Smarty PANCE: Internal Medicine Exam
Questions and Answers
acute interstitial nephritis
Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in
kidney function and is characterized by an inflammatory infiltrate in the
kidney interstitium. Drugs (remembered as the 5 Ps) are the most common
cause of AIN. The 5 Ps are Pee (diuretics, especially sulfa ones), Pain-free
(NSAIDs), Penicillins and cephalosporins, Proton pump inhibitors, and
rifamPin. Patients will present with elevated creatinine, eosinophils, WBC
casts, and hematuria. - correct answers✅✅A 62-year-old man presents to
your office with a sudden onset of fever and rash. His review of systems is
negative. He was recently started on omeprazole for acid reflux 14 days ago.
Routine laboratory tests reveal a serum creatinine of 3.5 mg/dL and
eosinophilia. Urine studies showed white blood cell casts. What is the most
likely diagnosis?
A Acute interstitial nephritis (AIN
B Acute tubular necrosis
C IGA Nephropathy
D Postreptococcal Glomerulonephritis
Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z-
thumb deformity
Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia,
erosions, and joint space narrowing. Later changes include subluxation
causing ulnar deviation, z- thumb, boutonniere, and swan neck deformities,
and ankylosis. - correct answers✅✅A 63-year-old woman presents with
pain in her hands for three years. She describes the pain as progressive -
coming on slowly and worsening over the course of the three years. She says
that her aunt and wheelchair-bound grandmother had problems with their
hands as well. A hand X-ray is obtained which shows soft tissue swelling and
marked juxta-articular osteopenia in her metacarpophalangeal and proximal
,Smarty PANCE: Internal Medicine Exam
Questions and Answers
interphalangeal joints, and minor bony erosions. Which of the following will
most likely be present on her plain film ten years from now?
A Pencil-in-cup deformity, ankylosis, periostitis, dactylitis
B Subchondral sclerosis, subchondral cysts, osteophytes, joint space
narrowing
C Subperiosteal bone resorption
D Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis,
z- thumb deformity
Thrombotic Thrombocytopenic purpura
This clinical presentation is consistent with thrombotic thrombocytopenic
purpura (TTP), which is associated with a pentad of signs and symptoms
including fever, microangiopathic hemolytic anemia, thrombocytopenia (with
associated petechiae), renal dysfunction, and neurological or mental status
changes. Physical exam demonstrates petechiae, a result of
thrombocytopenia, and his peripheral blood smear is positive for schistocytes
(RBC fragments), which are seen in microangiopathic hemolytic anemias
such as TTP. - correct answers✅✅A 45-year-old man is brought to the
emergency room by his partner because he has been acting confused for the
past day. He is febrile, with an oral temperature of 103.6 deg F; vital signs
are otherwise stable. His physical exam is significant for the petechiae on the
left foot; he has never noticed lesions like these before. He also has subtle
right-sided weakness affecting upper and lower extremities. Labs reveal
hemoglobin 7.0 g/dL, hematocrit 21%, white blood count of 10.2 x 10^3 µL,
and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal.
Schistocytes are noted on his peripheral blood smear. What is the most likely
diagnosis?
A Idiopathic thrombocytopenic purpura
B Disseminated intravascular coagulation
,Smarty PANCE: Internal Medicine Exam
Questions and Answers
C Thrombotic thrombocytopenic purpura
D Hemolytic uremic syndrome
Lymph Node Biopsy
This patient presents with possible lymphoma. Diagnosis is made by lymph
node biopsy. Bone marrow biopsy and CT scan of the chest are used for
staging of the disease. - correct answers✅✅A 26-year-old male presents
with a four-week history of fatigue, night sweats, and a painless mass in his
neck. Physical examination confirms the presence of an enlarged right
posterior cervical lymph node. What is the next best step in the evaluation of
this patient?
