BEYOND PANCE™ Sample 30

A 55-year-old man with a history of alcohol use disorder and liver cirrhosis is brought to the emergency department after vomiting large amounts of bright-red blood. In the trauma bay, his airway is secured with endotracheal intubation due to continuous hematemesis, and aggressive intravenous fluids are initiated. Despite initial resuscitation, his blood pressure remains 92/58 mm Hg with a heart rate of 118 /min. Mechanical ventilation is set at 18 /min. Laboratory studies reveal a hemoglobin of 7.5 g/dL (12–16), platelets of 120 × 10³/µL (150–400), and an International Normalized Ratio (INR) of 1.6 (0.9–1.2). On examination, he appears pale, diaphoretic, and unresponsive to verbal commands, with cool extremities and delayed capillary refill. The patient remains hemodynamically unstable. Which of the following is the most appropriate next step in management?

A 64-year-old man with a 40-pack-year smoking history is brought to a level 1 trauma center via emergency medical services (EMS) for crushing substernal chest pain that began 45 minutes ago. Additional symptoms include shortness of breath, diaphoresis, and radiation of pain to the left arm and jaw. Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus, managed with losartan, atorvastatin, and metformin, respectively. On arrival, he is anxious and diaphoretic. Vital signs: blood pressure is 163/90 mmHg, heart rate is 95/min, and respiratory rate is 22/min. An electrocardiogram (ECG) shows ST-segment elevations in leads II, III, and aVF. Laboratory studies are as follows:

A 56-year-old man is brought to the emergency department after collapsing at work. He is unresponsive and not breathing. Cardiac monitoring reveals a chaotic, irregular rhythm without identifiable QRS complexes. High-quality CPR is in progress, and two defibrillation shocks have been delivered without return of spontaneous circulation. Which of the following is the most appropriate pharmacologic agent to administer next?

A 52-year-old woman presents to the emergency department with severe epigastric pain that radiates to her back, along with nausea and vomiting for the past 24 hours. The pain improves when leaning forward. She consumes alcohol socially. On examination, she appears distressed, with epigastric tenderness and hypoactive bowel sounds. Laboratory studies are as follows:

A 45-year-old man is brought to the emergency department because of fever, chest pain, palpitations, and confusion for the past 3 hours. His medical history includes type 2 diabetes mellitus managed with metformin. According to his wife, he was diagnosed with a thyroid condition many years ago, but he has not taken any thyroid medications. Vital signs: temperature 102.2 °F (39 °C), heart rate 140/min, blood pressure 160/96 mm Hg. On examination, he appears confused and diaphoretic. The thyroid gland is diffusely enlarged with no palpable nodules. Cardiovascular and lung examinations reveal no abnormal findings aside from tachycardia. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of < 0.01 µU/mL (reference range: 0.4–4.0 µU/mL) and a free T₄ level of 5.0 ng/dL (reference range: 0.8–2.7 ng/dL). Which of the following is the most appropriate initial pharmacologic intervention to control the underlying thyroid hormone excess in this patient?

A 23-year-old woman with type 1 diabetes mellitus presents to the emergency department with nausea, vomiting, and abdominal pain for the past 12 hours. Her diabetes has been poorly controlled due to inconsistent insulin use. On arrival, she appears dehydrated and tachypneic. Vital signs: temperature 99 °F (37.2 °C), heart rate 118 /min, blood pressure 96/62 mm Hg, respiratory rate 28 /min. Laboratory studies are as follows:

A 60-year-old woman with chronic kidney disease and hypertension is brought to the emergency department by her daughter because of fatigue and palpitations for the past 2 days. Her current medications include lisinopril and spironolactone. Blood pressure is 137/80 mm Hg. An electrocardiogram (ECG) shows peaked T waves with a widened QRS complex. Laboratory studies are as follows:

