The Daily PANCE and PANRE Midterm Exam

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Question 1A 52 year-old male presents complaining of urinary frequency, with hesitancy, and nocturia for the past few months. During his physical examination, you note a nontender, non-enlarged prostate with an isolated right posterior lobe nodule. Which of the following options is most appropriate?Aorder a serum acid phosphatase levelBinitiate prazosin and schedule a follow-up appointment in 6 weeks Crefer the patient for an ultrasound of the prostate and order a PSA levelDreassure the patient and schedule a follow-up appointment in six monthsEinitiate norfloxacin therapy for 7 days and schedule follow-up in two weeksQuestion 1 Explanation: This patient has an isolated nodule of the prostate gland — cancer until proven otherwise. You should order an ultrasound and a PSA. BPH will present as diffuse enlargement, and not a discrete nodule.Question 2Which term is used to describe the characteristic concave or "spoon-shaped" nails of iron deficiency anemia?AleukonychiaHint: Leuko nychia is often associated with hypoalbuminaemia that causes partial or complete white discoloration of the nails. Leukonychia may also appear as a rare side effect of systemic chemotherapy in some oncological patients but may also be present with arsenic poisoning, renal failure pneumonia, or heart disease. BkoilonychiaCclubbingHint: Clubbing of the nails is an actual thickening or elevation of the nail bed - it is a sign of release of TNF associated with pulmonary disorders (tissue necrosis factor) typically found in bronchiectasis, lung cancers and cystic fibrosis (the nails are NOT necessarily cyanotic.) DonycholysisHint: Onycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. EOnycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. Hint: Paronychia is an infection of the nail bed and nail margin, usually from trauma or more commonly, nail-biting.Question 2 Explanation: Koilonychia is a spoon-shaping of the nail itself. It is usually a result of iron deficiency anemia. Leukonychia is often associated with hypoalbuminaemia that causes partial or complete white discoloration of the nails. Leukonychia may also appear as a rare side effect of systemic chemotherapy in some oncological patients but may also be present with arsenic poisoning, renal failure pneumonia, or heart disease. Clubbing of the nails is an actual thickening or elevation of the nail bed - it is a sign of release of TNF associated with pulmonary disorders (tissue necrosis factor) typically found in bronchiectasis, lung cancers and cystic fibrosis (the nails are NOT necessarily cyanotic.) Onycholysis is a painless separation of the nail from the nail bed. Several or all nails are usually affected - there are many causes. Paronychia is an infection of the nail bed and nail margin, usually from trauma or more commonly, nail-biting.Question 3Which of the following is NOT a characteristic feature of the nephrotic syndrome?AproteinuriaBhematuriaChypoalbuminemiaDhyperlipidemiaEgeneralized edemaQuestion 3 Explanation: Hematuria is present in NEPHRITIC syndrome. Nephrotic syndrome characteristically includes proteinuria (>3.5 gm/day), with resulting low serum albumin, hyperlipidemia, hypertension, hypercoagulability, and generalized edema (from oncotic third-spacing)Question 4A patient describes a history of recurrent bouts of uveitis. Her chemistry panel reveals elevated serum calcium and uric acid levels. Her anergy screen is negative. Her chest x-ray demonstrates bilateral hilar adenopathy. Which diagnosis is most likely?ASilicosisBSarcoidosisCAlpha-1 antitrypsin deficiencyDHistoplasmosisETuberculosisQuestion 4 Explanation: Sarcoid typically presents with hilar lvmphadenopathy and noncaseating granulomas of the lungs (and other organs). In addition, patients may get eye involvement (uveitis). Elevations of ACE, Calcium and uric acid are frequently seen.Question 5A 34-old female presents complaining of symmetrical redness and swelling of the small joints of her hands (PIPs and MCPs). She has noted that the symptoms are worst in the morning . Her erythrocyte sedimentation rate is elevated and her rheumatoid factor is negative. Which of the following diagnosis is most likely?Aprogressive systemic sclerosisHint: PSS involves squamous cell thickening and sclerosis causing taut skin of the face and hands and difficulty with esophageal motility. BCREST syndromeHint: CREST syndrome is a subset of PSS; CosteoarthritisDrheumatoid arthritisEankylosing spondylitis Hint: Ankylosing spondylitis would have an elevated ESR and negative RF, but mainly involves the SI joint and lumbar/thoracic spine fusion (bamboo spine)Question 5 Explanation: In spite of the negative RF, Rheumatoid arthritis is the most likely diagnosis. RA characteristically includes small joint symmetrical arthritis, with an elevated ESR (therefore inflammatory, and not OA). 