PANCE 1 (1-100)
CARDIOLOGY:
I. 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
2. Which of the following drugs is associated with a lupus-like reaction?
A. prednisone
B. tetracycline
C. procainamide
D. oral contraceptives
E. minoxidil
3. Which of the following is a cause of high output heart failure?
A. myocardial ischemia
B. complete heart block
C. aortic stenosis
D. beriberi
B. hemachromatosis
18. A 46 year old male with no past medical history presents complaining of chest pain for four hours. The patient admits to feeling very poorly over the past two weeks with fever and upper respiratory symptoms. The patient denies shortness of breath or diaphoresis. On examination the patient appears fatigued. Vital signs reveal a BP of 130/80, HR 90 and regular, RR1 4. The patient is afebrile. Labs reveal a Troponin I of
10.33 ugIL (0-0.4ug/L). Cardiac catheterization shows normal coronary arteries and an ejection fraction of 40% with global hypokinesis. Which of the following is the most likely diagnosis?
A. myocarditis
B. pericarditis
C. hypertrophic cardiomyopathy
D. coronary artery disease
E. coronary artery spasm
21. 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
24. A 55 year-old male presents complaining of “difficulty writing” using his dominant hand and some “slurred” speech. He has a hx of 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
I). hypodensity measuring 4 nmi by 4 mm in the internal capsule E. calcifications bilaterally, in the third ventricles
35. A previously healthy 24-year-old woman presents to the Emergency Department with palpitations and dyspnea. On ECG, she is found to be in atrial fibrillation with a rapid ventricular response. What key physical examination finding would suggest this patient’s diagnosis?
A. A loud systolic ejection murmur
B. Exopthalmos
C. A pericardial friction rub
D. Dry, coarse hair and cool skin
E. Significant weight gain in past 6 months
37. Which of the following agents has a mechanism of action that does not involve beta-receptors?
A. epinephrine
B. albuterol
C. propranolol
D. prazosin
E. ritodrine
ENDOCRINOLOGY:
4. A patient with a know history of Hashimoto’s thyroiditis presents with symmetric areas of depigmentation on her body. She denies use of skin bleaching agents or sun tanning. Which of the following is the most likely diagnosis?
A. Addison’s disease
B. acanthosis nigricans
C. rosacea
D. vitiligo
E. tinea versicolor
NEPHROLOGY:
5. Which of the following is NOT a characteristic feature of the nephrotic syndrome?
A. proteinuria
B. hematuria
C. hypoalbunuinemia
D. hyperlipidemia
E. generalized edema
20. Lab results for a post-operative oliguric patient reveals an increased BUN to creatinine ratio. The patient has a low fractional excretion of sodium (FENA < 1 %). Which of the following is the most likely diagnosis?
A. interstitial nephritis
B. acute tubular necrosis
C. acute glomerulonephritis
D. obstructive uropathy
E. decreased renal perfusion
38. A 51 year-old male with renal artery stenosis and an elevated BUN and creatinine, is newly diagnosed as hypertensive. Which of the following agents should be avoided?
A. hydrochlorothiazide-triamterene
B. prazocin
C. nifedipine
D. verapamil
E. furosemide
42. A 60 year-old male presents with fatigue, complaints of pallor, anorexia, nausea, asterixis, pruritis and weight loss. The patient also complains of numbness in his hands and feet and a recent occurrence of foot drop. Based on his clinical presentation, which of the following disorder is most likely to be responsible for this clinical picture?