A 68-year-old man presents to his family medicine physician associate (PA) with a six-month history of fatigue and mild exertional dyspnea. He has not experienced chest pain, fever, weight loss, or changes in appetite. His history includes hypertension and hyperlipidemia, managed with valsartan and rosuvastatin, respectively. He has made no significant dietary changes but has noticed occasional dark stools. On examination, he appears pale with mildly pale conjunctivae. There is no abdominal tenderness or hepatosplenomegaly. Laboratory studies are as follows:

A 24-year-old man is brought to the emergency department with fever, headache, photophobia, and neck stiffness for the past 12 hours. He appears ill and has a positive Brudzinski sign on examination. A lumbar puncture is performed. Which of the following cerebrospinal fluid (CSF) profiles is most characteristic of bacterial meningitis?

A 62-year-old man presents to the emergency department with a two-day history of fever, chills, and confusion. Medical history includes diabetes mellitus and hypertension, for which he takes metformin and losartan. On examination, his temperature is 102.5°F, blood pressure is 88/50 mmHg, heart rate is 112/min, respiratory rate is 24/min, and oxygen saturation is 92% on room air. Laboratory studies are as follows:

Special shout-out to Professor Peter Kreckel, RPh, legendary Saint Francis University PA Program pharmacology professor and dispenser of Skittles for correct answers during his lectures.

During pharmacology lectures at Saint Francis University, Professor Kreckel often rewarded correct answers with a small bag of Skittles. In one memorable session on the reproductive pharmacology module, he asked:

“Which medication acts as a selective estrogen receptor modulator (SERM) that provides estrogen-agonist effects on bone and antagonist effects on breast and uterine tissue, making it useful in the prevention and treatment of postmenopausal osteoporosis while also reducing the risk of estrogen-dependent breast cancer?”

Get this one right, and Professor Pete just might throw you a virtual bag of Skittles. 🍬

Which of the following pharmacologic agents best fits this description?

A 32-year-old postpartum woman presents with a ten-day history of progressive right breast pain, swelling, and fever. She was initially treated with dicloxacillin for lactational mastitis, but symptoms worsened despite adherence, leading to a switch to clindamycin with no improvement. She now reports worsening pain, fever, and new fluctuance in the affected area. Blood pressure is 100/62 mmHg, heart rate 118/min, respirations 20/min, temperature 102.1°F (38.9°C). Physical examination reveals a tense, erythematous, swollen right breast with a fluctuant, tender mass, along with cervical and axillary lymphadenopathy. Laboratory findings are as follows:

A 23-year-old man presents to the clinic with an eight-month history of worsening auditory hallucinations and persecutory delusions. He believes the government is tracking him and that people on television are sending him secret messages. He has difficulty maintaining employment, poor grooming, and disorganized thoughts. There is no known history of substance use or medical illness. Physical examination and vital signs are within normal limits. Antipsychotic therapy is planned. Which of the following tests is most appropriate to obtain before starting antipsychotic therapy?

A 42-year-old man visits his primary care physician associate (PA) because of longstanding low mood. He reports feeling “down” most days for as long as he can remember. He describes chronic low self-esteem, indecisiveness, and general dissatisfaction with life. The symptoms are mild and have not significantly impaired his occupational or social functioning. He reports no suicidal ideation, recent psychosocial stressors, or periods of elevated mood. Which of the following best explains this patient’s symptoms?

A 55-year-old man presents to the emergency department with a 12-hour history of severe, sharp, colicky left flank and low back pain radiating to the groin. He reports multiple similar episodes in the past year, previously attributed to kidney stones. His medical history includes hypertension, hyperparathyroidism, and rheumatoid arthritis, managed with lisinopril, calcitriol, and methotrexate, respectively. Laboratory studies show a serum calcium level of 12.2 mg/dL (reference range: 8.6–10.2 mg/dL) and a parathyroid hormone (PTH) level of 150 pg/mL (reference range: 10–65 pg/mL). A non-contrast CT scan of the abdomen and pelvis reveals a 9 mm left proximal ureteral stone. Referral to which of the following specialists is most appropriate for this patient?