80% of patients with RA will have a positive RF, but 20% will be negative. PSS involves squamous cell thickening and sclerosis causing taut skin of the face and hands and difficulty with esophageal motility. CREST syndrome is a subset of PSS; Ankylosing spondylitis would have an elevated ESR and negative RF, but mainly involves the SI joint and lumbar/thoracic spine fusion (bamboo spine)Question 6A 27 year-old nulliparous female presents because she's been trying to get  pregnant for two years, but has failed. She relates a history of a misdiagnosis of appendicitis that lead to abscess formation when she was 14 years old. Which of the following diagnostic studies would be most helpful at this point in her evaluation?ATSH levelHint: The TSH level would not be indicated (she has not had a pg loss)BhysterosalpingogramClaparoscopyHint: lap could diagnose the tubal scarring but would be done after an abnormal HSGDPAP smearHint: Pap smear is screening for cervical cancer and not indicated in this case of infertility;Epelvic ultrasoundHint: pelvic US would yield nothing diagnostically about the tubes.Question 6 Explanation: While I would disagree that an invasive procedures like HSG should be done first-line, the thing to reme mber in this question is that the patient has reason to have tubal scarring from adhesions (and there is no better answer listed to choose), so, for a board exam I would choose this answer. The TSH level would not be indicated (she has not had a pg loss), lap could diagnose the tubal scarring but would be done after an abnormal HSG. Pap smear is screening for cervical cancer and not indicated in this case of infertility; and pelvic US would yield nothing diagnostically about the tubes.Question 7A 14 year-old is experiencing a severe asthma attack. Although he is using accessory muscles to breath, auscultation of his chest reveals no audible wheezing. His heart rate is 160 and his respiratory rate is 52. Which of the following arterial blood gases represents the worst prognosis?ApH = 7.52; pC02 = 28; p02 = 80BpH = 7.44; pC02 = 38; p02 = 70CpH = 7.60; pC02 = 18; p02 = 60DpH= 7.40; pC02 = 40; p02 = 60E pH = 7.27; pC02 - 62; p02 = 64Question 7 Explanation: This patient has a RR of 52. I f she is ventilating, she is blowing of C02 (an acid) and would be alkalotic and should have a low C02. A pH which is acidic with a pC02 which is elevated means that she is no longer ventilating at all (she needs mechanical ventilation or she will die).Question 848 year-old nurse, with a body mass index of 31, presents for an evaluation for back pain. She relates that historically, she had a positive PPD test a year ago and did not follow-up as directed. She has recently been experiencing night sweats and coughing. An x-ray of her lumbar spine reveals osteopenia and cortical breakdown of vertebral bodies L4 and L5. Which of the following diagnosis is most suspect?Acompression fractures secondary to obesityBdegenerative joint diseaseCPotts diseaseDcompression fractures secondary to osteoporosisEspondylolisthesisQuestion 8 Explanation: Pott's disease is TB of the spine. She could have any of the other diseases; but the question states that she had a positive PPD and did not take meds. ..that is the clue that she has active TB in the spine.Question 9While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is:Aan increase in the absorption of the lidocaine.Ban increase in the diffusion of the lidocaine into the nerve's myelin sheath.Can increase in the blood flow to the area of injection.Dan increase in the duration of anesthesia.Ea decrease in the risk of infection at the site of injection.Question 9 Explanation: Lidocaine with epinephrine both increases duration of anesthesia and decreases blood flow to the area of injection-i.e. penis, nose, fingers, toesQuestion 10An EKG demonstrates a PR interval of 0.16 seconds, a P to QRS relationship of 1:1, a variable heart rate and an R to R interval that is noted to accelerate ad decelerate during the respiratory cycle. What is the diagnosis?AWenckebachHint: Wenckebach AVB would have a non-conducted P wave. Bthird degree heart blockHint: Third degree AVB would have a non-conducted P wave. Catrial fibrillationHint: A fib would have no P waves and an irregularly irregular rhythmDsinus arrhythmiaEatrial