A. chronic renal failure
B. middle cerebral artery occlusion
C. Guillain-Barre Syndrome
Ii Raynaud’s phenomena
E. diabetic peripheral neuropathy
UROLOGY:
6. A 35 year-old female patient presents to the urgent care clinic with right flank pain radiating into her groin. The pain is colicky arid recurs every few minutes, lasting only seconds, but very severe in intensity. You are able to obtain records which show that the patient has had three previous episodes of “ureteral stones” in the past year. She has always passed these stones on her own without sequelae. She has no current primary care provider. She is currently on no medications. Past Medical History is unremarkable. Physical examination is normal except for mild right CVA tenderness. You decide to obtain baseline laboratory analysis which reveals the following abnormalities:
Elevated Total Calcium
Normal alkaline phosphatase
Low S. Phosphorus
High PTFI
The most likely etiology for this patient’s calcium nephrolithiasis is:
A. Paget’s disease of bone
B. Osteoporosis
C. Primary Hyperparathyroidism
D. Milk-alkali syndrome
E. Osteomalacia
PULMONOLOGY:
7. A 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?
A. Silicosis
B. Sarcoidosis
C. Alpha-I antitrypsin deficiency
D. Histoplasmosis
E. Tuberculosis
15. 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; pCO2 = 28; p02 = 80
B. p1-I = 7.44; pCO2 = 38; p02 = 70
C. pH = 7.60; pCO2 = 18; p02 = 60
D. pH = 7.40; pCO2 40; p02 = 60
E. pH = 7.27; pCO2 = 62; p02 = 64
19. A 48 year-old nurse, with a body mass index of 3l, 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
25. A 78-year-old patient has just had hip replacement surgery for a fracture. The nurse contacts you 28 hours after surgery to report that the patient has had the sudden onset of tachypnea and right-sided pleuritic chest pain. You suspect a pulmonary embolism. Which of the following findings would you expect on physical examination of the lungs?
A. dullness to percussion
B. hyperresonance on percussion
C. bronchial breath sounds throughout
D. normal physical exam
E. egophany
26. A 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?
A. Streptococcal pneumoniae pneumonia
B. Mycoplasma pneumoniae pneumonia
C. Pneumocystis jiroveci (carinui) pneumonia
D. Bowen’s disease
E. Steven-Johnson syndrome
HEENT:
8. A 19 year-old presents with purulent nasal drainage, fever and moderate facial pain. The patient states they recently had a cold that they treated symptomatically. Which of the following is the most like pathogen for patient’s new symptoms?
A. streptococcus pneumoniae
B. mycoplasma pneumoniae
C. pseudomonas aeruginosa
D. staphylococcus aureus
E. hemophilus influenzae
12. A 49 year-old female PA presents to your clinic with a history of a sudden onset of
fever and productive cough 48 hours ago. She had just recovered from influenza about
10 days prior to the onset of fever. She has right pleuritic chest pain.
P 120 RR 20 T 102.4 Pulse ox 90% on room air BP 120/70
Physical examination of her lungs would be expected to reveal what physical findings:
-A. Jiyperresonance on percussion arid bronchial breath sounds on the right B. dullness to percussion, bronchial breath sounds and increased tactile fremitus on the right
C. dullness to percussion, pleural friction rub and decreased tactile fi-emitus on the right.
D. tympany on percussion, vesicular breath sounds and increased tactile fremitus on the right
E. Tympany on percussion, decreased breath sounds and increased expiratory phase on the right.
33. A 32 year old female patient presents complaining of 12 plus weeks of laryngitis. She had a URI within the past month, but all those symptoms have resolved. Her only other PMH includes rheumatic fever and some mitral regurgitation for which she has to take dental prophylaxis. She denies fevers, chills, sore throat, ear pain. She does have a slight cough, and it is somewhat exertional, but she hasn’t thought to mention it before.
Based on only this history, which of the following clinical interventions would be most important when considering the most important etiologies for her laryngitis?
