Free PANRE-LA Practice Test: 50 Questions in Two Practice Quarters
Two 25-question practice quarters covering the NCCPA PANRE/PANRE-LA blueprint’s 15 content categories (effective January 2023), five options per question, with the answer, an explanation, and a keyword look-up under each one. Keep your usual references open, as you would on PANRE-LA; these are original, unofficial Castleport questions, not NCCPA items.
Practice Quarter 1
Question 1
A 64-year-old man has had 40 minutes of substernal pressure and diaphoresis. ECG shows 2-mm ST elevation in leads II, III, and aVF, with ST elevation in right-sided lead V4R. He has chewed aspirin 325 mg, and the catheterization lab has been activated. After one sublingual nitroglycerin tablet, his BP falls from 108/70 to 78/48 mm Hg. HR is 58/min, lungs are clear, and jugular venous pressure is low. Which is the most appropriate next step while awaiting PCI?
Reveal answer and explanation
Answer: D. Inferior STEMI with ST elevation in V4R points to right ventricular infarction. Nitroglycerin can reduce preload and sharply lower blood pressure. With clear lungs and low JVP, a small isotonic fluid bolus with immediate reassessment is appropriate while urgent reperfusion proceeds; excessive fluid can worsen RV failure.
Why not the others: Furosemide (A), more nitrate (B), and morphine (E) all reduce preload further. Metoprolol (C) is wrong with hypotension and a heart rate of 58.
5-minute look-up: "right ventricular infarction hypotension" → look for "preload assessment," "cautious fluid challenge," and "avoid nitrates."
Level: Intervention (Complex) · Source: 2025 ACC/AHA acute coronary syndromes guideline, Table 6 and §4.6; JCS ACS guideline, §7, “RV Infarction,” fluid/preload discussion; ACC RV infarction key points, points 8–9 (2024).
Question 2
A 71-year-old woman with hypertension is found to have atrial fibrillation at a routine visit. Her rate is controlled on metoprolol. She has no prior stroke, TIA, diabetes, heart failure, or vascular disease. eGFR is 72 mL/min/1.73 m², she has no bleeding history, and echocardiography shows no mitral stenosis. She has no mechanical valve. Which is the most appropriate stroke-prevention strategy?
Reveal answer and explanation
Answer: E. Her CHA₂DS₂-VASc score is 3 (female sex 1, age 65–74 1, hypertension 1). Current guidance recommends oral anticoagulation at a score of 2 or more in men or 3 or more in women, and prefers a direct oral anticoagulant over warfarin unless she has moderate-to-severe mitral stenosis or a mechanical valve. She has neither.
Why not the others: Withholding therapy (A) leaves her untreated at an anticoagulation-level risk. Aspirin alone (B) or with clopidogrel (C) is not a substitute for anticoagulation for stroke prevention in AF. Warfarin (D) works, but DOACs are preferred when eligible.
5-minute look-up: "CHA2DS2-VASc anticoagulation threshold 2023 AF guideline."
Level: Intervention (Basic) · Source: 2023 ACC/AHA/ACCP/HRS atrial fibrillation guideline (PDF), §6.3.1, recommendations 1, 2 and 4 (printed p. e33).
Question 3
A 28-year-old man has 2 days of sharp chest pain that worsens when he lies flat or breathes in and improves when he sits forward. He had an upper respiratory infection last week. A scratchy sound is heard at the left sternal border. ECG shows diffuse concave ST elevation with PR depression and PR elevation in aVR. Troponin is normal. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: E. Pleuritic, positional chest pain, a friction rub, and widespread ST elevation with PR depression support acute pericarditis. A viral prodrome is common.
Why not the others: Inferior STEMI (A) would usually produce a regional coronary-territory ECG pattern rather than this combination of diffuse changes, positional pain, and a rub. Early repolarization (B) does not explain the pain and rub. PE (C) and dissection (D) are less consistent with the complete presentation.
5-minute look-up: "acute pericarditis diagnostic criteria ECG PR depression."
Level: Diagnosis · Source: ACC 2025 pericarditis guidance, clinical-evaluation/diagnostic-criteria paragraph; NHLBI heart inflammation causes, “Infections.”
Question 4
A 66-year-old man develops sudden dyspnea the day after a 12-hour flight. BP is 78/50 mm Hg and stays below 90 systolic after a 1-L fluid bolus; HR is 128/min, SpO₂ 86% on room air. Bedside echo shows a dilated RV. CT pulmonary angiography confirms large bilateral pulmonary emboli. He has no recent surgery, bleeding, stroke, or other contraindication to thrombolysis. In addition to anticoagulation, which is the most appropriate treatment?
