Listen to Podcast Episode 109: Ten PANCE, PANRE, and Rotation Review Questions

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Welcome to episode 109 of the Audio PANCE and PANRE Physician Assistant/Associate (PA) Board Review Podcast.

Join me today as we cover ten board review questions for your PANCE, PANRE, EOR, and EOC exams.

Resources and links from today’s episode:

• View my PANRE-LA Performance Score and see my process for taking PANRE-LA Questions
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I hope you enjoy this free audio component of the examination portion of this site. Smarty PANCE includes over 2,000 interactive board review questions, along with flashcards, ReelDx cases, integrated Picmonics, and lessons covering every blueprint topic available to all Smarty PANCE members.

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Interactive Exam to Complement Today’s Podcast

1. A 70-year-old man presents for evaluation of poorly controlled hypertension despite adherence to five different classes of antihypertensive medications. His medical history includes coronary artery disease with a myocardial infarction 3 years ago, peripheral artery disease, and type 2 diabetes mellitus. He reports no changes in his medication regimen and denies any recent lifestyle modifications. Physical examination reveals a blood pressure of 190/110 mm Hg in the left arm and 180/100 mm Hg in the right arm. His BMI is 24 kg/m². On auscultation, there is no abnormal heart sound. Which of the following additional findings is most likely to be seen in this patient?

A. Elevated serum aldosterone-to-renin ratio
B. Continuous murmur over the carotid arteries
C. Diminished femoral pulses
D. Continuous bruit in the lateral periumbilical area
E. Pitting edema in the lower extremities

Answer and topic summary

The answer is D. Continuous bruit in the lateral periumbilical area

Renal artery stenosis is a significant cause of secondary hypertension, particularly in patients with a history of atherosclerotic disease, as seen in this patient with coronary artery disease and peripheral artery disease. Resistant hypertension, uncontrolled despite multiple medications, is a hallmark. A continuous bruit in the lateral periumbilical area indicates turbulent blood flow through a narrowed renal artery, supporting this diagnosis.

Incorrect Answers:

• A. Elevated aldosterone-to-renin ratio suggests primary aldosteronism, less likely given the atherosclerotic history pointing to renal artery stenosis.
• B. A carotid murmur indicates carotid artery disease, unrelated to this hypertension scenario.
• C. Diminished femoral pulses align with peripheral artery disease, but don’t explain the resistant hypertension.
• E. Pitting edema suggests heart failure or venous insufficiency, not specific to renal artery stenosis.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Renal System ⇒ Congenital or structural renal disorders ⇒ Renal vascular disease

2. A 70-year-old woman comes to the emergency department due to sudden-onset chest pain followed by shortness of breath. The pain started 2 hours ago, and she experienced an episode of syncope lasting about 1 minute shortly after the pain began. She has a history of untreated hypertension and hyperlipidemia. Blood pressure is 180/95 mm Hg in both arms; pulse is 110/min and irregular; and respirations are 22/min. Pulses are symmetric and equal in all extremities. There is an S4 gallop. ECG shows atrial fibrillation with rapid ventricular response. Serum troponin is elevated. Chest x-ray shows an enlarged cardiac silhouette, and a CT scan confirms aortic dissection. Which of the following is the best next step in management?

A. Administration of aspirin and nitroglycerin
B. Immediate thrombolytic therapy
C. Initiation of anticoagulation with heparin
D. Emergency pericardiocentesis
E. Emergent aortic repair surgery

Answer and topic summary

The answer is E. Emergent aortic repair surgery

This patient’s sudden chest pain, syncope, hypertension, and CT-confirmed aortic dissection necessitate emergent surgical repair to prevent catastrophic complications like rupture. The enlarged cardiac silhouette and symptoms align with this diagnosis, making surgery the priority.

Incorrect Answers:

• A. Aspirin and nitroglycerin treat acute coronary syndromes, but nitroglycerin could worsen dissection by lowering blood pressure.
• B. Thrombolytics are contraindicated due to bleeding risk in dissection.
• C. Heparin is inappropriate in acute dissection due to bleeding risk, despite atrial fibrillation.
• D. Pericardiocentesis addresses tamponade, a possible complication, but isn’t the primary treatment for dissection.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Vascular Disease ⇒ Aortic aneurysm/dissection

3. A 25-year-old woman with a history of frequent sinus infections presents to the clinic for evaluation of ear pain. She recently returned from a vacation involving several flights. During the descent of her last flight, she experienced severe pressure and pain in her ears, followed by fullness and reduced hearing in her right ear. She has tried decongestants and nasal sprays without relief. On examination, the tympanic membrane appears retracted and immobile on pneumatic otoscopy. Which of the following is the most likely diagnosis?

