The Daily PANCE and PANRE Extended Edition Final Exam (Questions 30-60)

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Question 1
A patient complains of marked weakness, nausea, vomiting and weight loss. His skin appears well-tanned, although he denies any sun exposure. The laboratory studies demonstrate an elevated potassium, a low sodium and eosinophilia. What is the most likely diagnosis?
A
Cushing's syndrome
B
Cushing's disease
C
Addison's disease
D
acromegaly
E
scarlet fever
Question 1 Explanation: 
This is Addison's disease, autoimmune destruction of the entire adrenal gland. No Cortisol, increased ACTH (pigmentation), high K & low Na (no aldosterone).
Question 2
A patient with a hernia complains of severe pain and a persistent lump in the groin. The contents of the hernia are ischemic. What is the best description for the hernia?
A
reducable
B
irreducible
C
incarcerated
Hint:
Incarcerated means "not reducible"
D
strangulated
E
indirect
Question 2 Explanation: 
Incarcerated means "not reducible", strangulated means "ischemic", or no flow.
Question 3
A 46 year-old patient with chronic hypertension, suddenly discontinues the use of his antihypertensive agent. This patient presents to your office with a blood pressure of 198/116 in the left arm. The patient denies chest pain and shortness of breath. You note no evidence of acute end-organ changes on physical examination. His laboratory studies and EKG are normal. What diagnosis will you place on this patient's chart?
A
hypertensive emergency
Hint:
Hypertensive emergencies are severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction, and will require immediate BP reduction (not necessarily to normal ranges) to prevent or limit target organ damage. Examples include: hypertensive encephalopathy, intracranial hemorrhage, unstable angina pectoris, or acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, or eclampsia. While the level of BP at the time of presentation is usually very high (greater than 180/120 mm Hg), keep in mind that it is not the degree of BP elevation, but rather the clinical status ofthe patient that defines a hypertensive emergency. For example, a BP of 160/100 mm Hg in a 60-year-old patient who presents with acute pulmonary edema represents a true hypertensive emergency.
B
hypertensive urgency
C
malignant hypertension
D
idiopathic hypertension
E
hypertension of undetermined etiology
Question 3 Explanation: 
Traditionally, hypertensive crises have been divided into emergencies and urgencies. Hypertensive emergencies are severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction, and will require immediate BP reduction (not necessarily to normal ranges) to prevent or limit target organ damage. Examples include: hypertensive encephalopathy, intracranial hemorrhage, unstable angina pectoris, or acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, or eclampsia. While the level of BP at the time of presentation is usually very high (greater than 180/120 mm Hg), keep in mind that it is not the degree of BP elevation, but rather the clinical status of the patient that defines a hypertensive emergency. For example, a BP of 160/100 mm Hg in a 60-year-old patient who presents with acute pulmonary edema represents a true hypertensive emergency. Hypertensive urgencies are severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage. Most of these patients are, in fact, nonadherent to drug therapy or are inadequately treated hypertensive patients and often present to the ED for other reasons. Patients with severe elevations of BP can be managed in the ED with oral agents and appropriate follow-up within 24 hours to several days depending upon the individual characteristics of the patient. It is the correct differentiation of these two forms of hypertensive crises, however, that presents the greatest challenge to the physician.
Question 4
A patient returns from a Caribbean cruise. He admits to spending "a lot of time sitting at the bar." He presents today, complaining of atraumatic swelling of his right elbow. On examination, he is afebrile, and has a soft, well circumscribed mass over the olecranon. The rest of the examination is unremarkable. The diagnosis is:
A
lateral epicondylitis.
B
medial epicondylitis.
C
olecranon bursitis.
D
nursemaid's elbow.
E
a dislocated elbow.
Question 4 Explanation: 
Olecranon bursitis from leaning on a hard surface.
Question 5
Which of the following is most likely the cause of galactorrhea and amenorrhea?
