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Question 1 |
A patient presents complaining of severe pain and "burning" in an extremity. You note that the extremity is pale and cool to the touch. You cannot appreciate a palpable pulsation. Which of the following diagnostic modalities will identify the source of this patient's problem in approximately 95% of cases?
chest x-ray | |
echocardiogram | |
angiogram | |
abdominal flat plate | |
aortic ultrasound |
Question 1 Explanation:
An angiogram is the "gold standard" for occlusion of an arterial vessel. Arterial embolism/thrombosis is covered as part of the PANCE Cardiology Blueprint.
Question 2 |
A 31-year-old pharmacist complaining of rectal pain. He describes the pain as "a severe tightness that awakens him from sleep." His bowel activity is normal. He denies rectal bleeding and seepage. He adds that sleep interruption is problematic because, with the number of hours he works, every minute of sleep is important. What is the most likely diagnosis?
anal abseess Hint: Abscess would be constant | |
perianal fistula Hint: fistula would drain | |
proctalgia fugax | |
ulcerative colitis Hint: UC would cause bloody mucousy diarrhea | |
internal hemorrhoids. Hint: hemorrhoids would cause no pain, but bleeding. |
Question 2 Explanation:
proctalgia (rectal pain) fugax (comes and goes) is the best description. An abscess would be constant, fistula would drain, UC would cause bloody mucousy diarrhea, hemorrhoids would cause no pain, but bleeding. Disorders of the Anus and Rectum are covered as part of the PANCE GI and Nutrition Blueprint.
Question 3 |
A 38-year-old chronic smoker presents with shortness of breath and wheezing. He has had several similar episodes in the past. He states that each previous episode began after developing a "cold that moved into his chest." Usually, after treatment with albuterol (VENTOLIN) and several days, the wheezing stops. He adds that he has a chronic cough, productive of mucous, most mornings during the past several years. Which of the following best describes this patient's condition?
chronic emphysema | |
chronic bronchitis | |
chronic bronchitis with hypersensitive airways (asthmatic bronchitis) | |
cor pulmonale | |
bronchiectasis |
Question 3 Explanation:
This is the best descriptor. Chronic bronchitis is covered as part of the PANCE Pulmonary Blueprint.
Question 4 |
A patient is being treated for Tuberculosis. She is experiencing central scotomata, a loss of green-red color perception, and decreased visual acuity. Which agent is most likely responsible?
rifampin | |
isoniazid | |
streptomycin | |
ethambutol | |
para-aminosalicylic acid |
Question 4 Explanation:
Ethambutol is the TB drug that causes eye symptoms. It's helpful to remember "E" for Ethambutol causes "E"ye symptoms. Tuberculosis is covered as part of the PANCE Infectious Disease Blueprint.
Question 5 |
Secondary to a traumatic event, a child complains of pain in the index finger. An x-ray of the digit demonstrates a fracture line through the metaphysis of the proximal aspect of the middle phalanx, ending at the epiphyseal plate. What type of fracture does this child have?
Salter Harris Type I Hint: Salter I = slight increase in Space between epiphyseal plate and metaphysis | |
Salter Harris Type II | |
Salter Harris Type III Hint: Salter III = fx Lower (in the epiphyseal plate) | |
Salter Harris Type IV Hint: Salter IV = fit Through (both the metaphysis and epiphysis) | |
Salter Harris Type V Hint: Salter V = Really bad (comminuted fx compressing the epiphysis) This spells SALTR and may help you remember. |
Question 5 Explanation:
- Salter I = slight increase in Space between epiphyseal plate and metaphysis
- Salter II = fx Above the plate (in the metaphysis)
- Salter III = fx Lower (in the epiphyseal plate)
- Salter IV = fit Through (both the metaphysis and epiphysis)
- Salter V = Really bad (comminuted fx compressing the epiphysis) This spells SALTR and may help you remember.
Question 6 |
A 24-year-old male presents complaining of chest pain. He states that it is worse with swallowing and taking a deep breath. It is improved by sitting up and leaning forward. He denies trauma, a cough and shortness of breath. Which of the following tests would be most compatible with your suspected diagnosis?
a hiatal hernia visualized on chest x-ray | |
a normal erythrocyte sedimentation rate | |
calcified "popcorn" lesions in the lung fields bilaterally | |
diffuse ST segment elevation on his electrocardiograph | |
a widened A-a gradient on his arterial blood gas |
Question 6 Explanation:
This is pericarditis (by clinical presentation) which causes diffuse ST-segment elevation on ECG (there can be notching of the R wave as well). Acute pericarditis is covered as part of the PANCE Cardiology Blueprint.
