MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
A 75-year-old man presents to his primary physician with excessive fatigue over the past three
months and swollen lymph nodes in his neck. Upon further questioning, he also admits to night
sweats and early satiety. On physical exam, there are two palpable lymph nodes, one along the
cervical neck and the other in the inguinal region. Laboratory data shows a white blood count of
25,000 with a B cell proliferation. The peripheral blood smear reveals smudge cells. Which of the
following is the most likely diagnosis?
Chronic lymphocytic leukemia
Chronic myelogenous leukemia
Hairy cell leukemia
Waldenstrom Macroglobulinemia ✅✅Correct Answer ( A )
Explanation:
Chronic lymphocytic leukemia (CLL) is a monoclonal disorder characterized by a progressive
accumulation of functionally incompetent lymphocytes. CLL is a disease that primarily affects the
elderly, with the median age of presentation being 65 years of age. Onset is insidious, and it is not
unusual for CLL to be discovered incidentally after a blood cell count is performed for another
reason. Enlarged lymph nodes are the most common presenting symptom, but patients may present
with a wide range of symptoms such as splenomegaly, hepatomegaly, pallor, fatigue, and early
satiety. The complete blood count with differential shows absolute lymphocytosis, with more than
5000 B-lymphocytes/µL. Microscopic examination of the peripheral blood smear is indicated to
confirm lymphocytosis. It usually shows the presence of smudge cells. Chemotherapy is not needed
in CLL until patients become symptomatic or display evidence of rapid progression of disease.
Chronic myelogenous leukemia (CML) (B) is characterized by an increased proliferation of the
granulocytic cell line and is characterized by the presence of the Philadelphia chromosome.
Splenomegaly is the most common physical finding in patients with chronic myelogenous leukemia.
The most common symptoms and presenting complaints in hairy cell leukemia (C) are weakness and
fatigue due to anemia. A positive TRAP stain in conjunction with a characteristic bone marrow biopsy
is essentially diagnostic of hairy cell leukemia. Waldenstrom Macroglobulinemia (D) presents with
constitutional B symptoms, bleeding, and hyperviscosity due to the IgM monoclonal protein in their
bloodstream, and is not associated with smudge cells.
Waldenstrom Macroglobulinemia ✅✅Waldenstrom Macroglobulinemia (D) presents with
constitutional B symptoms, bleeding, and hyperviscosity due to the IgM monoclonal protein in their
bloodstream, and is not associated with smudge cells.
One Step Further
,MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
Question: Which leukemia is associated with Down Syndrome? ✅✅Answer: ALL.
A 47-year-old firefighter is brought to the emergency department by ambulance with several burns
to the body. He was at the scene of a structural fire and was trapped by falling debris that burned
through his protective clothing. Physical examination shows several areas with a white, dry, waxy
appearance that fail to blanch with pressure. He complains of a lack of sensation over the affected
area. Which of the following type of burn did this patient most likely suffer?
Deep partial thickness (second-degree burn)
Fourth-degree burn
Full thickness (third-degree burn)
Superficial (first-degree burn) ✅✅Correct Answer ( C )
Explanation:
This patient most likely suffered a full thickness (third-degree) burn. These burns typically have a
characteristic white, dry, waxy appearance. The diagnostic findings of full thickness burns are lack of
sensation in the burned skin, lack of capillary refill, and a leathery texture that is unlike normal skin.
All dermal epithelial elements are destroyed, leaving no potential for reepithelialization.
Deep partial thickness (second-degree) burns (A) have a reddish appearance or a layer of whitish,
nonviable dermis firmly adherent to the remaining viable tissue. Fourth-degree burns (B) typically
extend through the entire skin and into underlying fat, muscle, and bone. They characteristically
appear black, charred with eschar. Superficial (first-degree) burns (D) only involve the epidermis.
They characteristically appear red without blisters.
One Step Further
Question: What type of burn is described as having a reddish appearance or a layer of whitish,
nonviable dermis? ✅✅Answer: Deep partial thickness (second-degree) burn.
What is the most common type of hearing loss in the elderly population?