A. CBC with differential and platelet count
B. Direct or indirect laryngoscopy
C. Antibiotic therapy x 10-14 days for sinusitis
D. PPI therapy for 2-4 weeks
E. Echocardiogram
GYNECOLOGY:
9. Which of the following is the most common cause of secondary amenorrhea in a woman of reproductive years?
A. PCOS
B. pregnancy
C. excessive exercise
D. oral contraceptives
E. rapid weight change
11. 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
22. A 22 year old female is complaining of menorrhagia that has progressively worsened over the past year. Ultrasound reveals submucosal uterine fibroids. The patient desires to have more children. The most appropriate definitive treatment is:
A. Myomectomy
B. Hysterectomy
C. GnRH agonists
D. Oral Progesterone
E. Myometrial embolization
27. A 23 year-old pregnant woman presents to your clinic estimating that she is about 18 weeks. She has had no antenatal care to date. She is GIPO, with a negative past medical history. Her dates are approximate. Her funda] height appears to be between 16 and 18 weeks on exam. The rest of her PE is unremarkable. You obtain the normal antenatal laboratories including a TS-AFP. The TS-AFP comes back “abnormal” suggesting an increased likelihood for Down’s syndrome for a patient of her age. Your next step would be:
A. refer to a genetic specialist for aniniocentesis
B. repeat the TS-AFP
C. reassure the patient that at her age, Down syndrome is unlikely and no further
w/u need be done
D. obtain an US to establish the accuracy of her dates
E. obtain a quad-AFP, which is more accurate.
MUSCULOSKELETAL:
10. An 82 year-old female presents with a 6 month hlo aching in her shoulders and hips. The onset was fairly abrupt. The pain is bilateral, and especially severe in the morning. The patient says that it is painful to raise her hands above her head. She also mentions significant malaise and a 20 pound weight loss. She also feels depressed. On exam, BP and pulses are normal. There are no significant findings on musculoskeletal exam.
What is the likely diagnosis in this patient?
A. osteoarthritis
B. rheumatoid arthritis
C. polymyalgia rheumatica
I). polymyositis
E. systemic lupus erythematosus
28. The knee exam demonstrates significant forward translation of the tibia when the knee is at 20 degrees of flexion and the tibia is forced forward while the femur is stabilized. Which of the following knee maneuvers does this represent?
A. abduction stress test
B. anterior drawer sign
C. Lachman test
D. McMurray test
E. Patellar apprehension test
PSYCHIATRY:
13. A 28 year-old male patient is being treated for depression and has been taking paroxetine (Paxil) for the past two and a half months with a marked improvement in symptoms. The patient reports problems with sexual functioning which he believes is related to the medication. Which of the following is an immediate concern with abrupt discontinuation of the medication?
A. increased risk of suicide
B. diminished sexual functioning
C. risk of drug withdrawal symptoms
D. worsened depressive symptoms
E. malignant hypertension
PEDIATRICS:
14. A previously well 6 month-old presents with a runny nose and has been sneezing and coughing for 2 days. Two other members of the family have similar symptoms. Four hours ago his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyperexpansion of the chest, and easily audible wheezing without crackles. Which of the following is the most likely diagnosis?
A. bronchiolitis
B. epiglottitis
C. pneumonia
D. sepsis
E. viral croup
17. 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. Herpes virus.
E. Hemophilus influenzae.
23. Which of the following is the treatment of choice for stage one Lyme disease in a patient 14 years of age?
A. doxycycline
B. amoxicillin
C. chioramphenicol
D. azithromycin
E. vancomycin
36. A 12 year old boy presents to the office with pain in his legs with activity gradually becoming worse over the past month. He is unable to ride a bicycle with his friends due to the pain in his legs. Examination of the heart reveals an ejection click and accentuation of the second heart sound which increases with valsalva. Blood pressure obtained in both arms is elevated. Chest X-Ray reveals rib notching. Which of the following is the most likely diagnosis?
A. Abdominal aortic aneurysm
B. pheochromocytoma
C. Coarctation of the aorta
D. thoracic outlet syndrome
E. congenital aortic valve disease
SURGERY:
16. A 57-year old male sustained full thickness burns to his index and middle fingers on his right hand. Which of the following is the preferred management?
