MOCK PANCE EXAM-Block 4 (ROSH)
A 71-year-old man presents to the Emergency Department after falling on ice outside his home. He
complains of neck pain. He has an abrasion to his chin and decreased strength in his bilateral upper
extremities. Strength is intact in his lower extremities. Which mechanism of trauma is most consistent
with the suspected diagnosis?
Hyperextension injury
Hyperflexion injury
Penetrating injury
Rotational injury correct answersCorrect Answer ( A )
Explanation:
This patient has central cord syndrome that was caused by a hyperextension injury of the neck. Typically,
central cord syndrome occurs in a patient with preexisting cervical canal stenosis. In this case, the patient
fell forward hitting his chin on the ground, causing hyperextension of his cervical spine. The classic
finding of central cord syndrome is disproportionate loss of motor function in the upper extremities
greater than that of the lower extremities.
Anterior cord syndrome is typically caused by a hyperflexion injury (B). It presents with paraplegia and
loss of pain and temperature sensation. In anterior cord syndrome, the dorsal column is unaffected.
Therefore, position, vibration, and deep pressure sensory function will be preserved. Brown-Séquard
syndrome results from hemisection of the spinal cord often from a penetrating injury (C). There is
ipsilateral motor and position sense loss with contralateral loss of pain and temperature sensation. A
rotational injury (D) is unlikely to cause this patient's neurologic deficits.
One Step Further
Question: What is the purpose of the NEXUS criteria for cervical spine injury? correct answersAnswer:
Criteria that allows a clinician to clear a patient's cervical spine of a fracture clinically, without imaging.
A 50-year-old man with type II diabetes presents for follow up after failing to achieve glycemic control on
metformin alone. You decide to try combination therapy with dapagliflozin. He asks what side effects are
associated with this new medication. What adverse effect can you tell him might occur?
,Constipation
Hypoglycemia
Urinary tract infection
Weight gain correct answersCorrect Answer ( C )
Explanation:
Initial treatment of type II diabetes is most often lifestyle modifications in combination with metformin.
For those who fail to achieve their target A1c with monotherapy metformin, there are a number of non-
insulin agents to consider adding. Sodium-glucose cotransporter 2 (SGLT2) inhibitors work by blocking
glucose reabsorption in the proximal renal tubule. This forces glucose to be excreted in the urine, but
also leads to an increased risk of urinary tract infections for patients taking this medication.
One Step Further
Question: What is the target A1c for non-pregnant adults with type II diabetes? correct answersAnswer:
Less than 7%.
A five-year-old girl presents to your office for a well child visit. During physical exam, you notice that her
left eye turns inward toward the nose while the right eye is looking straight ahead. Which of the
following is the most likely diagnosis?
Chalazion
Ectropion
Nystagmus
Strabismus correct answersCorrect Answer ( D )
Explanation:
Strabismus is defined as a misalignment of the eyes in which both eyes are unable to direct towards the
same object at once. It may be vertical or horizontal. There are several types of strabismus identified
based on the direction of eye deviation. The inward deviation of one eye in relation to the other is called
esotropia. Strabismus generally presents by age two and has no racial or sex prevalence. When
evaluating an infant, strabismus must be differentiated from ocular instability of infancy or
pseudostrabismus. Strabismus may be diagnosed using several clinical tests, including the cover test,
corneal light reflex, and the Brückner or simultaneous red reflex test. Children determined to have
strabismus should be referred to an ophthalmologist. Treatment depends on the etiology. Initial
management involves addressing visual impairment.
,One Step Further
Question: Which type of strabismus occurs when one eye turns upward while the other looks straight
ahead? correct answersAnswer: Hypertropia.
A previously healthy six-year-old girl presents to your office with a bright red, raised rash on bilateral
cheeks, sparing her nose and the areas surrounding her mouth and eyes. Her mother reports that a few
days before the rash appeared she had a headache, fever, sore throat, and runny nose. Which of the
following is the most likely cause of her symptoms?
Human herpesvirus-6
Human parvovirus B19
Streptococcus pyogenes
Varicella-zoster virus correct answersCorrect Answer ( B )
Explanation:
Erythema infectiosum (EI), also called "Fifth disease," is a benign viral exanthem caused by human
parvovirus B19. Patients generally present with prodromal symptoms approximately two to three days
before the appearance of the rash, including fever, headache, coryza, sore throat, pruritus, arthralgias,
and abdominal pain. Incidence of EI happens most frequently in winter and early spring. Most infections
occur in children aged five to 15 years with males and females affected equally. Diagnosis is clinical
based on presentation. The disease is self-limited and treatment generally involves reassurance about
the normal course of the disease and oral analgesics for any pain or discomfort.
Human herpesvirus-6 (A) causes roseola, which generally presents in younger infants. Symptoms of
roseola include a sudden onset high fever and a mild, pink, morbilliform rash. Streptococcus pyogenes
(C) is a bacteria that causes streptococcus pharyngitis and scarlet fever. The rash of scarlet fever is a
diffuse, blanchable erythematous rash with multiple papules, giving it a "sandpaper" type quality.
Varicella-zoster virus (D) causes two different forms of disease, varicella (chicken pox) and herpes zoster
(shingles). Chicken pox more commonly affects children and is self-limited. The rash of chicken pox is a
pruritic, vesicular one that follows a number of stages. The lesions begin as macules that become
papules, then vesicles that can develop a pustular component leading to crusted papules. Individuals
generally have lesions in different stages of development at the same time.
One Step Further
Question: True or false: Human parvovirus B19 can be transmitted vertically from mother to child?
correct answersAnswer: True
, A 33-year-old man presents with worsening right lower quadrant abdominal pain for the past 3 days. On
examination, you notice positive McBurney's and Rovsing's signs. You suspect an acute appendicitis. At
what vertebral levels are you most likely to find somatic changes?
T1-T5
T11-L2
T2-T6
T6-T9 correct answersCorrect Answer ( B )
Explanation:
A viscero-somatic reflex occurs when localized visceral stimuli produce patterns of reflex response to
vertebral segmentally related structures. The lower gastrointestinal tract is innervated by the lower
thoracic and upper lumbar spinal cord levels. The appendix has sympathetic nervous system innervation
from the level of T12.
A six-year-old girl is brought to the clinic because of fever. Five days ago, she had fever with a maximum
temperature of 39oC that was minimally responsive to antipyretics. This was accompanied by clear
rhinorrhea. Last night, the parents noted a rash on her chest and back. The girl also has decreased
activity and appetite. On physical examination, her temperature is 38.6 oC, heart rate is 108 beats per
minute, respiratory rate is 22 cycles per minute, bilateral bulbar conjunctival injection, cracked red lips,
nonhyperemic posterior pharyngeal wall, morbilliform rash over the trunk, palpable right anterior
cervical lymph node measuring 2 cm, clear breath sounds, no murmur, and soft abdomen. A complete
blood count shows anemia and leukocytosis with left shift. Urinalysis shows pyuria. Which of the
following is the most likely diagnosis?
Epstein-Barr virus infection
Kawasaki disease
Measles infection
Scarlet fever correct answersCorrect Answer ( B )
Explanation:
The girl has clinical findings that are suspicious for Kawasaki disease. Kawasaki disease (KD) or
mucocutaneous lymph node syndrome is one of the most common vasculitides of childhood. The clinical
features of Kawasaki disease reflect widespread inflammation of primarily medium-sized muscular
arteries. Diagnosis is based upon evidence of systemic inflammation (like fever) in association with signs
of mucocutaneous inflammation. The characteristic bilateral nonexudative conjunctivitis, erythema of