Cerumen impaction
Chronic otitis media with effusion
Otosclerosis
Sensorineural hearing loss ✅✅Correct Answer ( D )
,MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
Explanation:
Hearing loss affects more than 80% of those older than 85 years of age. Men usually experience
greater hearing loss compared to women. More than 90% of older persons with hearing loss have
age-related sensorineural hearing loss, which is a gradual, symmetric loss of hearing (predominantly
of high frequencies) that is worse in noisy environments. Sensorineural hearing loss involves
problems converting mechanical vibrations to electrical potential in the cochlea or in auditory nerve
transmission to the brain. Hearing loss can be detrimental to a person and it prevents them from
wanting to be in a social environment due to being embarrassed by this condition. Depression is
common in elderly with hearing loss. Formal audiometric testing in a sound-protected environment
is the diagnostic standard, however this testing is costly. Physical examination includes inspection of
the auditory canal and tympanic membrane for obstruction or effusion. The Weber and Rinne tests
were designed to distinguish conductive from sensorineural hearing loss by comparing air and bone
conduction. Hearing aids are available as behind-the-ear, in-the-ear, and in-the-canal models. The
choice of aid is predominantly determined by the patient's perception of ease of use and
appearance, however only approximately 25% of eligible patients acquire hearing aides. In selected
patients, including those who do not tolerate hearing aids, middle ear implants may provide
comparable improvement in sound quality and clarity to hearing aids.
One Step Further
Question: How are acoustic neuromas diagnosed? ✅✅Answer: These intracranial, extra-axial
tumors arise from the Schwann cell sheath invading either the vestibular or cochlear nerve and are
diagnosed on MRI.
A four-year-old boy is brought to the ED for right hip pain for the last three days. He has been
walking with a slight limp. On examination, he has minimal pain with passive movement of the right
hip. Which of the following is most consistent with a diagnosis of transient synovitis rather than
septic arthritis?
Abnormal radiographs of the hip
Erythrocyte sedimentation rate of 50 mm/hr
Oral temperature of 36.8°C
Serum white blood cell count of 20,000 cells/µL ✅✅Correct Answer ( C )
Explanation:
An oral temperature of 36.8°C is most consistent with a diagnosis of transient synovitis, as generally
children with transient synovitis are afebrile. The most important part of diagnosing transient
synovitis is to exclude underlying septic arthritis. Transient synovitis is a self-limited non-pyogenic
inflammation of the synovium that most commonly occurs in boys between the ages of three and six
years of age. The exact etiology is unknown although in many cases follows a mild upper respiratory
, MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
infection. Children will complain of hip pain, walk with a limp or refuse to bear weight. They are
generally otherwise well appearing and non-toxic. This is a diagnosis of exclusion and if there is any
concern for septic arthritis, the patient should undergo arthrocentesis and synovial fluid analysis to
exclude septic arthritis. Patients with transient synovitis often respond to non-steroidal anti-
inflammatory medications and rest. They can generally be managed at home with 12-24 hour follow
up at the primary care physician's office. The prognosis is excellent.
One Step Further
Question: What is the most common cause of acute onset childhood hip pain? ✅✅Answer:
Transient synovitis.
A 72-year-old man presents with episodic exertional syncope and dyspnea that has been occurring
over the last two months. Physical exam demonstrates a mid-systolic murmur heard best at the
second intercostal space near the left sternal border. Echocardiogram demonstrates aortic valve
stenosis. Which of the following would you expect to find on physical exam?
Decrease in the intensity of the murmur with isometric handgrip
Decrease in the intensity of the murmur with squatting
Increase in the intensity of the murmur with standing
Increase in the intensity of the murmur with Valsalva maneuver ✅✅Correct Answer ( A )
Explanation:
A decrease in the intensity of the murmur with isometric handgrip is typically associated with aortic
stenosis. The carotid artery pulse wave contour will be small and slow rising in individuals with this
valvular disease. The characteristic murmur auscultated is mid-systolic and heard best at the second
intercostal space near the left sternal border. There is a classic "crescendo-decrescendo" murmur.
The murmur decreases in intensity with isometric handgrip, standing, and Valsalva maneuvers.
Squatting typically does not have an effect on the intensity of the murmur. Secondary left ventricular
hypertrophy may be a primary finding with electrocardiogram. EKG can also show nonspecific ST and
T-wave abnormalities. Echocardiography is the main diagnostic imaging tool used for evaluation of
aortic stenosis. Treatment is usually achieved with aortic valve replacement although medical
management can be used to relieve symptoms of angina and dyspnea on exertion as well as manage
left ventricular heart failure that can be associated with the stenosis.
One Step Further
Question: In patients with aortic stenosis, what secondary findings might be demonstrated on
electrocardiography? ✅✅Answer: Left atrial and left ventricular hypertrophy.