Question 7 |
A 2-month-old febrile male is brought to your facility to be evaluated for loss of appetite, irritability, and an acute petechial rash. Rectal temperature is 102.8F. Which of the following diagnostic studies is the most important in this child's evaluation?
white blood cell count and differential | |
urinalysis | |
CSF analysis | |
serum glucose | |
chest X-ray (CXR) |
Question 7 Explanation:
Any infant (neonate) with fever and rash should have a lumbar puncture (LP). While I would certainly do a CBC, even if it was normal, I would want the LP.
Question 8 |
Your 27-year-old sister is visiting and requests you to provide refills of dexamethasone and homatropine ophthalmic drops for her. What condition is most likely being treated?
conjunctivitis | |
glaucoma | |
iritis | |
Herpes keratitis | |
blepharitis |
Question 8 Explanation:
Iritis is treated with steroid drops (dexamethasone) and miotic drops *homatropine, like atropine (to constrict and fix the pupil to help the pain and open the angle until the iritis is resolved). Iritis and disorders of the Eye (PEARLS) are covered as part of the PANCE EENT Blueprint.
Question 9 |
A 58-year-old male presents complaining of weakness of his grip. Your examination reveals that the problem is bilateral. During the next few office visits, you note the development of hyperactivity of his DTRs, extensor plantar reflexes, and dysarthria. The patient's sensory system remains normal and he denies any urinary symptomatology. Which of the following is the most likely diagnosis?
multiple sclerosis Hint: MS may have dysarthria, but reflexes are normal, sensation is impaired and bladder function is frequently affected | |
Alzheimer's disease Hint: Alzheimer's has normal neuro exam with cognitive disability. | |
Huntington's chorea Hint: Huntington's causes a movement disorder with writhing choreiform movements of the body | |
amyotrophic lateral sclerosis | |
myasthenia gravis Hint: Myasthenia causes fatigue of the ocular muscles typically worsening at the end of the day. |
Question 9 Explanation:
ALS (Lou Gehrig's disease) is a progressive bilateral muscle disease which causes fasciculations (lower motor neuron), and hyperreflexia, plantar reflexes (upper motor neuron) and dysarthria. Sensation is normal as is bladder function.
- MS may have dysarthria, but reflexes are normal, sensation is impaired and bladder function is frequently affected.
- Alzheimer's has normal neuro exam with cognitive disability.
- Huntington's causes a movement disorder with writhing choreiform movements of the body.
- Myasthenia causes fatigue of the ocular muscles typically worsening at the end of the day.
Question 10 |
Which of the following is NOT a characteristic feature of multiple myeloma?
elevated serum calcium | |
osteoporosis | |
"punched out" osseous lesions | |
plasma cell infiltration of bone marrow | |
hypogammaglobulinemia |
Question 10 Explanation:
Multiple myeloma is a HYPERgammaglobulinemia - all of the other findings occur in multiple myeloma. Multiple myeloma is covered as part of the PANCE Hematology Blueprint.
Question 11 |
Which of the following is NOT a risk factor for the development of osteoporosis?
low testosterone levels in men | |
low levels of physical activity | |
inadequate dietary protein | |
cigarette smoking | |
chronic corticosteroid use |
Question 11 Explanation:
Low dietary Calcium, not protein, is a risk factor for osteoporosis. All of the others are risk factors. Osteoporosis is covered as part of the PANCE Musculoskeletal Blueprint.
Question 12 |
A 12-year-old male presents complaining of no appetite for 24 hours and pain near his navel. During the night, the pain moved to the right lower abdomen. He is now nauseated and vomiting and has a low-grade fever. In the operating room, a normal appendix is discovered. What is the most likely diagnosis?
mesenteric ischemia | |
diverticulitis | |
mesenteric adenitis | |
cholecystitis | |
proctitis |
Question 12 Explanation:
Mesenteric adenitis (lymphadenopathy of the mesentery - usually from a virus) can mimic appendicitis and usually occurs in kids. There is usually no way to diagnose it pre-operatively, except perhaps with a CT of the abdomen (usually done nowadays before going to the OR).
