The Audio PANCE and PANRE Physician Assistant Board Review Podcast
Health & Fitness:Medicine
Podcast Episode 103: Ten PANRE & PANRE-LA Intervention Complex Practice Questions
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Welcome to episode 103 of the Audio PANCE and PANRE Physician Assistant/Associate Board Review Podcast.
Join me today as we cover ten NCCPA-style board review questions for your PANRE and PANRE-LA exams.
Special from today’s episode: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.
1. A 65-year-old man presents to your office with complaints of constipation for the past six months. He says that he has difficulty passing stools, which are hard and dry. He also reports occasional abdominal pain and bloating. He denies any weight loss, blood in stools, fever, or night sweats. His medical history is significant for hypertension and type 2 diabetes mellitus. His medications include metformin, lisinopril, and aspirin. He does not smoke or drink alcohol. On physical examination, his vital signs are normal. His abdomen is soft and nontender, with normal bowel sounds. There are no masses or organomegaly palpable. Which of the following is the most appropriate next step in evaluating this patient?
A) Colonoscopy
B) Barium enema
C) Thyroid function tests
D) Stool osmolarity
E) Dietary modification
The correct answer is A) Colonoscopy
Colonoscopy is a procedure that involves inserting a flexible tube with a camera into the colon to visualize the mucosa and detect any abnormalities such as polyps, tumors, inflammation, or bleeding. It is indicated for patients with chronic constipation who are older than 50 years or have any red flag features for colorectal malignancy, such as weight loss, blood in stools, anemia, or a family history of colon cancer. This patient meets the age criterion and should undergo colonoscopy to rule out any serious causes of his constipation.
Answer explanations:
(Review PANRE Blueprint Topic: Constipation)
2. A 60-year-old male presents to the emergency department with chest pain and shortness of breath. ECG reveals ST segment elevation in the anterior leads. Which of the following laboratory tests is the most specific for the diagnosis of acute myocardial infarction (AMI)?
A) Troponin
B) Creatinine kinase-MB (CK-MB)
C) Myoglobin
D) C-reactive protein (CRP)
E) Brain natriuretic peptide (BNP)
The correct answer is A) Troponin
Acute myocardial infarction (AMI) is a serious medical emergency that requires prompt diagnosis and treatment. Cardiac biomarkers such as troponin, creatinine kinase-MB (CK-MB), and myoglobin are commonly used to diagnose AMI. Among these biomarkers, troponin is the most specific for the diagnosis of AMI. Troponin is a protein found in cardiac muscle cells, and its release into the bloodstream is a specific marker of myocardial injury. Elevated troponin levels are typically seen within 3-4 hours after the onset of symptoms and can remain elevated for up to 10-14 days after an AMI.
Incorrect answer explanations:
(Review PANRE Blueprint Topic: Acute myocardial infarction: ST-segment elevation myocardial infarction (STEMI))
3. A 65-year-old woman with a history of atrial fibrillation, hypertension, and obesity presents to the emergency department with acute onset of severe left leg pain and swelling. She has been taking warfarin for anticoagulation but admits to missing some doses in the past week. Her blood pressure is 180/100 mmHg, pulse is 110 beats/min and irregular, and respiratory rate is 20 breaths/min. Her physical examination reveals a warm, tender, erythematous left lower extremity with prominent superficial veins and a positive Homan’s sign. Her international normalized ratio (INR) is 1.5. What is the most appropriate next step in the management of this patient?
A) Start heparin infusion and adjust warfarin dose
B) Order duplex ultrasonography of the lower extremities
C) Administer tissue plasminogen activator (tPA)
D) Perform venography of the left leg
E) Apply compression stockings and elevate the leg
The correct answer is B) Order duplex ultrasonography of the lower extremities
Duplex ultrasonography is a non-invasive test that uses sound waves to visualize the blood flow in the veins of the legs. It can detect thrombi by measuring the diameter, compressibility, and flow characteristics of the veins. It has high sensitivity and specificity for diagnosing DVT. It is considered the first-line diagnostic test for patients with suspected DVT. If negative, it can be repeated in one week or combined with D-dimer testing to rule out DVT.
Incorrect answer explanations:
(Review PANRE Blueprint Topic: Deep venous thrombosis)
4. A 7-year-old child presents with honey-colored crusting lesions on the face and extremities. The lesions started as small red papules that quickly progressed to vesicles and then ruptured, leaving behind a honey-colored crust. The child has no fever and is otherwise healthy. What is the most appropriate initial treatment for this condition?