A. Acute otitis media
B. Otitis externa
C. Eustachian tube dysfunction
D. Chronic otitis media
E. Tympanic membrane perforation

Answer and topic summary

The answer is C. Eustachian tube dysfunction

Eustachian tube dysfunction is likely due to pressure changes during flight descent, causing ear pain, fullness, and hearing reduction. The retracted, immobile tympanic membrane on otoscopy confirms impaired pressure equalization, common after air travel in those with sinus issues.

Incorrect Answers:

• A. Acute otitis media typically shows a bulging tympanic membrane and fever, not retraction.
• B. Otitis externa affects the ear canal, with pain on outer ear movement, not tympanic retraction.
• D. Chronic otitis media involves persistent inflammation and perforation, not acute travel-related symptoms.
• E. Perforation would show a hole in the tympanic membrane, not retraction.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint EENT ⇒ Ear Disorders (PEARLS) ⇒ Inner ear (PEARLS) ⇒ Dysfunction of the eustachian tube

4. A 68-year-old man is brought to the emergency department due to sudden difficulty with speech and comprehension. He speaks fluently, but his sentences are nonsensical, and he appears frustrated. He cannot understand simple commands, repeat phrases, or find the right words. Which branch occlusion of the following arteries is most likely responsible for this condition?

A. Anterior cerebral artery
B. Posterior cerebral artery
C. Middle cerebral artery
D. Basilar artery
E. Vertebral artery

Answer and topic summary

The answer is C. Middle cerebral artery

Middle cerebral artery (MCA) occlusion in the dominant hemisphere causes Wernicke’s aphasia, marked by fluent, nonsensical speech and poor comprehension, as seen here. The MCA supplies the lateral frontal, temporal, and parietal lobes, critical for language processing.

Incorrect Answers:

• A. Anterior cerebral artery affects leg strength and personality, not aphasia.
• B. Posterior cerebral artery causes visual deficits, not language issues.
• D. Basilar artery impacts the brainstem, causing cranial nerve deficits, not aphasia.
• E. Vertebral artery affects the cerebellum and brainstem, not language areas.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Vascular Disorders ⇒ Stroke

5. A 30-year-old woman presents to the emergency department with right wrist pain after falling on an outstretched hand while playing tennis. She reports immediate pain and swelling. On examination, there is tenderness in the anatomical snuffbox and pain with axial loading of the thumb. X-ray confirms a fracture. What is the most likely diagnosis?

A. Distal radius fracture
B. Scaphoid fracture
C. Colles’ fracture
D. Lunate dislocation
E. Wrist sprain

Answer and topic summary

The answer is B. Scaphoid fracture

A scaphoid fracture, common after a fall on an outstretched hand, presents with snuffbox tenderness and pain on thumb loading. X-ray confirmation aligns with this diagnosis, though initial films may miss it, requiring follow-up imaging if suspected.

Incorrect Answers:

• A. Distal radius fracture causes diffuse wrist pain, not isolated snuffbox tenderness.
• C. Colles’ fracture, a distal radius type, shows dorsal displacement, not snuffbox-specific signs.
• D. Lunate dislocation impairs wrist function broadly, with distinct X-ray findings.
• E. Wrist sprain lacks fracture-specific tenderness and X-ray evidence.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ Upper Extremity Disorders ⇒ Fractures and dislocations of the forearm, wrist, and hand

6. A 45-year-old man presents to the emergency department with severe left lower abdominal pain starting suddenly two hours ago. He reports nausea and vomiting but denies prior episodes. Examination shows localized tenderness and guarding in the left lower quadrant. Vital signs are stable. Labs reveal leukocytosis with a left shift. CT scan is on order. What is the most likely diagnosis?

A. Acute diverticulitis
B. Acute appendicitis
C. Renal colic
D. Small bowel obstruction
E. Acute cholecystitis

Answer and topic summary

The answer is A. Acute diverticulitis

Acute diverticulitis typically presents with sudden left lower quadrant pain, nausea, vomiting, and leukocytosis. CT findings like pericolic fat stranding confirm this common sigmoid colon condition in adults.

Incorrect Answers:

• B. Appendicitis causes right lower quadrant pain, not left.
• C. Renal colic presents with flank-to-groin pain and hematuria, not quadrant-specific tenderness.
• D. Small bowel obstruction shows crampy pain and distension, with distinct CT findings.
• E. Cholecystitis causes right upper quadrant pain, not left lower.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint GI and Nutrition ⇒ Colorectal disorders ⇒ Diverticular disease 

7. A 50-year-old man presents with red-colored urine for 3 days. He denies pain during urination but has mild hypertension managed with lifestyle changes. Vital signs are stable (BP 125/80 mm Hg, HR 78/min). Urinalysis shows numerous red blood cells and casts, but no white cells or bacteria. What is the best next step in management?