A Bone marrow biopsy and aspiration
B Lymph node biopsy
C CT scan of the chest
D Reexamine in 2-4 weeks
Venodilation
Stable angina pectoris results when myocardial oxygen demand exceeds
oxygen supply. Nitrates, the first-line therapy for acute episodes and they act
principally through smooth muscle relaxation and venodilation which causes
blood pooling in the peripheral vasculature with a concomitant reduction in
preload. Decreased preload decreases cardiac contractility and oxygen
demand. - correct answers✅✅A 46-year-old man comes to the office
because of a four-month history of intermittent episodes of chest discomfort
and tightness. His symptoms typically occur only on exertion, such as when
gardening or playing with his children, and are relieved by rest. He says the
episodes last less than 20 minutes. He has otherwise been healthy and his
personal medical history is noncontributory. His father has coronary artery
, Smarty PANCE: Internal Medicine Exam
Questions and Answers
disease but is alive and well. Physical exam, laboratory studies and ECG are
normal. The medication most appropriate for treating his acute episodes acts
by which of the following mechanisms?
A Blocking calcium channels
B Controlling coronary artery vasospasm
C Decreasing heart rate
D Venodilation
E Arteriolodilation
Electrocardiogram
Electrocardiogram is the gold standard for diagnosing myocardial infarction
within the first 6 hours of symptom onset. Electrocardiogram changes will
include ST-segment elevation (signifying transmural infarct), ST-segment
depression (signifying subendocardial infarct), and Q waves (signifying
transmural infarct). - correct answers✅✅A 48-year-old man comes to the
emergency department because of severe substernal chest pain radiating to
his left arm that began 1.5 hours prior to arrival. The pain is accompanied by
diaphoresis and shortness of breath. His blood pressure is 165/94 mm Hg,
pulse is 82/min, and respiratory rate is 18/min. An acute myocardial
infarction is suspected. Which of the following tests is the most important
tool in the initial evaluation of this patient?
A Aspartate aminotransferase
B Creatine kinase-myocardial bound
C Electrocardiogram
D Echocardiogram
E Lactate dehydrogenase
Questions and Answers
acute interstitial nephritis
Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in
kidney function and is characterized by an inflammatory infiltrate in the
kidney interstitium. Drugs (remembered as the 5 Ps) are the most common
cause of AIN. The 5 Ps are Pee (diuretics, especially sulfa ones), Pain-free
(NSAIDs), Penicillins and cephalosporins, Proton pump inhibitors, and
rifamPin. Patients will present with elevated creatinine, eosinophils, WBC
casts, and hematuria. - correct answers✅✅A 62-year-old man presents to
your office with a sudden onset of fever and rash. His review of systems is
negative. He was recently started on omeprazole for acid reflux 14 days ago.
Routine laboratory tests reveal a serum creatinine of 3.5 mg/dL and
eosinophilia. Urine studies showed white blood cell casts. What is the most
likely diagnosis?
A Acute interstitial nephritis (AIN
B Acute tubular necrosis
C IGA Nephropathy
D Postreptococcal Glomerulonephritis
Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis, z-
thumb deformity
Rheumatoid arthritis's early signs include soft tissue swelling, osteopenia,
erosions, and joint space narrowing. Later changes include subluxation
causing ulnar deviation, z- thumb, boutonniere, and swan neck deformities,
and ankylosis. - correct answers✅✅A 63-year-old woman presents with
pain in her hands for three years. She describes the pain as progressive -
coming on slowly and worsening over the course of the three years. She says
that her aunt and wheelchair-bound grandmother had problems with their
hands as well. A hand X-ray is obtained which shows soft tissue swelling and
marked juxta-articular osteopenia in her metacarpophalangeal and proximal
,Smarty PANCE: Internal Medicine Exam
Questions and Answers
interphalangeal joints, and minor bony erosions. Which of the following will
most likely be present on her plain film ten years from now?