A) Topical corticosteroids
B) Oral antihistamines
C) Oral doxycycline
D) Topical mupirocin
E) Oral acyclovir
The correct answer is D) Topical mupirocin
The presentation of honey-colored crusting lesions on the face and extremities in a child is consistent with impetigo, a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. The most appropriate initial treatment for impetigo is topical antibiotics such as mupirocin. This is because impetigo is a localized skin infection, and topical antibiotics can effectively treat it without the need for systemic antibiotics. The topical antibiotic is applied to the affected area 2-3 times per day for 5-7 days.
Incorrect answer explanations:
(Review PANRE Blueprint Topic: Impetigo)
5. A 72-year-old woman with a history of hypertension, diabetes mellitus, and atrial fibrillation presents to the emergency department with sudden onset of left-sided weakness and slurred speech. She was last seen normal 2 hours ago by her daughter. Her vital signs are: blood pressure 180/100 mmHg, pulse 110 beats/min irregularly irregular, respiratory rate 18 breaths/min, temperature 36.5°C (97.7°F), and oxygen saturation 98% on room air. On physical examination, she has left facial droop, left hemiparesis (4/5 strength), and dysarthria. Her NIH Stroke Scale score is 8. A non-contrast head CT scan shows no evidence of hemorrhage. What is the most appropriate next step in management?
A) Administer intravenous alteplase
B) Administer intravenous heparin
C) Perform carotid endarterectomy
D) Perform mechanical thrombectomy
E) Start oral aspirin
The correct answer is A. Administer intravenous alteplase
The patient has a clinical diagnosis of acute ischemic stroke, which is caused by occlusion of a cerebral artery by a thrombus or embolus. The most important factor in determining the treatment of acute ischemic stroke is the time from symptom onset to presentation. If the patient presents within 4.5 hours of symptom onset and has no contraindications, intravenous alteplase (a tissue plasminogen activator or tPA) should be administered as soon as possible to dissolve the clot and restore blood flow to the ischemic brain tissue. Intravenous alteplase has been shown to improve functional outcomes and reduce disability after acute ischemic stroke. The patient meets the criteria for intravenous alteplase because she presented within 4.5 hours of symptom onset, has no evidence of hemorrhage on head CT scan, and has no other contraindications such as recent surgery, active bleeding, severe hypertension (>185/110 mmHg), or use of anticoagulants. The other answer choices are incorrect because they are not indicated or effective in this scenario.
Incorrect answer explanations:
(Review PANRE Blueprint Topic: Stroke)
[dt_sc_button type=”type2″ link=”https://smartypance.com/lessons/vascular-disorders/stroke-reeldx266/” size=”small” target=”_blank” timeline_button=”no”]View blueprint lesson[/dt_sc_button]6. A 65-year-old man with a history of hypertension and peptic ulcer disease presents to your clinic for a routine follow-up. He reports feeling well and has no complaints. His medications include lisinopril and omeprazole. His vital signs are normal. A complete blood count (CBC) shows:
What is the most likely cause of this patient’s anemia?
A) Chronic kidney disease
B) Folate deficiency
C) Gastrointestinal bleeding
D) Thalassemia trait
E) Vitamin B12 deficiency
The answer is C. Gastrointestinal bleeding
The patient has a microcytic anemia, which is characterized by a low MCV (15%), indicating increased variation in red blood cell size due to iron deficiency. To confirm iron deficiency, iron studies such as serum ferritin, serum iron, total iron-binding capacity (TIBC), and transferrin saturation should be ordered. The patient should also undergo endoscopy to evaluate for the source and severity of gastrointestinal bleeding and rule out malignancy. The other answer choices are incorrect because they are not causes of microcytic anemia but rather causes of normocytic or macrocytic anemia.
Incorrect answer explanations:
(Review PANRE Blueprint Topic: Iron Deficiency Anemia)
7. A 42-year-old woman with a history of GERD presents to your clinic for follow-up. She has been taking omeprazole 20 mg daily for the past 6 months and reports significant improvement in her heartburn and regurgitation symptoms. She has also made lifestyle modifications such as avoiding spicy and fatty foods, quitting smoking, and elevating the head of her bed. She asks you if she can stop taking omeprazole or reduce the dose. What is the most appropriate next step in management?
A) Continue omeprazole 20 mg daily indefinitely
B) Discontinue omeprazole and monitor symptoms
C) Switch to famotidine 20 mg twice daily
D) Taper omeprazole to every other day for 4 weeks
E) Perform an upper endoscopy
The correct answer is D) Taper omeprazole to every other day for 4 weeks
Explanation:
The patient has a history of GERD that has responded well to PPI therapy and lifestyle modifications. The goal of treatment is to achieve symptom relief and prevent complications such as esophagitis, stricture, Barrett’s esophagus, or adenocarcinoma. PPIs are more effective than H2 blockers or antacids for healing erosive esophagitis and maintaining remission. However, long-term use of PPIs may be associated with adverse effects such as increased risk of fractures, infections, hypomagnesemia, vitamin B12 deficiency, and chronic kidney disease. Therefore, it is reasonable to attempt a step-down approach after achieving symptom control with PPIs for at least 8 weeks. This involves tapering the dose of PPI gradually over 2-4 weeks to avoid rebound acid hypersecretion. If symptoms recur after discontinuation of PPIs, then switching to an H2 blocker or restarting PPI maintenance therapy with the lowest effective dose may be indicated.