A
Sheehan's syndrome
Hint:
I would choose Sheehan's syndrome if the question stated that the patient had a postpartum hemorrhage
B
prolactin - secreting adenoma
C
Frohlich's syndrome
D
Cushing's disease
E
a basophilic adenoma of the pituitary
Question 5 Explanation: 
Prolactin-secreting adenoma is the most common cause of galactorrhea/amenorrhea (after exclusion of pregnancy). I would choose Sheehan's syndrome if the question stated that the patient had a postpartum hemorrhage. The others do not cause this.
Question 6
A young female presents with several "target-like lesions" on her arms, legs and thorax. She takes birth control pills and recently completed a ten-day course of penicillin. What is the most likely diagnosis?
A
erythema multiforme
B
erythem nodosum
Hint:
erythema nodosum causes PAINFUL purple nodules on the anterior shins.
C
erysipelas
D
pleurodynia
E
erythema chronicum migrans
Question 6 Explanation: 
Target lesions are erythema multiforme - commonly caused by drugs (many drugs) and some illnesses, like mycoplasma Another common problem with OCP's is erythema nodosum which causes PAINFUL purple nodules on the anterior shins.
Question 7
Which of the following statements regarding infectious mononucleosis is FALSE?
A
Infectious mononucleosis is caused by the Epstein-Barr virus.
B
Most adults (>90%) have been infected with the Epstein-Barr virus
C
Splenic rupture is a dreaded complication of infectious mononucleosis.
D
Streptococcal pharyngitis and infectious mononucleosis never coexist.
E
The usual mode of transmission of the viral etiology of infectious mononucleosis is through infected saliva.
Question 7 Explanation: 
Strep commonly co-exists with mono.
Question 8
Which of the following increases the likelihood that a patient will precipitate calcium-containing kidney stones?
A
an increase in daily water intake
B
an increase in daily sodium chloride intake
C
a reduction in daily sugar consumption
D
a reduction in daily protein consumption
E
"normal" daily dairy product consumption
Question 8 Explanation: 
The combination of high sodium intake and high animal protein intake will raise urinary calcium more than high calcium intake will. The reason is that only a net of 100 to 300 mg of calcium is absorbed from the intestine/day. In contrast, 10,000 mg of calcium is filtered and 9,700 to 9,900 mg is reabsorbed by the kidney. Since sodium and animal protein inhibit calcium reabsorption by the kidney, it is not surprising that they affect urinary calcium substantially.
Question 9
A 54 year-old female enters your practice. She has a history of poor interpersonal relationships, chronic headaches and previous suicide attempts. After a few visits, you appreciate that she has an extremely demanding attitude and often directs anger toward you. Which of the following is the most likely diagnosis?
A
dysthymic disorder
B
narcissistic disorder
C
borderline personality disorder
D
somatization disorder
E
anxiety
Question 9 Explanation: 
This is a typical "borderline personality disorder" presentation.
Question 10
Which of the following is most likely to present with dysphagia?
A
rheumatoid arthritis
B
ankylosing spondylitis
C
systemic lupus erythematosus
D
scleroderma
E
periarteritis nodosa
Question 10 Explanation: 
Dysphagia is the most common presenting symptom in a patient with scleroderma.
Question 11
Which of the following etiologies of acute hepatitis would most likely be followed by the development of chronic hepatitis?  
A
hepatitis A virus
B
hepatitis B virus
C
hepatitis C virus
D
hepatitis D virus
E
hepatitis E virus
Question 11 Explanation: 
Hepatitis C is the most common blood borne infection in the US, causes chronic hepatitis in almost all persons infected, is the most common reason for liver failure in the US, and the most common reason for liver transplant.
Question 12
Which of the following diagnostic studies should be performed on all patients with acute exacerbations of asthma that present for evaluation?
A
chest x-ray
Hint:
CXR is not necessary unless you suspect the patient has pneumonia.
B
white blood cell count
C
serum theophylline level
D
peak expiratory flow rate
E
arterial blood gas analysis
Hint:
ABG's may be indicated in a severe asthma attack, but not typically.
Question 12 Explanation: 
Peak flows should be done in ALL asthma patients with an acute exacerbation. It gives you a baseline, and allows you to decide how effective nebulizer treatments are. CXR is not necessary unless you suspect the patient has pneumonia. ABG's may be indicated in a severe asthma attack, but not typically.
