PANCE
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PANCE is a trademark of its owner, which is not affiliated with and does not endorse Test Treasure Publication or TTP Prep.
10 sample questions for the PANCE, with the correct answer and an explanation for each. No account needed. Try each one before you open the answer.
Sections covered on the exam: Musculoskeletal, Infectiousdiseases, Hematologic, Psychiatry/Behavioralscience, Pulmonary, Reproductive, Neurologic, Cardiovascular System, Dermatologic System, Gastrointestinal/Nutrition, Professionalpractice, Eyes, Ears, Nose, and Throat, Renal, Genitourinary, Mixed Organ Systems, Renal System, Endocrine System, Clinical Task Areas, Reproductive System.
Question 1 · Musculoskeletal
A 3-day-old girl is examined in the newborn nursery before discharge. She was born at 39 weeks' gestation by cesarean delivery performed for persistent breech presentation. She is the first child of her parents. There is no family history of hip problems. Vital signs are normal. The Ortolani and Barlow maneuvers are negative bilaterally, thigh and gluteal folds are symmetric, and leg lengths are equal. The remainder of the examination is normal. Which of the following is the most appropriate recommendation for hip evaluation?
Answer: B. Hip ultrasonography at 6 weeks of age
Breech presentation in the third trimester, female sex, positive family history, and first-born status are risk factors for developmental dysplasia of the hip. Even with a normal examination, infants with breech presentation (especially girls) should undergo hip ultrasonography at about 6 weeks of age, or radiographs at about 4 months if ultrasound is unavailable. Ultrasound in the first weeks of life yields frequent false positives because of physiologic ligamentous laxity from maternal hormones. Radiographs are not useful before the femoral head ossifies at 4 to 6 months. A Pavlik harness is used for confirmed instability or dysplasia, not a normal examination.
Question 2 · Psychiatry/Behavioralscience
A 16-year-old girl is brought to the office by her parents because of a 12-kg (26-lb) weight loss over 6 months. She runs 10 miles daily, eats only vegetables, and says she "still needs to lose weight around the thighs." She has not had a menstrual period in 5 months. She denies binge eating or vomiting. Her BMI is 15.8 kg/m². Which of the following is most likely to be found on physical examination?
Answer: B. Fine, downy lanugo hair on the trunk and back
Restriction of intake with intense fear of weight gain, distorted body image, significantly low body weight, excessive exercise, and amenorrhea indicate anorexia nervosa, restricting type. Starvation produces lanugo (fine, downy hair), dry skin, hypothermia, bradycardia, orthostatic hypotension, and cold acrocyanotic extremities; bradycardia below 50/min is an indication for hospitalization. A resting tachycardia and fever are not expected and would suggest infection or hyperthyroidism instead. Hyperreflexia with clonus suggests hyperthyroidism or serotonin excess. Acanthosis nigricans is associated with insulin resistance and obesity, not starvation.
Question 3 · Mixed Organ Systems
A 19-year-old man comes to the clinic with a mildly itchy rash for 2 weeks. It began as a single 3-cm oval, salmon- colored patch on his chest, and 10 days later numerous smaller oval patches appeared on his trunk and proximal arms. Each patch has a fine collarette of scale just inside its border, and their long axes follow the skin cleavage lines of the back. The palms, soles, and oral mucosa are spared. He had a mild cold last month. He has no new sexual partners, and a rapid plasma reagin test is nonreactive. Which of the following is the most likely diagnosis?
Answer: A. Pityriasis rosea
A herald patch followed 1 to 2 weeks later by smaller oval salmon-colored patches with a collarette of scale, aligned along skin cleavage lines on the trunk and proximal extremities and sparing the palms and soles, is characteristic of pityriasis rosea, possibly related to human herpesvirus 6 or 7 reactivation. It resolves spontaneously in 6 to 8 weeks; treatment is reassurance and antipruritics. Secondary syphilis can mimic it closely but commonly involves the palms and soles and is excluded by a nonreactive RPR. Guttate psoriasis has thicker, silvery-scaled drop-like papules, often after streptococcal pharyngitis. Tinea versicolor has hypo- or hyperpigmented macules with fine scale, and tinea corporis has central clearing with scaly advancing borders.