Incorrect answer choices:
(Review PANRE Blueprint Topic: GERD)
8. Which of the following is an appropriate step-down therapy for a patient with well-controlled asthma on medium-dose inhaled corticosteroids (ICS) and long-acting beta agonists (LABA)?
A) Discontinue LABA and continue medium-dose ICS
B) Discontinue ICS and continue LABA
C) Reduce ICS dose by 50% and continue LABA
D) Reduce both ICS and LABA doses by 50%
E) Switch to low-dose ICS/formoterol as needed
The answer is E. Switch to low-dose ICS/formoterol as needed
This patient has well-controlled asthma on medium-dose ICS and LABA, which corresponds to step 4 of the asthma treatment algorithm. Step-down therapy can be considered for patients with at least 3 months of continuous good control of asthma. The goal of step-down therapy is to reduce medication use to the lowest effective dose while maintaining asthma control. According to the Global Initiative for Asthma (GINA), one option for stepping down from step 4 is to switch to low-dose ICS/formoterol as needed. This regimen involves using a combination inhaler containing low-dose ICS (budesonide) and formoterol (a fast-acting LABA) both as maintenance therapy and as reliever therapy instead of a short-acting beta agonist (SABA). This strategy has been shown to reduce exacerbations, improve symptom control, and decrease steroid exposure compared with conventional maintenance therapy with higher doses of ICS/LABA plus SABA as needed.
(Review PANRE Blueprint Topic: Asthma)
9. A 35-year-old woman presents to her primary care provider with complaints of chronic worry and nervousness for the past 8 months. She says she worries about everything, such as her health, her family, her work, and her finances. She has difficulty sleeping, concentrating, and relaxing. She also experiences muscle tension, headaches, and palpitations. She denies any history of trauma, substance abuse, or other psychiatric disorders. She has no medical problems and takes no medications. Her vital signs are normal and her physical examination is unremarkable. Which of the following is the most likely diagnosis?
A) Panic disorder
B) Obsessive-compulsive disorder
C) Post-traumatic stress disorder
D) Generalized anxiety disorder
E) Adjustment disorder
The correct answer is D) Generalized anxiety disorder
Generalized anxiety disorder (GAD) is characterized by persistent, excessive, and unrealistic worry about everyday things that lasts for at least 6 months. The worry causes significant distress or impairment in social, occupational, or other areas of functioning. The anxiety is not attributable to any specific triggers or stressors. The diagnosis of GAD requires at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
(Review PANRE Blueprint Topic: Generalized Anxiety Disorder)
10. A 65-year-old man with a history of type 2 diabetes mellitus presents to the emergency department with altered mental status, polyuria, and polydipsia. He has been feeling unwell for the past week with a urinary tract infection that he has been self-treating with cranberry juice. His vital signs are: blood pressure 180/100 mmHg, heart rate 110 beats per minute, respiratory rate 24 breaths per minute, temperature 37.8°C (100°F), and oxygen saturation 95% on room air. His physical examination reveals dry mucous membranes, poor skin turgor, and decreased level of consciousness. His laboratory tests show:
Which of the following is the most appropriate initial treatment?
A) Intravenous insulin infusion
B) Intravenous normal saline infusion
C) Intravenous sodium bicarbonate infusion
D) Intravenous potassium chloride infusion
E) Subcutaneous insulin glargine injection
The correct answer is B) Intravenous normal saline infusion
This patient has hyperosmolar hyperglycemic syndrome (HHS), which is a complication of diabetes mellitus characterized by severe hyperglycemia (>600 mg/dL), hyperosmolality (>320 mOsm/kg), and dehydration in the absence of ketoacidosis. HHS is often triggered by an acute stressor such as infection, medication noncompliance, or excessive carbohydrate intake. The mainstay of treatment for HHS is fluid replacement with isotonic saline to correct dehydration, lower serum glucose and osmolality, and improve renal function. Insulin therapy can be initiated after adequate fluid resuscitation, usually at a low dose (0.05-0.1 units/kg/hour). Electrolyte abnormalities such as hypokalemia or acidosis should be corrected as needed.
Incorrect answer explanations:
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