Question 13
A mother brings her four year-old son to your clinic. She noted several "blisters" on his check and around his nose. On examination, you note several large flaccid, thin-roofed bullae on both cheeks and extensive involvement around the nose, as well as the extremities. Which treatment is the most appropriate?
A
bacitracin ointment
B
mupirocin ointment
C
erythromycin orally
Hint:
Erythromycin is not a bad choice, but choose diclox for staph aureus.
D
amoxicillin orally
E
dicloxacillin orally
Question 13 Explanation: 
This is impetigo (staph skin infection) For the Boards, use Dicloxacillin for staph. Mupirocin cream would be indicated if there was only a small area infected, although there now is an indication for Mupirocin (Bactroban) for staph in the nose. Erythromycin is not a bad choice, but choose diclox for staph aureus.
Question 14
A mother brings her adult son to your office, relating a history of two weeks of difficulty sleeping, irritability, and problems with relationships with others. He has also been very talkative, expressed a multitude of "great ideas" and just seems to "talk constantly." Several weeks ago, he seemed depressed. Which of the following diagnostic studies would be the most helpful in his evaluation?
A
complete blood count
B
random blood sugar
C
free T4 level
D
liver function studies
E
head CT scan
Question 14 Explanation: 
This Q suggests bipolar disorder - thyroid function should be checked in all patients with a psych diagnosis.
Question 15
A 47 year-old male presents with "crushing chest pain." He is a diabetic and smoker, with a history of hyperlipidemia and angina. Which of the following physical findings is most suggestive of acute myocardial ischemia?
A
physiologic split second heart sound (split S2)
B
crackles in both lungs that do not change with coughing
C
chest tenderness with palpation of the costosternal junctions
D
an S4 gallop that is not present when the patient is asymptomatic
E
sinus bradycardia
Question 15 Explanation: 
S4 is almost always present in an acute MI.
Question 16
During a newborn's first feeding attempt, choking, coughing and cyanosis occur. Historically, the mother had polyhydramnios during the pregnancy. Which diagnosis is most likely the explanation for the newborn's distress?
A
choanal atresia
B
respiratory distress syndrome
C
polycystic kidney disease
D
congenital heart disease
E
tracheoesophageal fistula
Question 16 Explanation: 
This is the classic presentation of TE fistula - when the patient drinks he aspirates because there is a connection between the trachea and the esophagus.
Question 17
You diagnose a patient with shingles involving the trigeminal nerve. Since there is involvement of the tip of the nose, you examine her thoroughly to exclude concurrent involvement of the:
A
tympanic membrane
B
cornea
C
nasal septum
D
contralateral pinna
E
ipsilateral epitrochlear node
Question 17 Explanation: 
This is Hutchinson's sign and suggests an involvement of the cornea with herpes. An ophthalmologic referral is indicated. (Fluorescein staining would show a dendritic lesion on the cornea).
Question 18
A 65 year-old female is referred to your office by her rheumatologist, complaining of a severe, unilateral headache of a piercing quality. You examine the patient and cannot appreciate any pulsation of the temporal artery on the side of her head, ipsilateral to her cephalgia. While awaiting consultation of the appropriate specialist, you prescribe prednisone. Why has the prednisone been prescribed in this case?
A
to reduce the stenosis of the contralateral temporal artery
B
to reduce the swelling of the patient's berry aneurysm
C
because the patient is at risk for developing blindness
D
because the patient most likely has pseudotumor cerebri
E
because of the associated risk of angioedema developing in her oropharynx
Question 18 Explanation: 
This is temporal arteritis (or giant cell arteritis). It is a vasculitis and can cause blindness if not treated aggressively with steroids.
Question 19
A 59 year-old, heavy smoker, presents for the evaluation of facial swelling. Upon examination, you note swelling, not only of the face, but also of the neck and upper extremities. You appreciate diminished breath sounds and tactile fremitus in the right upper lobe. Which of the following diagnosis is most likely?