Review Diseases of the Small Intestine and Colon (PEARLS) from the PANCE GI and Nutrition Blueprint
Question 13 |
A patient that must be on a beta-blocking agent has reactive airway disease and commonly experiences central nervous system side effects from medications. Which of the following beta-blockers would most likely be tolerated by this patient?
atenolol | |
metoprolol | |
nadolol | |
propranolol | |
pindolol |
Question 13 Explanation:
This is a picky question for the Boards. Of these Beta-blockers (which are usually AVOIDED) in reactive airway disease - metoprolol is the most "cardioselective", so theoretically could be used.... although, on an exam, I would avoid beta-blockers in general.
Asthma is covered as part of the PANCE Pulmonary Blueprint
Question 14 |
A polarized light microscopic study of joint fluid demonstrates negative birefringent crystals. What is the diagnosis?
rheumatoid arthritis | |
septic arthritis | |
pseudogout gout Hint: Calcium Pyrophosphate (pseudogout) is Prism-shaped crystals with Positive birefringence - To remember this think "P"seudogout has "P"rism shaped crystals and "P"ositive birefringence. | |
aseptic arthritis | |
gout |
Question 14 Explanation:
Uric acid (gout) is "Needle-shaped crystals with Negative birefringence). Calcium Pyrophosphate (pseudogout) is Prism-shaped crystals with Positive birefringence - To remember this think "P"seudogout has "P"rism shaped crystals and "P"ositive birefringence. Gout/pseudogout are covered as part of the PANCE Musculoskeletal Blueprint
Question 15 |
Which of the following agents is most appropriate in the treatment of a pregnant patient infected with Chlamydia?
tetracycline Hint: Tetracyclines (A & E) should be avoided. | |
penicillin Hint: PCN does not work for Chlamydia. | |
norfloxacin Hint: Quinolones (norfloxacin) are contraindicated. | |
erythromycin | |
doxycycline Hint: Doxycycline is contraindicated in the second and third trimesters of pregnancy. |
Question 15 Explanation:
Azithromycin 1 g orally in a single dose is both safe and effective - it is now considered first-line treatment by the CDC for use in pregnancy. Of the choices above, erythromycin is best and is considered an alternative regimen.
PCN does not work for Chlamydia.
Tetracyclines (A & E) should be avoided. Quinolones (norfloxacin) are contraindicated. Note: Erythromycin estolate is contraindicated during pregnancy because of drug-related hepatotoxicity. So you would use either Erythromycin base or Erythromycin ethylsuccinate. Chlamydia is covered as part of the PANCE Infectious Disease Blueprint.
Question 16 |
Typically, it produces a local burning, followed in 3 to 4 hours by a white area of vasoconstriction. Subsequently, a bleb forms at the bite site, darkens, and is followed over hours to days by tissue necrosis. Which of the following inflicts this envenomation?
brown recluse spider | |
black widow spider | |
scorpion
| |
Dermacentor andersoni tick | |
the centipede |
Question 16 Explanation:
This is a brown recluse spider bite. Spider bites are covered as part of the PANCE Dermatology Blueprint
Question 17 |
A patient with acute renal failure provides a urine specimen that demonstrates normal osmolality and sodium content. The urine contains no casts, but RBCs are present. Which of the following is the most likely etiology of this patient's acute renal failure?
prerenal cause Hint: In pre-renal ARF, the sodium content of the urine would be decreased (because the patient is volume depleted, so the kidneys try to retain Na - less is in the urine) | |
intrarenal — glomerulonephritis | |
intrarenal — acute tubular necrosis Hint: In intrarenal disease, the urine would contain casts. | |
intrarenal — interstitial nephritis | |
postrenal cause |
Question 17 Explanation:
In pre-renal ARF, the sodium content of the urine would be decreased (because the patient is volume depleted, so the kidneys try to retain Na - less is in the urine). In intrarenal disease, the urine would contain casts. So, this is postrenal disease (usually a big prostate or stones) which would cause normal urine with rbc's. Acute renal failure is covered as part of the PANCE Genitourinary Blueprint.
Question 18 |
All of the following, when administered to the physically dependent opiate abuser, can precipitate withdrawal symptoms EXCEPT:
naloxone | |
pentazocine | |
nalbuphine | |
methadone | |
buprenorphine |
Question 18 Explanation:
That is why we use methadone when weaning folks from opiates (like heroin). Substance Use Disorders are covered as part of the PANCE Psychiatry Blueprint.