flutterHint: A flutter would have "flutter waves" or a regular rhythm of 150.Question 10 Explanation: This is sinus arrhythmia. Wenckebach & third degree AVB would have a non-conducted P wave. A fib would have no P waves and an irregularly irregular rhythm. A flutter would have "flutter waves" or a regular rhythm of 150.Question 11A 42 year-old female presents after finding a firm, painless bump in her right eyelid. On examination, you note a 6 mm mass within the tarsus of the right eye. The skin is freely movable over the mass. The remainder of the ophthalmoscopic examination is unremarkable. Which of the following is the most likely diagnosis?ApterygiumHint: Pterygium involves the sclera. BchalazionCectropionHint: Ectropion is when the eyelid sags outwardly and the lid doesn't close well.Dexternal hordeolumHint: Hordeolum are acute and red and painful.Einternal hordeolum Hint: Hordeolum are acute and red and painful. Question 11 Explanation: A chalazion is a painless chronic mass in the eyelid. Hordeolum are acute and red and painful. Pterygium involves the sclera. Ectropion is when the eyelid sags outwardly and the lid doesn't close well.Question 12A 22 year-old patient was involved in an automobile accident and is comatose. Which of the following diagnostic modalities would be least useful in this patient's evaluation?ACT scanHint: CT would be the imaging test of choice. Bskull radiographsCMRI scanHint: MRI should be done for a more chronic bleed.DEEGHint: EEG would help to establish brain activity. EPET scanHint: PET scan (while not done often) would establish physiologic function (uptake of glucose). Question 12 Explanation: Of these choices, the skull film is LEAST useful. Whether or not the skull is fractured, any LOC in a head trauma requires imaging for bleeding. CT would be the imaging test of choice. MRI should be done for a more chronic bleed. EEG would help to establish brain activity. PET scan (while not done often) would establish physiologic function (uptake of glucose). A positive or negative plain film of the skull would supply NO FURTHER INFORMATION.Question 13Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases?Achronic lymphocytic leukemia (CLL)Hint: CLL has no clear distinguishing feature except increased lymphocytes.B acute lymphocytic leukemia (ALL)Hint: ALL occurs in children. Cchronic myelogenous leukemia (CML)Dacute myelogenous leukemia (AML)Hint: AML is associated with Auer rodsEmultiple myelomaHint: Multiple myeloma has Bence-Jones protein. Question 13 Explanation: Philadelphia Chromosome occurs in CML. ALL occurs in children. AML is associated with Auer rods. Multiple myeloma has Bence-Jones protein. CLL has no clear distinguishing feature except increased lymphocytes.Question 14Which of the following thyroid profiles is most compatible with a diagnosis of primary hypothyroidism?Aa low TSH (thyroid stimulating hormone) level and a high T4Ba low TSH level and a normal T4Ca low TSH level and a low T4D a high TSH level and a low T4Ea high TSH and a high T4Question 14 Explanation: Low T4 is diagnostic for low thyroid function. If the pituitary is normal (as in primary thyroid disease) the TSH should be high as the pituitary tries to stimulate the failing thyroid gland.Question 15All of the following are factors that predispose a patient to the development of  gastroesophageal reflux EXCEPT:Ahiatal hernia.BpregnancyCscleroderma.Dan incompetent esophageal sphincter Epernicious anemia.Question 15 Explanation: Pernicious anemia has no correlation with GERD. It is an autoimmune destruction of the gastric parietal cells that make intrinsic factor. Signs Methyl Dopa (Aldomet) is indicate d in pg. ACEI's (captopril) are contraindicated in pg. B-Blockers can be used but may cause growth restriction. Diuretics are not used in pg. CCB's and centrally acting agents (while not contraindicated) should be avoided.Question 176 year-old child falls onto his right arm. An x-ray demonstrates a buckle in the cortices of the distal radius, proximal to the growth plate, without angulation. What is the term used to describe this fracture?ASalter-Harris Type IIIBSalter Harris Type IVCSalter Harris Type VDtorusEgreenstickHint: Greenstick fracture is also common in children in long bones and is a fracture which "bends" the bone without fracturing it.Question 17 Explanation: Torus or buckle fracture is most common in a child. This is proximal to the epiphyseal plate and so is not a Salter-Harris issue. Greenstick fracture is also common in children in long bones and is a fracture which "bends" the bone without fracturing it.Question 1855 year-old