A Pencil-in-cup deformity, ankylosis, periostitis, dactylitis
B Subchondral sclerosis, subchondral cysts, osteophytes, joint space
narrowing
C Subperiosteal bone resorption
D Subluxations (e.g. boutonniere and swan-neck deformities), joint ankylosis,
z- thumb deformity
Thrombotic Thrombocytopenic purpura
This clinical presentation is consistent with thrombotic thrombocytopenic
purpura (TTP), which is associated with a pentad of signs and symptoms
including fever, microangiopathic hemolytic anemia, thrombocytopenia (with
associated petechiae), renal dysfunction, and neurological or mental status
changes. Physical exam demonstrates petechiae, a result of
thrombocytopenia, and his peripheral blood smear is positive for schistocytes
(RBC fragments), which are seen in microangiopathic hemolytic anemias
such as TTP. - correct answers✅✅A 45-year-old man is brought to the
emergency room by his partner because he has been acting confused for the
past day. He is febrile, with an oral temperature of 103.6 deg F; vital signs
are otherwise stable. His physical exam is significant for the petechiae on the
left foot; he has never noticed lesions like these before. He also has subtle
right-sided weakness affecting upper and lower extremities. Labs reveal
hemoglobin 7.0 g/dL, hematocrit 21%, white blood count of 10.2 x 10^3 µL,
and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal.
Schistocytes are noted on his peripheral blood smear. What is the most likely
diagnosis?
A Idiopathic thrombocytopenic purpura
B Disseminated intravascular coagulation
,Smarty PANCE: Internal Medicine Exam
Questions and Answers
C Thrombotic thrombocytopenic purpura
D Hemolytic uremic syndrome
Lymph Node Biopsy
This patient presents with possible lymphoma. Diagnosis is made by lymph
node biopsy. Bone marrow biopsy and CT scan of the chest are used for
staging of the disease. - correct answers✅✅A 26-year-old male presents
with a four-week history of fatigue, night sweats, and a painless mass in his
neck. Physical examination confirms the presence of an enlarged right
posterior cervical lymph node. What is the next best step in the evaluation of
this patient?
A Bone marrow biopsy and aspiration
B Lymph node biopsy
C CT scan of the chest
D Reexamine in 2-4 weeks
Venodilation
Stable angina pectoris results when myocardial oxygen demand exceeds
oxygen supply. Nitrates, the first-line therapy for acute episodes and they act
principally through smooth muscle relaxation and venodilation which causes
blood pooling in the peripheral vasculature with a concomitant reduction in
preload. Decreased preload decreases cardiac contractility and oxygen
demand. - correct answers✅✅A 46-year-old man comes to the office
because of a four-month history of intermittent episodes of chest discomfort
and tightness. His symptoms typically occur only on exertion, such as when
gardening or playing with his children, and are relieved by rest. He says the
episodes last less than 20 minutes. He has otherwise been healthy and his
personal medical history is noncontributory. His father has coronary artery
, Smarty PANCE: Internal Medicine Exam
Questions and Answers
disease but is alive and well. Physical exam, laboratory studies and ECG are
normal. The medication most appropriate for treating his acute episodes acts
by which of the following mechanisms?
A Blocking calcium channels
B Controlling coronary artery vasospasm
C Decreasing heart rate
D Venodilation
E Arteriolodilation
Electrocardiogram
Electrocardiogram is the gold standard for diagnosing myocardial infarction
within the first 6 hours of symptom onset. Electrocardiogram changes will
include ST-segment elevation (signifying transmural infarct), ST-segment
depression (signifying subendocardial infarct), and Q waves (signifying
transmural infarct). - correct answers✅✅A 48-year-old man comes to the
emergency department because of severe substernal chest pain radiating to
his left arm that began 1.5 hours prior to arrival. The pain is accompanied by
diaphoresis and shortness of breath. His blood pressure is 165/94 mm Hg,
pulse is 82/min, and respiratory rate is 18/min. An acute myocardial
infarction is suspected. Which of the following tests is the most important
tool in the initial evaluation of this patient?
A Aspartate aminotransferase
B Creatine kinase-myocardial bound
C Electrocardiogram
D Echocardiogram
E Lactate dehydrogenase