A
Pancoast tumor
B
Tuberculosis
C
pneumothorax
D
superior vena cava syndrome
E
pneumonia
Question 19 Explanation: 
This is superior vena cava syndrome suggestive of bronchogenic carcinoma causing lymphadenopathy in the mediastinum which can impinge on the SVC.
Question 20
Which type of breathing pattern is classically observed at the bedside during acute diabetic ketoacidosis?
A
Biot's
B
Cheyne-Stokes
Hint:
may be caused by damage to respiratory centers, or by physiological abnormalities in chronic heart failure, and is also seen in newborns with immature respiratory systems and in visitors new to high altitudes.
C
Kussmaul's
D
Apneustic
E
Ataxic
Question 20 Explanation: 
Kussmaul's is the pulmonary compensation for the metabolic acidosis of DKA. The lungs blow off C02(an acid) to normalize the pH. Remember "K" for Ketoacidosis
Question 21
A 57 year-old female with a history of pancreatitis presents for the third time in three weeks complaining of midepigastric pain. At this visit, you perform a CT scan, which reveals a mass in the pancreas. Which of the following is the most likely diagnosis?
A
epithelial cell carcinoma
B
gastrinoma
C
adenocarcinoma
D
teratoma
E
insulinoma
Question 21 Explanation: 
This patient has chronic pancreatitis which predisposes this patient to cancer. The head of the pancreas is sometimes palpable.
Question 22
A patient's blood pressure is 172/96 mm Hg. Which of the following is the LEAST likely the etiology?
A
pericardial effusion
Hint:
Pericardial effusion would cause diastolic pressures.
B
aortic regurgitation
C
arteriovenous fistula
Hint:
AV fistula would cause increased systolic pressures with decreased diastolic pressures as well.
D
thyrotoxicosis
Hint:
Thyrotoxicosis would cause high systolic, but low diastolic pressures (increased HR reduces filling time, so less EDV).
E
patent ductus arteriosus
Hint:
PDA would cause increased systolic pressures with reduced diastolic pressures.
Question 22 Explanation: 
Pericardial effusion would cause diastolic pressures. AV fistula would cause increased systolic pressures with decreased diastolic pressures as well. Thyrotoxicosis would cause high systolic, but low diastolic pressures (increased HR reduces filling time, so less EDV). PDA would cause increased systolic pressures with reduced diastolic pressures.
Question 23
A patient presents after falling down some stairs. The chief complaint is pain to the right thumb. During the examination, you note gross laxity in the first metacarpophalangeal joint when moving the right thumb into abduction. An x- ray reveals no fracture. Which of the following structures is injured?
A
radial collateral ligament of the thumb
B
ulnar collateral ligament of the thumb
C
flexor tendons of the thumb
D
extensor tendons of the thumb
E
median nerve, causing thenar musculature hypotonicity
Question 23 Explanation: 
This is the ulnar collateral ligament - must be referred. Look at the anatomy of the thumb!
Question 24
A 24 year-old female presents complaining of recurrent bilateral breast pain, worst during the last few days of her menstrual cycle. She states that she does have “lumpy” breasts. On examination, you note several small nodular lesions in both breasts that are freely movable. The axilla are bilateral unremarkable. You suspect:
A
a fibroadenoma.
B
carcinoma of the breast
C
fibrocystic breast changes.
D
Bowen’s disease.
E
her mammogram to be normal.
Question 24 Explanation: 
Fibrocystic breast disease is most likely in this patient
Question 25
Which of the following is the most effective prophylaxis for traveler’s diarrhea?
A
Metronidazole
B
Ciprofloxacin
C
Tetracycline
D
Ampicillin
Question 25 Explanation: 
Options for prophylaxis of traveler’s diarrhea include norfloxacin, ciprofloxacin, ofloxacin, or trimethoprim/sulfamethoxazole.
Question 26
A patient is started on a new antipsychotic medication for his disorder. Three days later he develops altered consciousness, lead-pipe rigidity, diaphoresis and catatonia. Vital signs reveal respiratory rate of 20, temperature of 105.6 degrees F, and pulse oximetry of 95% room air. Which of the following would be the most appropriate initial intervention in this patient?