Question 4 · Gastrointestinal/Nutrition
A 4-week-old firstborn boy is brought to the clinic because of vomiting after nearly every feed for 5 days. The emesis is forceful and nonbilious, and he appears hungry immediately afterward. He has had fewer wet diapers over the past 2 days. Temperature is 37.0°C (98.6°F) and pulse is 168/min. He has dry mucous membranes and a sunken anterior fontanelle; the abdomen is soft and not distended. Which of the following sets of serum findings is most likely?
Answer: D. Hypochloremic, hypokalemic metabolic alkalosis
Projectile nonbilious vomiting with persistent hunger in a 3- to 6-week-old firstborn male is characteristic of hypertrophic pyloric stenosis. Repeated loss of gastric hydrochloric acid produces hypochloremic metabolic alkalosis. Volume depletion activates the renin- angiotensin-aldosterone system, and aldosterone promotes renal sodium retention at the cost of potassium and hydrogen ion excretion, worsening hypokalemia and producing paradoxical aciduria. Hyperchloremic, hypokalemic metabolic acidosis is the pattern of diarrheal bicarbonate loss. Hyponatremic, hyperkalemic metabolic acidosis in an infant with vomiting suggests salt-wasting congenital adrenal hyperplasia, which typically presents with shock and ambiguous genitalia in girls. The diagnosis is confirmed by abdominal ultrasonography, and fluids and electrolytes are corrected before pyloromyotomy.
Question 5 · Psychiatry/Behavioralscience
A 36-year-old woman comes to the office because of constant worry for the past year about her job, finances, and her children's safety, even though she acknowledges things are going well. She has difficulty falling asleep, muscle tension in her neck, irritability, and trouble concentrating at work. She has no history of substance use and drinks one glass of wine weekly. Vital signs are normal, as are physical examination, CBC, and TSH. She wants to begin a medication along with cognitive behavioral therapy. Which of the following is the most appropriate long-term pharmacotherapy?
Answer: D. Sertraline
Excessive, difficult-to-control worry about multiple domains for at least 6 months with restlessness, muscle tension, irritability, poor concentration, and sleep disturbance is generalized anxiety disorder. First-line pharmacotherapy is a selective serotonin reuptake inhibitor such as sertraline or escitalopram (or an SNRI such as venlafaxine or duloxetine), combined with cognitive behavioral therapy. Alprazolam and other benzodiazepines provide rapid relief but carry risks of dependence, tolerance, and withdrawal and are not recommended for long-term monotherapy. Propranolol treats somatic symptoms of performance anxiety only. Bupropion lacks efficacy for anxiety and may worsen it. Hydroxyzine is a short-term adjunct.
Question 6 · Hematologic
A 64-year-old man is on postoperative day 8 after coronary artery bypass grafting and has received subcutaneous unfractionated heparin since surgery. His platelet count was 230,000/mm3 on postoperative day 2 and is now 85,000/mm3. Today he developed a painful, swollen left calf, and duplex ultrasonography shows a popliteal vein thrombosis. He has no bleeding. Serum creatinine and liver enzymes are normal. Which of the following is the most appropriate anticoagulant therapy?
Answer: C. Intravenous argatroban
A platelet decline of more than 50% beginning 5 to 10 days after heparin exposure, with new venous thrombosis, indicates heparin- induced thrombocytopenia, an IgG-mediated disorder against platelet factor 4-heparin complexes that causes a prothrombotic state. All heparin must be stopped, and a non-heparin anticoagulant such as argatroban (a direct thrombin inhibitor) is started, while PF4 antibody and functional assays are sent. Subcutaneous enoxaparin cross-reacts with the antibodies and is contraindicated. Starting oral warfarin during acute thrombocytopenia can cause venous limb gangrene from protein C depletion; it is begun only after platelet recovery, overlapped with a non-heparin agent.
Question 7 · Reproductive
A 30-year-old nulligravid woman presents with 3 years of progressively worsening pelvic pain that begins 2 days before menses and persists throughout, along with deep dyspareunia and painful defecation during menses. She has been trying to conceive for 14 months. Her menses are regular and of normal volume. Urine hCG is negative. Which of the following is most likely to be found on bimanual and rectovaginal examination?