male presents complaining of "difficulty wrtiing" using his dominant hand and some "slurred" speech. He has a h/o hypertension, DM type II, and hypertriglyceridemia. Which of the following would you anticipate to find on a CT scan of his head, as the explanation for his chief complaint?Ahemorrhage in the distribution of his posterior cerebral arteryBhemorrhage in the distribution of the middle cerebral arteryChypodensity measuring 12 mm by 21 mm in the distribution of the posterior cerebral arteryDhypodensity measuring 4 mm by 4 mm in the internal capsuleE calcifications bilaterally, in the third ventriclesHint: Calcifications are not indicative of stroke at allQuestion 18 Explanation: The main clue in this question is that most strokes are ischemic - especially with THIS patient's history (ruling out hemorrhagic infarct - A & B). Calcifications (E) are not indicative of stroke at all. When trying to decide between C & D - the size of the area needs to correlate with the patient's sxs. If the patient had a HUGE infarct (12 x 21) he would have significantly more sxs than just some slurred speech and difficulty writing. (In addition, as it turns out, the internal capsule is supplied by the MCA - which is the most common vessel involved in an ischemic stroke)Question 19A female in her third trimester of pregnancy developed hypertension, diffuse edema, proteinuria and hyperreflexia. She was treated with intravenous magnesium sulfate and is now hyporeflexic and drowsy. What do you prescribe now?Acalcium BdiazepamCan amphetamineDadditional magnesiumEoxygenQuestion 19 Explanation: Pre-eclampsia causes hyper-reflexia. Magnesium is the treatment. The sign of Mg toxicity is loss of reflexes...this is treated with Calcium.Question 20This papulosquamous eruption is most common in young adults. A single oval patch is generally noted several days before a more generalized, fawn-colored rash erupts. This rash is most prevalent on the trunk, and the proximal upper and lower extremities. The rash spontaneously disappears over 5 to 6 weeks. The diagnosis is:Apityriasis rosea.Btinea corporisCpsoriasis.Datopic dermat itis.EsporotrichosisQuestion 20 Explanation: This is the classic presentation of pityriasis rosea. Remember that the differential diagnosis includes secondary syphilis, so if a positive sexual history - consider ordering a VDRL/RPR. The "herald" patch which is described is pathognomonic for pityriasis.Question 21A patient presents complaining of generalized swelling. Her urine is positive for protein. Her serum testing reveals hyperlipidemia and hypoalbuminemia. Which of the following is the most likely diagnosis?AcirrhosisBnephrotic syndromeCnephritic syndromeDcystititsEpyelonephritis Question 21 Explanation: This is a classic presentation of nephrotic syndrome.Question 22A patient is experiencing an acute exacerbation of asthma. Which of the following drugs would be the least useful in the management of this asthma attack?AalbuterolBcromolyn sodiumCprednisoneDtheophylineEepinephrineQuestion 22 Explanation: Cromolyn is a mast cell stabilizer and must be present in the system PRIOR to the symptoms. It would be useless in a patient already having symptoms.Question 23A 34 year-old female patient presents to the ER with sharp pleuritic-type chest pain. An x-ray reveals pericarditis. On more careful questioning, the patient admits to a polyarticular arthritis involving the small joints of her hands. Her obstetrical history is positive for two third trimester spontaneous abortions. At this point, you would suspect which autoimmune process as the cause of her symptoms:ARheumatoid arthritisBSystemic Lupus ErythematosisCWegener's granulomatosis DSjogren's SyndromeESclerodermaQuestion 23 Explanation: 40-60% of patients with SLE have serositis (pleuritis and pericarditis). That, combined with joint pains, habitual AB - should cause you to order an ANA.Question 24A patient with AIDS develops severe headaches. A CT scan demonstrates multiple ring-enhancing lesions of the brain. What diagnosis is most likely?AToxoplasmosisBHistoplasmosisClymphomaDCytomegalovirusHint: CMV i s common as well and typically causes retinitis. EHerpes encephalitis Hint: Herpes encephalitis can happen frequently too, but causes a diffuse encephalitis.Question 24 Explanation: Toxo occurs commonly in HTV, and is a parasitic infection causing ring-enhancing lesions (but lots of things can cause ring-enhancing lesions). CMV is common as well and typically causes retinitis. Herpes encephalitis can happen frequently too, but causes a diffuse encephalitis.Question 25A Caucasian male has a history