A. Abdominal ultrasound
B. Measurement of 24-hour urinary protein excretion
C. Reassurance and no additional workup
D. Urine culture
E. Cystoscopy

Answer and topic summary

The answer is B. Measurement of 24-hour urinary protein excretion

Red blood cell casts and hematuria suggest glomerulonephritis. Measuring 24-hour urinary protein excretion assesses proteinuria severity, aiding diagnosis of glomerular disease, as dipstick tests may miss subtle changes.

Incorrect Answers:

• A. Ultrasound evaluates non-glomerular causes like stones, not initial for glomerular hematuria.
• C. Reassurance is inappropriate with casts indicating pathology.
• D. Urine culture is unnecessary without infection signs (no WBCs/bacteria).
• E. Cystoscopy targets lower tract issues, not glomerular causes suggested by casts.

Smarty PANCE Content Blueprint Review:

Covered under ⇒  PANCE Blueprint Renal System ⇒ Acute kidney injury (ReelDx + Lecture)

8. A 6-year-old boy presents with swelling and pain in his left knee after a fall. He has had similar episodes after minor injuries. Examination shows a swollen, tender knee with limited motion, no bruising or petechiae. Labs reveal prolonged PTT and normal platelet count. Which additional finding is most likely upon further history and examination?

A. Hematuria
B. Frequent nosebleeds
C. Sister with heavy menstrual bleeding
D. Maternal grandfather with bleeding history
E. Petechiae

Answer and topic summary

The answer is D. Maternal grandfather with history of bleeding following minor trauma

Hemophilia, an X-linked recessive disorder, causes hemarthrosis after minor trauma, with prolonged PTT and normal platelets. A maternal grandfather with bleeding history supports this genetic pattern.

Incorrect Answers:

• A. Hematuria occurs less often than joint bleeding in hemophilia.
• B. Nosebleeds are less typical than hemarthrosis in hemophilia.
• C. Heavy menstrual bleeding suggests von Willebrand disease, not hemophilia (male-predominant).
• E. Petechiae indicate platelet issues, not clotting factor deficiencies like hemophilia.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Hematology ⇒ Coagulation Disorders  ⇒ Clotting factor disorders

Also covered on the Internal Medicine EOR and Emergency Medicine EOR topic lists

9. A 19-year-old man is admitted with progressive lower extremity weakness. He had tingling in his toes 7 days ago, now with difficulty walking, swallowing, and facial weakness. He had a GI illness 3 weeks ago. Neurologic exam shows 1/5 lower and 3/5 upper extremity strength, absent lower reflexes, and decreased upper reflexes. He struggles to hold his head up. What is the best next step in management?

A. Intravenous immunoglobulin therapy
B. Mechanical ventilation
C. Spinal MRI
D. Muscle biopsy
E. Lumbar puncture

Answer and topic summary

The answer is B. Mechanical ventilation

Guillain-Barré syndrome (GBS) presents with ascending weakness and areflexia post-infection. Difficulty swallowing and facial weakness signal respiratory compromise, necessitating immediate mechanical ventilation to prevent failure.

Incorrect Answers:

• A. IVIG treats GBS but isn’t urgent over respiratory support.
• C. Spinal MRI aids diagnosis but isn’t immediate priority.
• D. Muscle biopsy is irrelevant for GBS management.
• E. Lumbar puncture supports diagnosis but delays critical respiratory intervention.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Neurology ⇒ Peripheral Nerve Disorders ⇒ Guillain-Barré syndrome

10. A 25-year-old woman presents with severe, sharp chest pain for 48 hours, radiating to her left shoulder. It worsens lying down or with deep breaths, improves sitting forward. She had a recent upper respiratory infection. Temperature is 37.9°C (100.2°F), ECG shows diffuse ST elevations. What is the most appropriate initial treatment?

A. Acetaminophen and antibiotics
B. Ibuprofen and colchicine
C. Acetaminophen and steroids
D. Ibuprofen and steroids
E. Steroids and antibiotics

Answer and topic summary

The answer is B. Ibuprofen and colchicine

Acute pericarditis, often viral post-infection, causes sharp chest pain relieved by sitting forward, with diffuse ST elevations on ECG. Ibuprofen (NSAID) and colchicine reduce inflammation and prevent recurrence as first-line treatment.

Incorrect Answers:

• A. Acetaminophen lacks anti-inflammatory effect; antibiotics aren’t indicated for viral etiology.
• C. Steroids aren’t first-line due to recurrence risk; acetaminophen is less effective.
• D. Ibuprofen is correct, but steroids aren’t initial therapy.
• E. Steroids and antibiotics are not standard first-line for viral pericarditis.

Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Traumatic, infectious, and inflammatory heart conditions (PEARLS) ⇒ Acute pericarditis

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