A
Immediate oral SSRI’s and Benadryl
B
Supportive care with fluids and antipyretics
C
IV antibiotics and naloxone
D
Intubation and mechanical ventilation
Question 26 Explanation: 
Neuroleptic malignant syndrome is characterized by extrapyramidal signs, blood pressure changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, cardiovascular instability, fever, pulmonary congestion and diaphoresis. Controlling fever and fluid support are the best initial management. With a normal pulse oximetry mechanical ventilation is not indicated.
Question 27
Which of the following is most frequently associated with renal cell carcinoma?
A
Hematuria
B
Inguinal pain
C
Hypocalcemia
D
Fever
Question 27 Explanation: 
Gross or microscopic hematuria, flank pain, or mass is common in renal cell carcinoma.
Question 28
What is the mechanism of action for aspirin?
A
Inhibits platelet aggregation by blocking cyclooxygenase-1 activity
B
Exerts antiplatelet effects by blocking the platelet membrane adenosine diphosphate receptors
C
Inhibits the platelet membrane glycoprotein IIb/IIIa receptor
D
Converts plasminogen to the natural fibrinolytic agent plasmin
Question 28 Explanation: 
Aspirin inhibits platelet aggregation by blocking cyclooxygenase-1 activity.
Question 29
A 28 year-old man presents to the emergency department complaining of sudden onset of shortness of breath associated with sharp right-sided chest pain increased with breathing. On physical examination, respirations are 20 per minute and blood pressure is 120/76 mm Hg. Auscultation of the chest reveals absent breath sounds over the right apex with normal heart sounds. Percussion of the right apex is noted to be hyperresonant. Which of the following is the most likely diagnosis?
A
Hemothorax
B
Pneumothorax
C
Pulmonary embolus
D
Foreign body aspiration
Question 29 Explanation: 
This patient most likely has a spontaneous pneumothorax which is supported by the presenting symptoms of sudden onset of dyspnea and pleuritic chest pain as well as the physical exam findings of absent breath sounds and hyperresonance to percussion.
Question 30
A 73-year-old female with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 37 deg C, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97%.  You note periumbilical ecchymosis on physical exam. An abdominal CT with contrast is obtained which can be seen here. What is the best definitive management for this patient?
A
Emergent endovascular aneurysm repair
B
Administration of tissue plasminogen activator
Hint:
Administration of tissue plasminogen activator would prevent clotting and would increase bleeding in this patient.
C
Volume resuscitation and watchful waiting
Hint:
A ruptured AAA is a surgical emergency and should immediately be taken to the OR. Thus, watchful waiting is never the correct management in these patients.
D
Administration of tranexamic acid
Hint:
While tranexamic acid has been shown to decrease bleeding in major trauma patients, it does not have a role in the treatment of AAA rupture.
E
Administer IV blood products
Hint:
This patient should be given IV blood products given the hemorrhage that is occuring, however the question asked what is the best definitive management for this patient. Blood products do not definitively treat the underlying pathology.
Question 30 Explanation: 
This patient presents with a ruptured abdominal aortic aneurysm (AAA). Emergency operative repair is required and endovascular aneurysm repair is preferred and has a better survival rate than open repair. Abdominal aortic aneurysm is a local enlargement of the abdominal aorta larger than 3 cm that is commonly observed in elderly patients. Risk factors include smoking, high blood pressure, and other heart or blood vessel diseases. AAA rupture is a true emergency with mortality exceeding 90%. The majority of patients (~70%) do not make it to the hospital alive. Symptoms include vague back, abdominal, or chest pain and are often accompanied by hypotension and hypovolemic shock. If the AAA ruptures in the intraabdominal cavity, death usually results. Retroperitoneal rupture can result in temporary tamponade which can increase survival and allow enough time for surgical intervention to be performed. Treatment is emergency operative repair. The two primary operative approaches are endovascular and open repair. Endovascular aneurysm repair is preferred and has a better survival rate than open repair, which has a mortality rate exceeding 50%.
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