Daily PANCE questions Flashcards
A 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?
A. Order a serum acid phosphatase level
B. Initiate prazosin and schedule a follow-up appointment in 6 weeks
C. Refer the patient for an ultrasound of the prostate and order a PSA level
D. Reassure the patient and schedule a follow-up appointment in six months
E. initiate norfloxacin therapy for 7 days and schedule follow-up in two weeks
Answer: C
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.
Which term is used to describe the characteristic concave or “spoon-shaped” nails of iron deficiency anemia?
A. leukonychia B. koilonychias C. clubbing D. onycholysis E. paronychia
B. Koilonychia
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.
A 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?
A TSH level B hysterosalpingogram C laparoscopy D PAP smear E pelvic ultrasound
Answer: B
While I would disagree that an invasive procedures like HSG should be done first-line, the thing to remember 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.
A 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?
A pH = 7.52; pC02 = 28; p02 = 80 B pH = 7.44; pC02 = 38; p02 = 70 C pH = 7.60; pC02 = 18; p02 = 60 D pH= 7.40; pC02 = 40; p02 = 60 E pH = 7.27; pC02 - 62; p02 = 64
This patient has a RR of 52. If 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).
48 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?
A compression fractures secondary to obesity
B degenerative joint disease
C Potts disease
D compression fractures secondary to osteoporosis
E spondylolisthesis
Answer: C
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.
While suturing a wound, you opt to use lidocaine with epinephrine. The rationale for your choice is:
A an increase in the absorption of the lidocaine.
B an increase in the diffusion of the lidocaine into the nerve’s myelin sheath.
C an increase in the blood flow to the area of injection.
D an increase in the duration of anesthesia.
E a decrease in the risk of infection at the site of injection.
Answer: D
Lidocaine with epinephrine both increases duration of anesthesia and decreases blood flow to the area of injection-i.e. penis, nose, fingers, toes
An 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?
A Wenckebach B third degree heart block C atrial fibrillation D sinus arrhythmia E atrial flutter
Answer: D
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.
Combinations of antimicrobial agents are commonly employed in the treatment of meningitis in infants less than three months old. Ampicillin is commonly an agent included in this regimen. Ampicillin is used empirically for the possible presence of:
A Escherichia coli. B Listeria monocytogenes. C Cytomegalovirus. D Herpesvirus. E Hemophilus influenzae.
Answer: B
While E. Coli can infect an infant delivered vaginally, AMPICILLIN is given to eliminate Listeria. CMV & HSV are viruses. E. Coli & H. Flu are also typically resistant to amp, and more likely a broader spectrum antibiotic would be used.
A 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?
A pterygium B chalazion C ectropion D external hordeolum E internal hordeolum
Answer: B
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.
A 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?
A CT scan B skull radiographs C MRI scan D EEG E PET scan
Answer: B
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.
Which white blood cell disorder is characterized by the presence of the Philadelphia chromosome in 90% of cases?
A chronic lymphocytic leukemia (CLL) B acute lymphocytic leukemia (ALL) C chronic myelogenous leukemia (CML) D acute myelogenous leukemia (AML) E multiple myeloma
Answer: C
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.
Which of the following thyroid profiles is most compatible with a diagnosis of primary hypothyroidism?
A a low TSH (thyroid stimulating hormone) level and a high T4 B a low TSH level and a normal T4 C a low TSH level and a low T4 D a high TSH level and a low T4 E a high TSH and a high T4
Answer: D
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.
All of the following are factors that predispose a patient to the development of gastroesophageal reflux EXCEPT:
A hiatal hernia. B pregnancy C scleroderma. D an incompetent esophageal sphincter E pernicious anemia.
Answer: E
Pernicious anemia has no correlation with GERD. It is an autoimmune destruction of the gastric parietal cells that make intrinsic factor. Signs & symptoms are not present until B12 levels are very low (and include peripheral neuropathies & ataxia)
A patient warrants antihypertensive medication use for the duration of her pregnancy. Which of the following is the antihypertensive recommended for such patients?
A alpha-methyldopa B captopril C nifedipine D propranolol E clonidine
Answer: A
Methyl Dopa (Aldomet) is indicated in pregnancy. 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.
A 6 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?
A Salter-Harris Type III B Salter Harris Type IV C Salter Harris Type V D torus E greenstick
Answer: D, torus
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.
A 55 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?
A. hemorrhage in the distribution of his posterior cerebral artery
B. hemorrhage in the distribution of the middle cerebral artery
C. hypodensity measuring 12 mm by 21 mm in the distribution of the posterior cerebral artery
D. hypodensity measuring 4 mm by 4 mm in the internal capsule
E. calcifications bilaterally, in the third ventricles
Answer D, hypodensity measuring 4 mm by 4 mm in the internal capsule
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)
A 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?
A. calcium B. diazepam C. an amphetamine D. additional magnesium E. oxygen
Answer: A, calcium
Pre-eclampsia causes hyper-reflexia. Magnesium is the treatment. The sign of Mg toxicity is loss of reflexes…this is treated with Calcium
This 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:
A. pityriasis rosea. B. tinea corporis C. psoriasis. D. atopic dermatitis. E. sporotrichosis
Answer: A
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.
A 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?
A. cirrhosis B. nephrotic syndrome C. congestive heart failure D. cystitits E. pyelonephritis
Answer: B, nephrotic syndrome
This is a classic presentation of nephrotic syndrome.
A 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?
A. albuterol B. cromolyn sodium C. prednisone D. theophyline E. epinephrine
Answer: B, cromolyn sodium
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.
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:
A. Rheumatoid arthritis B. Systemic Lupus Erythematosis C. Wegener's granulomatosis D. Sjogren's Syndrome E. Scleroderma
Answer: B
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.
A patient with AIDS develops severe headaches. A CT scan demonstrates multiple ring-enhancing lesions of the brain. What diagnosis is most likely?
A. Toxoplasmosis B. Histoplasmosis C. lymphoma D. Cytomegalovirus E. Herpes encephalitis
Answer: A
Toxo occurs commonly in HIV, 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.