A. immediate surgical referral
B. daily debridement and dressing changes
C. topical antibiotics and an occlusive dressing
D. topical silver sulfadiazine, leaving the wounds open
E. immediate ice immersion
OPHTHAMOLOGY:
29. Which of the following is a potential complication for a traumatic hyphema?
A. retinal detachment
B. acute angle closure glaucoma
C. cataract formation
D. chronic conjunctivitis
E. chronic open angle glaucoma
34. The most common cause of preventable blindness in the United States is:
A. macular degeneration.
B. cataracts.
C. retinal detachments.
D. chronic open-angle glaucoma.
E. trauma
41. Papilledema may be caused by all of the following EXCEPT:
A. Chronic subdural hematoma
B. Malignant hypertension
C. Acute subdural hematoma
D. Hemorrhagic stroke
F. Brain tumor
NEUROLOGY:
31. The most frequent finding in a person presenting with a brain abscess is:
A. nuchal rigidity
B. headache
C. seizures
D. vomiting
E. fever
GI:
32. A patient with extrahepatic biliary obstruction is most likely to have:
A negative urine bilirubin
B. marked increase in direct (conjugated) bilirubin
C. increased in indirect (unconjugated) bilirubin
D. normal colored urine
E. steatorrhea
DERMATOLOGY:
39. Which of the following diseases is correlated almost 100% with a dermatologic condition called dermatitis herpetiformis?
A. Crohns colitis
B. Ulcerative colitis
C. Irritable bowel syndrome
D. Chlamydial urethritis
B. Celiac sprue
GU:
40. A male patient presents with mild mental retardation, small testicles, infertility rounded body type. Which karotype is most consistent with this phenotype?
A.XO
B. XXY
C. XXX
D. XXIXY
F. Trisomy 21
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43. 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?
A. rifampin
B. isoniazid
C. streptomycin
D. ethambutol
E aminosalicylic acid
44. An elderly patient is recovering from a pneumonia caused by Influenza. Suddenly, the patient’s condition deteriorates. You order a chest x-ray that demonstrates an air- fluid level, suggestive of an abscess. You empirically begin treatment for:
A. Streptococcal pneumoniae.
B. Chiamydia.
C. Hemophilus inlluenzae.
D. Staphylococcus aureus.
E. Legionella pneumophila.
45. You are on call to the emergency department when you are asked to evaluate a 42- year-old male who has been brought in by the family in the past for treatment of depression; however, over the last week he has exhibited increased energy, decreased sleep, excessive spending, and increased risk-taking behavior. On mental status exam, you see a black male oriented to person, place, time, and date. He is overactive with elevated mood, pressured speech, is easily distracted and difficult to interrupt. What would you suspect as the likely diagnosis?
A. Affective disorder (i.e. depression)
B. Bipolar affective disorders
C. Schizophrenia
D. Dementia
E. Somatoform disorder
46. Secondary to a traumatic even, a child complains of pain in the index fmger. An x ray of the digit demonstrates a fracture line through the metaphysic of the proximal aspect of the middle phalanx, ending at the epiphyseal plate. What type of fracture does this child have?
A. Salter Harris Type I
B. Salter Harris Type II
C. Salter Harris Type III
D. Salter Harris Type IV
E. Salter Harris Type V
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47. At birth an infant weighs 8 pounds. The optima] weight for this infant at 1 year would be:
A. 16 pounds
J3. 20 pounds
C. 24 pounds
11). 28 pounds
E. 32 pounds
48. 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 sitting up and leaning forward. He denies trauma, a cough and shortness of breath. Which of the following test would be most compatible with your suspected diagnosis?
A. a hiatal hernia visualized on chest x-ray
B. a normal erythrocyte sedimentation rate
C calcified “popcorn” lesions in the lung fields bilaterally
ID. diffuse ST segment elevation on his electrocardiograph
E. a widened A-a gradient on his arterial blood gas
49. A typical presenting sign andlor symptom in a patient with hyperparathyroidism due to a parathyroid adenoma would include:
A. a solitary thyroid nodule
B. hyperactivity or restlessness