Question 19 |
During a sports 'screening physical' examination, a 15-year-old male is noted to have a murmur. You perform bedside maneuvers in an attempt to delineate which type of murmur you are auscultating. Which of the following would be the finding associated with the highest risk of sudden death for this patient?
the intensity of the murmur increases during a valsalva maneuver | |
the intensity of the murmur decreases during standing | |
the murmur does not change while the patient squat | |
the intensity of the murmur decreases during exercise | |
elevation of the legs while the patient is supine increases the intensity of the
murmur |
Question 19 Explanation:
Hypertrophic cardiomyopathy (most common cause of sudden cardiac death in this age individual) would have a systolic ejection murmur which would INCREASE with Valsalva (decreased preload causing a smaller LV volume and an increase in the obstruction)
The murmur would DECREASE with squat or elevating the legs (increase preload, make the LV volume larger and decrease the obstruction). Hypertrophic Cardiomyopathy is covered as part of the PANCE Cardiology Blueprint.
Question 20 |
A 44-year-old male presents with a fever, a cough productive of brownish sputum, rigors and lethargy for seven days. A chest x-ray reveals a right middle lobe infiltrate and a right-sided pleural effusion. A thoracentesis is performed. Which of the following results from the pleural fluid analysis would be most characteristic of acute pneumonia?
pleural fluid:serum LDH ratio >0.6 | |
pleural fluid specific gravity < 1.006 | |
pleural fluid without protein | |
pleural fluid without LDH | |
pleural fluid:serum protein ratio <0.5 |
Question 20 Explanation:
The question suggests bacterial pneumonia. The pleural fluid should have high LDH (pleural > serum), a high specific gravity (lots of "stuff' in the fluid), a large amount of protein (WBC's, bacteria, and "stuff"). Bacterial pneumonia is covered as part of the PANCE Pulmonary Blueprint.
Question 21 |
A patient presents with severe diarrhea described as watery and bloody. He states he ate some chicken at a farm and wasn't sure if it was cooked well enough. His stool demonstrates many WBC's and S-shaped gram-neg rods. Which of the following antimicrobial agent of choice should be used to treat this patient?
metronidazole | |
erythromycin | |
ampicillin | |
ciprofloxacin | |
doxycycline |
Question 21 Explanation:
Campylobacter = erythromycin. Infectious and Noninfectious Diarrhea is covered as part of the PANCE GI and Nutrition Blueprint.
Question 22 |
An 82-year-old man presents with acute, non-colicky, constant pain in the left flank. He denies fever or urinary symptoms. Since onset, the pain has migrated from the flank to the central abdomen and now radiates into the left inguinal area. He has a history of hypertension and a 50-pack-year smoking history. Which of the following diagnoses must be ruled out immediately?
Acute bacterial prostatitis Hint: Prostatitis usually presents with urinary symptoms, perineal pain, and fever, which are absent here. | |
Spigelian hernia Hint: Spigelian hernias are rare and typically present as a localized bulge on the abdominal wall, not with radiating pain. | |
Calyceal obstruction Hint: Calyceal obstruction usually presents with flank pain and hematuria, without the pattern of radiating pain described. | |
Acute biliary colic Hint: Biliary colic typically presents with right upper quadrant pain radiating to the right shoulder, associated with nausea, not left-sided pain radiating to the left inguinal area. The presentation described is more suggestive of a vascular etiology like an aortic dissection, given the constant nature of pain and its movement pattern. Prompt evaluation with imaging is recommended to rule out life-threatening conditions like aortic aneurysm or dissection, especially in elderly patients with a history of hypertension or vascular disease. | |
Dissecting aortic aneurysm |
Question 22 Explanation:
This is constant, migrating pain—not crampy like biliary colic or kidney stones. It's not perineal like prostatitis or associated with urinary symptoms. The location (flank to abdomen to groin), the patient's age, and vascular risk factors (hypertension, smoking) scream aortic dissection or rupturing abdominal aortic aneurysm (AAA). In elderly patients, aortic emergencies must be ruled out first when pain is severe, radiating, and unrelenting. Don't be distracted by the unusual location—vascular disasters don’t read textbooks! Aortic aneurysm/dissection is covered as part of the PANCE Cardiology Blueprint.