Questions and Answers
A 75-year-old man presents to his primary physician with excessive fatigue over the past three
months and swollen lymph nodes in his neck. Upon further questioning, he also admits to night
sweats and early satiety. On physical exam, there are two palpable lymph nodes, one along the
cervical neck and the other in the inguinal region. Laboratory data shows a white blood count of
25,000 with a B cell proliferation. The peripheral blood smear reveals smudge cells. Which of the
following is the most likely diagnosis?
Chronic lymphocytic leukemia
Chronic myelogenous leukemia
Hairy cell leukemia
Waldenstrom Macroglobulinemia ✅✅Correct Answer ( A )
Explanation:
Chronic lymphocytic leukemia (CLL) is a monoclonal disorder characterized by a progressive
accumulation of functionally incompetent lymphocytes. CLL is a disease that primarily affects the
elderly, with the median age of presentation being 65 years of age. Onset is insidious, and it is not
unusual for CLL to be discovered incidentally after a blood cell count is performed for another
reason. Enlarged lymph nodes are the most common presenting symptom, but patients may present
with a wide range of symptoms such as splenomegaly, hepatomegaly, pallor, fatigue, and early
satiety. The complete blood count with differential shows absolute lymphocytosis, with more than
5000 B-lymphocytes/µL. Microscopic examination of the peripheral blood smear is indicated to
confirm lymphocytosis. It usually shows the presence of smudge cells. Chemotherapy is not needed
in CLL until patients become symptomatic or display evidence of rapid progression of disease.
Chronic myelogenous leukemia (CML) (B) is characterized by an increased proliferation of the
granulocytic cell line and is characterized by the presence of the Philadelphia chromosome.
Splenomegaly is the most common physical finding in patients with chronic myelogenous leukemia.
The most common symptoms and presenting complaints in hairy cell leukemia (C) are weakness and
fatigue due to anemia. A positive TRAP stain in conjunction with a characteristic bone marrow biopsy
is essentially diagnostic of hairy cell leukemia. Waldenstrom Macroglobulinemia (D) presents with
constitutional B symptoms, bleeding, and hyperviscosity due to the IgM monoclonal protein in their
bloodstream, and is not associated with smudge cells.
Waldenstrom Macroglobulinemia ✅✅Waldenstrom Macroglobulinemia (D) presents with
constitutional B symptoms, bleeding, and hyperviscosity due to the IgM monoclonal protein in their
bloodstream, and is not associated with smudge cells.
One Step Further
,MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
Question: Which leukemia is associated with Down Syndrome? ✅✅Answer: ALL.
A 47-year-old firefighter is brought to the emergency department by ambulance with several burns
to the body. He was at the scene of a structural fire and was trapped by falling debris that burned
through his protective clothing. Physical examination shows several areas with a white, dry, waxy
appearance that fail to blanch with pressure. He complains of a lack of sensation over the affected
area. Which of the following type of burn did this patient most likely suffer?
Deep partial thickness (second-degree burn)
Fourth-degree burn
Full thickness (third-degree burn)
Superficial (first-degree burn) ✅✅Correct Answer ( C )
Explanation:
This patient most likely suffered a full thickness (third-degree) burn. These burns typically have a
characteristic white, dry, waxy appearance. The diagnostic findings of full thickness burns are lack of
sensation in the burned skin, lack of capillary refill, and a leathery texture that is unlike normal skin.
All dermal epithelial elements are destroyed, leaving no potential for reepithelialization.
Deep partial thickness (second-degree) burns (A) have a reddish appearance or a layer of whitish,
nonviable dermis firmly adherent to the remaining viable tissue. Fourth-degree burns (B) typically
extend through the entire skin and into underlying fat, muscle, and bone. They characteristically
appear black, charred with eschar. Superficial (first-degree) burns (D) only involve the epidermis.
They characteristically appear red without blisters.
One Step Further
Question: What type of burn is described as having a reddish appearance or a layer of whitish,
nonviable dermis? ✅✅Answer: Deep partial thickness (second-degree) burn.
What is the most common type of hearing loss in the elderly population?
