurosyphilis, and might also be a sign of diabetic neuropathy.

The therapeutic range for valproic acid (total) is 50-125 µg/mL. The toxic level is greater than 150 µg/mL.

This is Prinzmetal's Angina Prinzmetal's angina should be suspected any time a person has severe chest pain accompanied by dramatic ECG changes, but a cardiac catheterization shows apparently normal coronary arteries. Once the diagnosis is suspected, the cardiologist usually performs what is called "provocative testing," to show whether coronary artery spasm can be induced. If so, Prinzmetal's angina can be definitively diagnosed. Two types of "provocation" are often used to attempt to induce coronary artery spasm - hyperventilation, and ergonovine.

Clotting is the end result of a complex series of enzymatic reactions involving clotting factors, all of which are produced in the liver except factor VIII, which is produced by vascular endothelial cells. The prothrombin time is a measure of the rate at which prothrombin is converted to thrombin, reflecting the extrinsic pathway of coagulation. Factors involved in the synthesis of prothrombin include II, V, VII, and X Measurement of the prothrombin time in patients with liver disease is most useful in cases of acute liver disease. Unlike the serum albumin, the prothrombin time allows an assessment of current hepatic synthetic function; factor VII has the shortest serum half-life (six hours) of all the clotting factors.

Effectiveness figures are based on 100 couples using the method for a year and show the percentage of women who do not get pregnant while using the method for 1 year.

METHOD	USE EFFECTIVENESS (Actual Use)	THEORETICAL  EFFECTIVENESS  (Perfect Use)
EVRA PATCH	92%	99.7%
PILL - Combined - Progestin	92% 92%	99.7% 99.7%
NUVARING	92%	99.7%
IUD Copper T Levonorgestrel (Mirena)	99.2% 99.9%	99.4% 99.9%
DIAPHRAGM & SPERMICIDE	84%	94%
SPERMICIDE & MALE CONDOMS**	no confirmed data	99%
FEMALE CONDOM ALONE	79%	95%
MALE CONDOM ALONE	85%	98%
SPERMICIDES***	71%	82%
TUBAL LIGATION	99.5%	99.5%
VASECTOMY	99.85%	99.9%
CERVICAL CAP Woman has had children Woman has not had children	68% 84%	74% 91%
DEPO-PROVERA	97%	99.95%
SPONGE Woman has had children Woman has not had children	68% 84%	80% 91%
FERTILITY AWARENESS METHOD	75%	95-97%
WITHDRAWAL	73%	96%
NO METHOD (CHANCE)	15%	15%

*Adapted from Contraceptive Technology, 19th Revised Edition

Mitral stenosis (MS) is characterized by obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve apparatus. The most common cause of mitral stenosis is rheumatic fever. Other less common etiologies include congenital mitral stenosis, malignant carcinoid disease, systemic lupus erythematosus, rheumatoid arthritis, mucopolysaccharidoses of the Hunter-Hurler phenotype, Fabry disease, Whipple disease, and methysergide therapy.

Bony bumps on the finger joint closest to the fingernail are called Heberden's nodes. Bony bumps on the middle joint of the finger are known as Bouchard's nodes.

Excess deaths from bladder, stomach, lung, hematopoietic, and other cancers have occurred among workers involved in the manufacture of rubber products. These workers may also risk adverse respiratory effects, dermatologic effects, reproductive effects, injuries, and repetitive trauma disorders. The adverse health effects cannot be attributed to a single chemical or group of chemicals because workplace exposures vary greatly and chemical formulations change frequently. Epidemiologic, toxicologic, and industrial hygiene studies are needed to assess the risk of cancer and other adverse health effects for rubber products workers. Learn More

This patient has a common viral syndrome. Antibiotics or amantadine are not warranted.

Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process. Although these are not strictly speaking tumours or cancers they can still cause significant problems because of their erosive and expansile properties resulting in the destruction of the ossicles as well as their possible spread through the base of the skull into the brain. They are also often infected and result in chronically draining ears.

Immunologic parameters include autoantibodies (eg, RF, anti-CCP antibodies, and ANAs). RF is an immunoglobulin (Ig) M antibody directed against the Fc fragment of IgG that is present in approximately 60-80% of patients with RA over the course of their disease (but in fewer than 40% of patients with early RA). RF values fluctuate somewhat with disease activity, though titers of RF generally remain high even in patients with drug-induced remissions. RF is not specific for RA but is also present in other connective tissue diseases, infections, and autoimmune disorders, as well as in 1-5% of healthy people. The presence of RF predicts radiographic progression of bone erosions, independent of disease activity. Learn More

Duodenal atresia is the congenital absence or complete closure of a portion of the lumen of the duodenum. It causes increased levels of amniotic fluid during pregnancy (polyhydramnios) and intestinal obstruction in newborn babies. Radiography shows a distended stomach and distended duodenum, which are separated by the pyloric valve, a finding described as the "double-bubble sign."