Question 23 |
A 32-year-old female presents with an acute narrow-complex tachycardia noted on her twelve lead EKG. Her blood pressure is 110/72. Her heart rate is 156. She denies chest pain and dyspnea. What do you order next for this patient?
bretylium 500 mg intravenously | |
verapamil 5 mg intravenously | |
adenosine 6 mg intravenously | |
digoxin 0.5 mg intravenously | |
lidocaine 100 mg intravenously |
Question 23 Explanation:
The treatment for SVT (regular narrow complex tachycardia in a young healthy patient) could be valsalva or carotid massage, and then adenosine 6 mgm. IV bolus. Supraventricular tachycardia is covered as part of the PANCE Cardiology Blueprint.
Question 24 |
A 56-year-old male presents complaining of night sweats, weight loss, a cough and shortness of breath. A urinalysis demonstrates hematuria. The patient had a positive PPD skin test six months ago but was never treated. You order a chest x-ray and expect to find pathology in which area of the lung?
the anterior aspect of the lung bases | |
the lingual of the left lung | |
the right middle lobe | |
the posterior aspect of the lung bases | |
the apices of the lungs |
Question 24 Explanation:
TB reactivated typically appears in the apices of the lung fields. Tuberculosis is covered as part of the PANCE Pulmonary Blueprint.
Question 25 |
A mother brings her nine-year-old son to your office, along with the snake that bit him 20 minutes earlier. Which of the following, if identified during your examination of the snake, is most suggestive that the snake is poisonous?
elliptical pupils | |
a rounded head | |
a double row of caudal plates | |
the length of the snake | |
the presence of a black band next to a red band |
Question 25 Explanation:
There are two families of poisonous snakes: Viperidae is pit vipers, rattlesnakes, water moccasins, copperheads. They are distinguished by elliptical pupils vs. round in non-venomous snakes. Elapidae contains cobras, mambas, taipan and coral snakes. There are differentiated by their color bands, "red on yellow kills a fellow", "red on black, venom lack". Most poisonous snakes in the US - coral snakes.
Mambas are the most poisonous in the world; cobras are hooded at the neck and are next most poisonous but neither of these is found in the U.S. Animal and insect bites are covered as part of the PANCE Infectious Disease Blueprint.
Question 26 |
Which of the following vaccines can prevent cancer?
rubella vaccine | |
rubeola vaccine | |
hepatitis B vaccine | |
influenza vaccine | |
tetanus vaccine |
Question 26 Explanation:
Think of Hep B and Hep C as carcinogens. We don't have a Hep C vaccine yet, but we DO have a Hep B vaccine. Since chronic Hep B and Hep C infection cause liver cancer, a vaccine can "prevent" it. Acute and chronic hepatitis are covered as part of the PANCE Genitourinary Blueprint.
Question 27 |
A 51-year-old male who has smoked for 32 years, presents complaining of a persistent cough. His chest x-ray is unremarkable. The cough began shortly after he started a new medication. Which medication do you suspect as the cause?
verapamil | |
digoxin | |
captopril | |
acetaminophen | |
lovastatin |
Question 27 Explanation:
ACEI's cause chronic cough. Captopril is the prototypical ACEI. Ace inhibitors and other cardiac medications are covered as part of the PANCE Cardiology Blueprint
Question 28 |
Which of the following is associated with a reduced risk of ovarian cancer?
delivering the first child at an age greater than 40 years old | |
a positive family history of ovarian cancer | |
present age greater than 50 years old | |
being nulliparous | |
oral contraceptive use |
Question 28 Explanation:
OCP's protect (reduce risk by 40% for a decade after one year of use). Ovarian Neoplasms are covered as part of the PANCE Reproductive System Blueprint.
Question 29 |
A patient is given a new product for an acute migraine headache. Shortly after the injection, the patient complains of significant chest tightness. Which of the following medications do you suspect this patient received?
promethazine | |
metoclopramide | |
sumitriptan | |
trimethobenzamide | |
ketorolac |
Question 29 Explanation:
Sumatriptan (Imitrex) and all triptans can cause chest tightness as it is a potent vasoconstrictor. You must use it with caution in a patient with risk factors for coronary disease and in uncontrolled hypertension. Migraine headaches are covered as part of the PANCE Neurology Blueprint.
Question 30 |
Which of the following does NOT increase the likelihood of infection in a cancer patient?
thrombocytopenia | |
malnutrition | |
the presence of catheters or shunts for therapeutic intervention | |
neutropenia | |
splenectomy |
Question 30 Explanation:
Decreased platelets could predispose the patient to bleeding, the others would increase his risk for infection. Thrombocytopenia is covered as part of the PANCE Hematology Blueprint.
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