Answer: A. Nodularity of the uterosacral ligaments
Cyclic pelvic pain that begins before menses, deep dyspareunia, dyschezia, and infertility suggest endometriosis. Implants commonly involve the uterosacral ligaments and cul-de-sac, producing tender nodularity on rectovaginal examination; a fixed, retroverted uterus and tender adnexal masses (endometriomas) may also be found. The examination may be normal, and definitive diagnosis is by laparoscopic visualization with biopsy. A Diffusely enlarged, boggy, tender uterus suggests adenomyosis, which usually causes heavy menses in multiparous women in their 40s. An Irregularly enlarged, firm, nontender uterus suggests leiomyomas.
Question 8 · Gastrointestinal/Nutrition
A 63-year-old man comes to the emergency department with 3 days of left lower quadrant pain and fever. Temperature is 38.6°C (101.5°F), blood pressure is 132/80 mm Hg, and pulse is 96/min. There is left lower quadrant tenderness with localized guarding and no diffuse rigidity. Leukocyte count is 16,200/mm3. CT of the abdomen and pelvis with contrast shows sigmoid wall thickening with inflamed diverticula and a 5-cm rim-enhancing pericolic fluid collection; there is no free air. Intravenous antibiotics are started. Which of the following is the most appropriate next step in management?
Answer: C. CT-guided percutaneous abscess drainage
This patient has complicated sigmoid diverticulitis with a 5-cm pericolic abscess (Hinchey stage I–II). Abscesses of about 3 cm or larger in hemodynamically stable patients are best treated with intravenous antibiotics plus CT-guided percutaneous drainage, which often avoids emergency surgery or allows a later single-stage elective resection. Smaller abscesses may respond to antibiotics alone. Emergent sigmoid resection with end colostomy (Hartmann procedure) is reserved for generalized purulent or feculent peritonitis, failure of drainage, or instability. Colonoscopy is avoided during acute diverticulitis because of perforation risk and is done 6 to 8 weeks later to exclude cancer. Outpatient oral therapy is appropriate only for uncomplicated disease.
Question 9 · Psychiatry/Behavioralscience
A 38-year-old man comes to the office because of poor sleep for 3 months. Four months ago, he was the driver in a highway collision in which his passenger was killed. Since then, he has recurrent nightmares of the crash, becomes panicked and sweaty when he hears screeching tires, and takes back roads to avoid the highway. He feels detached from his wife, blames himself for the death, startles easily, and has difficulty concentrating at work. He drinks two beers nightly. Physical examination is normal. Which of the following is the most likely diagnosis?
Answer: A. Posttraumatic stress disorder
After exposure to actual death, this patient has intrusion symptoms (nightmares, physiologic reactivity to reminders), avoidance, negative alterations in cognition and mood (detachment, self-blame), and hyperarousal (startle, poor concentration) lasting longer than 1 month, meeting criteria for posttraumatic stress disorder. First-line treatment is trauma-focused psychotherapy, with an SSRI or venlafaxine as pharmacotherapy. Acute stress disorder has the same symptom clusters but lasts 3 days to 1 month after the trauma. Adjustment disorder applies when symptoms do not meet criteria for another specific disorder. Generalized anxiety disorder involves diffuse worry unrelated to a traumatic event.
Question 10 · Musculoskeletal
A 44-year-old woman comes to the office because of pain and swelling of her hands and wrists for 5 months. She has morning stiffness lasting 90 minutes. Examination shows symmetric swelling and tenderness of the second and third metacarpophalangeal and proximal interphalangeal joints and both wrists. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies are positive, and C-reactive protein is elevated. Hand radiographs show periarticular erosions. Liver and renal function are normal, hepatitis B and C serologies are negative, and she is not planning pregnancy. Which of the following is the most appropriate initial disease-modifying therapy?
Answer: E. Methotrexate
Symmetric inflammatory polyarthritis of the small joints of the hands and wrists with prolonged morning stiffness, seropositivity for rheumatoid factor and anti-CCP, and erosions indicates rheumatoid arthritis with poor prognostic features. Methotrexate is the anchor, first-line conventional DMARD for moderate to high disease activity, given weekly with folic acid, with CBC, liver, and renal monitoring. It is teratogenic and requires contraception. Hydroxychloroquine monotherapy is reserved for mild, nonerosive disease. TNF inhibitors such as infliximab are added when targets are not met on methotrexate and require tuberculosis screening. Colchicine and allopurinol are used for gout.
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