Symptoms of mitral stenosis usually manifest during the third or fourth decade of life and nearly half of the patients do not recall a history of acute rheumatic fever. Patients are generally asymptomatic at rest during the early stage of the disease. However, factors that increase heart rate such as fever, severe anemia, thyrotoxicosis, exercise, excitement, pregnancy, and atrial fibrillation may result in dyspnea. Nearly 15% of patients develop embolic episodes that are usually associated with atrial fibrillation. Rarely, embolic episodes may occur even in the patient with sinus rhythm. Systemic embolization may lead to stroke, renal failure, or myocardial infarction. Hoarseness can develop from compression of the left recurrent laryngeal nerve against the pulmonary artery by the enlarged left atrium. Also, compression of bronchi by the enlarged left atrium can cause persistent cough. Hemoptysis may occur and is usually not fatal. Pregnant women with mild mitral stenosis may become symptomatic during their second trimester because of the increase in blood volume and cardiac output. Learn More

Sarcoidosis is a multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. The age-adjusted incidence is 11 cases per 100,000 population in whites but 34 cases per 100,000 population in African Americans. Corticosteroids are the mainstay of therapy. Generally, prednisone given daily and then tapered over a 6-month course is adequate for pulmonary disease. Earlier recommendations suggested an initial dose of 1 mg/kg/d of prednisone; however, more recent expert opinions endorse a lower dose (eg, 40 mg/d), which is tapered to every-other-day long-term therapy over several weeks. In one study, treatment of acute exacerbations of pulmonary sarcoidosis with steroid doses as low as 20 mg of prednisone for a median of 21 days improved spirometry back to baseline and improved clinical symptoms.

Chlamydial genital infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged ≤25 years.

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. There are several risk factors, including previous history of PID, multiple sexual partners, and younger age. Learn More

Haustral markings are the radiological appearance of the haustral folds within the colon. Disappearance of the haustral folds results in the lead pipe appearance of ulcerative colitis.

This is the classic presentation of a common migraine headache.

The diagnosis of alcoholic hepatitis is straightforward and requires no further diagnostic studies in patients presenting with a history of alcohol abuse, typical symptoms and physical findings, evidence of liver functional impairment, and compatible liver enzyme levels. In milder cases of alcoholic hepatitis, a mild elevation of the aspartate aminotransferase (AST) level may be the only diagnostic clue. Learn More

The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding; unfortunately, only about 50% of patients present with all 3 symptoms. About 40-50% of patients with an ectopic pregnancy present with vaginal bleeding, 50% have a palpable adnexal mass, and 75% may have abdominal tenderness.

Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults in the United States. Acute rheumatic fever and rheumatic heart disease are thought to result from an autoimmune response, but the exact pathogenesis remains unclear. Although rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States, incidence of this disease has decreased in developed countries, and the mortality rate has dropped to just above 0% since the 1960s. Worldwide, rheumatic heart disease remains a major health problem. Chronic rheumatic heart disease is estimated to occur in 5-30 million children and young adults; 90,000 individuals die from this disease each year. The mortality rate from this disease remains 1-10%.

The term mallet finger has long been used to describe the deformity produced by disruption of the terminal extensor mechanism at the distal interphalangeal (DIP) joint. Mallet finger is the most common closed tendon injury that is seen in athletes; this injury is also common in nonathletes after "innocent" trauma. Mallet finger has also been referred to as drop, hammer, or baseball finger (although baseball accounts for only a small percentage of such injuries).

Erythema nodosum (EN) is an acute, nodular, erythematous eruption that usually is limited to the extensor aspects of the lower legs. Chronic or recurrent erythema nodosum is rare but may occur. Erythema nodosum is presumed to be a hypersensitivity reaction and may occur in association with several systemic diseases or drug therapies, or it may be idiopathic. The inflammatory reaction occurs in the panniculus. Classic presentation of erythema nodosum with nodular red swellings over the shins.

There are five different types of kidney failure: Acute Prerenal Kidney Failure This is caused by insufficient blood flow to the kidneys. Without enough blood flow, the kidneys cannot filter toxins from the blood. This type is usually curable by resolving the cause of inadequate blood flow. Acute Intrinsic Kidney Failure This can be caused by direct trauma to the kidneys, such as physical impact, accidents, toxin overload, or ischemia (a lack of oxygen to the kidneys). Severe bleeding, shock, renal blood vessel obstruction, or glomerulonephritis (inflammation of the tiny filters in your kidneys) can all cause ischemia. Chronic Pre-Renal Kidney Failure When low blood flow to the kidneys is not treated and the condition remains for an extended period of time, chronic pre-renal kidney failure can occur. The kidneys begin to shrink and lose the ability to function. Chronic Intrinsic Kidney Failure Damage to the kidneys over an extended period due to intrinsic kidney disease can develop into chronic intrinsic kidney failure. Chronic Post-Renal Kidney Failure This happens when a long-term blockage of the urinary tract prevents urinary waste elimination, which causes pressure and eventual kidney damage.

Injuries to the head and neck region have a lower risk of infection than injuries to the extremities. The risk of infection is increased with puncture wounds, treatment delay (6-12 h), and in patients older than 50 years. Likewise, patients who are immunocompromised are at increased risk. The most common organisms are Staphylococcus species, Streptococcus species, Pasteurella multocida, and anaerobic organisms. When the infection develops in less than 48 hours from the time of the bite think Pasteurella. Most Pasteurella isolates are susceptible to oral antimicrobials such as amoxicillin, amoxicillin/clavulanic acid, minocycline, fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin), and trimethoprim-sulfamethoxazole.

Cluster headache (CH), also known as histamine headache, is a primary neurovascular primary headache disorder, the pathophysiology and etiology of which are not well understood. As the name suggests, CH involves a grouping of headaches, usually over a period of several weeks. According to the diagnostic criteria developed by the International Headache Society (IHS), CH has the following characteristics: The patient experiences attacks of severe or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain) that last 15-180 minutes and occur from once every other day to 8 times a day. The attacks are associated with 1 or more of the following (all ipsilateral): conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, or eyelid edema.