of a meconium ileus as a newborn, steatorrhea and a positive sweat test. What is the most likely diagnosis?Avon Gierke's diseaseHint: Von Gierke disease is a condition in which the body cannot break down glycogen for energy. Gycogen is stored in the liver and muscles and is normally broken down into glucose when you do not eat. Von Gierke disease is also called Type I glycogen storage disease (GSD I).BHurler's syndromeCcystic fibrosisDHunter's syndromeECri du chat syndromeQuestion 25 Explanation: This is the classic presentation of CF.Question 26A 32 year-old male presents with dyspnea and a nonproductive cough. His is tachycardic, tachypneic and febrile. Auscultation of his chest reveals scattered rhonchi. His chest x-ray demonstrates a diffuse interstitial infiltrate. His ABG demonstrates moderate hypoxemia and his LDH is elevated. What is the most likely diagnosis?AStreptococcal pneumoniae pneumoniaHint: S. pneumo is the most common CAP, but would present with a focal/lobar consolidationBMycoplasma pneumoniae pneumonia Hint: While mycoplasma patients can be acutely ill, they are more likely (especially on the Boards) to present as mildly ill with normal PE and no hypoxia. CPneumocystis carinii pneumoniaDBowen's diseaseESteven-Johnson syndromeQuestion 26 Explanation: Many AIDS patients present initially w ith PCP. These are the classic sns & sxs of PCP pneumonia. While mycoplasma patients can be acutely ill, they are more likely (especially on the Boards) to present as mildly ill with normal PE and no hypoxia. S. pneumo is the most common CAP, but would present with a focal/lobar consolidation.Question 27A patient describes a history of a "curtain being brought down over my right  eye it stayed there for a few minutes then was lifted back up." In which of  the following arteries is the etiology of this complaint located?Aanterior cerebralBmiddle cerebralC posterior cerebralDinternal carotidEexternal carotidQuestion 27 Explanation: This is amaurosis fugax....a form of "TIA" of the optic artery — it arises from the internal carotid - most common location for occlusion in TIA. Question 28Upon review of an EKG you notice periodic, repetitively absent QRS complexes and "grouped beating." Which of the following is the explanation?Athird degree heart blockHint: in third degree, there is no rhyme or reason to the rhythm.B Mobitz Type II heart blockHint: In Mobitz II, the PR intervals are the same - so no "grouped" beatingC Mobitz Type I heart blockDfirst degree heart blockEsinus tachycardiaQuestion 28 Explanation: I don't like the wording of this question, but typically "group beating" suggests Wenckebach. The fact that there are absent QRS complexes means there is a second or third degree AVB. In Mobitz II, the PR intervals are the same - so no "grouped" beating, in Third degree, there is no rhyme or reason to the rhythm. In Wenckebach, the rhythm "repeats", causing a "regularly irregular" rhythm.Question 29A 14 month-old female is brought to your office with a 3-day history of a fever of 104 degrees rectally. Suddenly, today, the fever stopped and a rash deve loped. Examination reveals a diffuse, fine, maculopapular rash. Presently, the child does not appear ill. The most likely diagnosis is:ArubellaHint: Rubella has mild illness with a fine macular rasBrubeolaHint: Rubeola (measles) is an acute illness, the child is toxic, has conjunctivitis and Koplik spots. Cerythema infectiosum (Fifth's disease) Hint: Fifth's disease has mild illness with a "lacey" rash on the extremities. DRoseolaEchicken poxHint: Chicken pox has vesicles.Question 29 Explanation: This is typical for Roseola. Rubella has mild illness with a fine macular rash. Rubeola (measles) is an acute illness, the child is toxic, has conjunctivitis and Koplik spots. Fifth's disease has mild illness with a "lacey" rash on the extremities. Chicken pox has vesicles.Question 30At what age does the first tooth usually erupt in an infant?A2-4 monthsHint: See B for explanationB6-8 monthsC 10-12 monthsD 14-16 monthsQuestion 30 Explanation: The first tooth in an infant to erupt is the central incisor at the average age of 6-8 months. Once you are finished, click the button below. Any items you have not completed will be marked incorrect. Get Results There are 30 questions to complete. List Return Shaded items are complete. 123456789101112131415161718192021222324252627282930End Return You have completed questions question Your score is Correct Wrong Partial-Credit You have not finished your quiz. If you leave this page, your progress will be lost. 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