Cerumen impaction
Chronic otitis media with effusion
Otosclerosis
Sensorineural hearing loss ✅✅Correct Answer ( D )
,MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
Explanation:
Hearing loss affects more than 80% of those older than 85 years of age. Men usually experience
greater hearing loss compared to women. More than 90% of older persons with hearing loss have
age-related sensorineural hearing loss, which is a gradual, symmetric loss of hearing (predominantly
of high frequencies) that is worse in noisy environments. Sensorineural hearing loss involves
problems converting mechanical vibrations to electrical potential in the cochlea or in auditory nerve
transmission to the brain. Hearing loss can be detrimental to a person and it prevents them from
wanting to be in a social environment due to being embarrassed by this condition. Depression is
common in elderly with hearing loss. Formal audiometric testing in a sound-protected environment
is the diagnostic standard, however this testing is costly. Physical examination includes inspection of
the auditory canal and tympanic membrane for obstruction or effusion. The Weber and Rinne tests
were designed to distinguish conductive from sensorineural hearing loss by comparing air and bone
conduction. Hearing aids are available as behind-the-ear, in-the-ear, and in-the-canal models. The
choice of aid is predominantly determined by the patient's perception of ease of use and
appearance, however only approximately 25% of eligible patients acquire hearing aides. In selected
patients, including those who do not tolerate hearing aids, middle ear implants may provide
comparable improvement in sound quality and clarity to hearing aids.
One Step Further
Question: How are acoustic neuromas diagnosed? ✅✅Answer: These intracranial, extra-axial
tumors arise from the Schwann cell sheath invading either the vestibular or cochlear nerve and are
diagnosed on MRI.
A four-year-old boy is brought to the ED for right hip pain for the last three days. He has been
walking with a slight limp. On examination, he has minimal pain with passive movement of the right
hip. Which of the following is most consistent with a diagnosis of transient synovitis rather than
septic arthritis?
Abnormal radiographs of the hip
Erythrocyte sedimentation rate of 50 mm/hr
Oral temperature of 36.8°C
Serum white blood cell count of 20,000 cells/µL ✅✅Correct Answer ( C )
Explanation:
An oral temperature of 36.8°C is most consistent with a diagnosis of transient synovitis, as generally
children with transient synovitis are afebrile. The most important part of diagnosing transient
synovitis is to exclude underlying septic arthritis. Transient synovitis is a self-limited non-pyogenic
inflammation of the synovium that most commonly occurs in boys between the ages of three and six
years of age. The exact etiology is unknown although in many cases follows a mild upper respiratory
, MOCK PANCE EXAM- Block 3 (ROSH)
Questions and Answers
infection. Children will complain of hip pain, walk with a limp or refuse to bear weight. They are
generally otherwise well appearing and non-toxic. This is a diagnosis of exclusion and if there is any
concern for septic arthritis, the patient should undergo arthrocentesis and synovial fluid analysis to
exclude septic arthritis. Patients with transient synovitis often respond to non-steroidal anti-
inflammatory medications and rest. They can generally be managed at home with 12-24 hour follow
up at the primary care physician's office. The prognosis is excellent.
One Step Further
Question: What is the most common cause of acute onset childhood hip pain? ✅✅Answer:
Transient synovitis.
A 72-year-old man presents with episodic exertional syncope and dyspnea that has been occurring
over the last two months. Physical exam demonstrates a mid-systolic murmur heard best at the
second intercostal space near the left sternal border. Echocardiogram demonstrates aortic valve
stenosis. Which of the following would you expect to find on physical exam?
Decrease in the intensity of the murmur with isometric handgrip
Decrease in the intensity of the murmur with squatting
Increase in the intensity of the murmur with standing
Increase in the intensity of the murmur with Valsalva maneuver ✅✅Correct Answer ( A )
Explanation:
A decrease in the intensity of the murmur with isometric handgrip is typically associated with aortic
stenosis. The carotid artery pulse wave contour will be small and slow rising in individuals with this
valvular disease. The characteristic murmur auscultated is mid-systolic and heard best at the second
intercostal space near the left sternal border. There is a classic "crescendo-decrescendo" murmur.
The murmur decreases in intensity with isometric handgrip, standing, and Valsalva maneuvers.
Squatting typically does not have an effect on the intensity of the murmur. Secondary left ventricular
hypertrophy may be a primary finding with electrocardiogram. EKG can also show nonspecific ST and
T-wave abnormalities. Echocardiography is the main diagnostic imaging tool used for evaluation of
aortic stenosis. Treatment is usually achieved with aortic valve replacement although medical
management can be used to relieve symptoms of angina and dyspnea on exertion as well as manage
left ventricular heart failure that can be associated with the stenosis.
One Step Further
Question: In patients with aortic stenosis, what secondary findings might be demonstrated on
electrocardiography? ✅✅Answer: Left atrial and left ventricular hypertrophy.