Reveal answer and explanation
Answer: B. Persistent hypotension indicates cardiopulmonary failure from acute PE. With no contraindication and an acceptable bleeding risk, systemic thrombolysis is a reasonable reperfusion treatment in addition to anticoagulation. It is the best option listed.
Why not the others: A filter (A) does not treat shock or provide reperfusion and is not a substitute for treatment in this anticoagulation-eligible patient. Outpatient care (C), oral anticoagulation alone (D), and observation (E) are inappropriate for this hemodynamically unstable patient.
5-minute look-up: "2026 acute pulmonary embolism guideline systemic thrombolysis persistent hypotension."
Level: Intervention (Complex) · Source: 2026 AHA/ACC acute pulmonary embolism guideline: Top Things to Know, points 4–5 (persistent hypotension and advanced reperfusion).
Question 5
A 30-year-old has asthma symptoms most days and wakes with cough and wheeze 1–2 nights a week. FEV₁ is 75% of predicted. She uses albuterol about 5 days a week and takes no controller. Which maintenance regimen is most appropriate?
Reveal answer and explanation
Answer: C. Weekly night waking together with reduced lung function supports starting medium-dose inhaled corticosteroid (ICS)-formoterol maintenance-and-reliever therapy (MART) under GINA 2026. The same inhaler provides scheduled maintenance treatment and additional doses for symptoms; this corresponds to Track 1, Step 4.
Why not the others: SABA alone (A) is unsafe and leaves inflammation untreated. Montelukast (B) is a less effective alternative. A LABA without an inhaled corticosteroid (D) increases the risk of severe asthma events. Prednisone alone (E) treats a flare, not the long-term disease.
5-minute look-up: "GINA 2026 Table 3 initial treatment adults medium-dose MART" and "Track 1 Step 4."
Level: Intervention (Basic) · Source: GINA 2026 Summary Guide (PDF), Table 3 (printed p. 22), Track 1 treatment pathway, and medication-safety sections.
Question 6
A 22-year-old tall, thin man who smokes and has no known lung disease develops sudden left-sided pleuritic chest pain and mild dyspnea while watching television. He has decreased breath sounds and hyperresonance over the left hemithorax. The trachea is midline, BP is 124/78 mm Hg, HR 96/min, SpO₂ 95%. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: D. A young, tall, thin smoker with no known lung disease, sudden pleuritic pain at rest, decreased breath sounds, and hyperresonance has a primary spontaneous pneumothorax.
Why not the others: The stable blood pressure and mild dyspnea favor a pneumothorax without tension physiology (A). Effusion (B) is dull to percussion. Pneumonia (C) usually brings fever, cough, and dullness. Pericarditis (E) doesn't cause unilateral hyperresonance.
5-minute look-up: "primary spontaneous pneumothorax risk factors exam findings."
Level: Diagnosis · Source: BTS Pleural Disease Guideline, spontaneous-pneumothorax introduction; BTS Appendix 1, p. 1 high-risk box; MedlinePlus pneumothorax, causes and examination.
Question 7
A 46-year-old woman has epigastric pain radiating to the back. Lipase is five times the upper limit of normal. Ultrasound shows gallstones with a normal common bile duct; bilirubin is normal, and she has no fever or signs of cholangitis. HR is 104/min, BP 128/76 mm Hg. She has no heart or kidney disease. Which is the best initial management?
Reveal answer and explanation
Answer: B. The 2024 ACG guideline suggests moderately aggressive fluid resuscitation, preferring lactated Ringer's over normal saline, with reassessment to avoid both under- and over-resuscitation. In mild disease, an early low-fat solid diet as tolerated is preferred over keeping patients NPO.
Why not the others: Routine NPO (A) is outdated. Prophylactic antibiotics (C) are not recommended without infection. Medical therapy is suggested over early ERCP (D) in biliary pancreatitis without cholangitis. Early CT (E) isn't needed when the diagnosis is clear and adds little in the first days.
5-minute look-up: "ACG 2024 acute pancreatitis fluids lactated Ringer feeding."
Level: Intervention (Basic) · Source: ACG 2024 Acute Pancreatitis Guideline Highlights (PDF), p. 1, “Diagnosis” and “Initial Assessment and Management.”
Question 8
A 34-year-old woman has iron deficiency anemia that hasn't responded to 3 months of oral iron, plus bloating and chronic loose stools. She eats a regular diet that includes bread daily. Which is the best initial test?
Reveal answer and explanation
Answer: A. Refractory iron deficiency with GI symptoms suggests celiac disease. IgA tTG, checked with total IgA to exclude IgA deficiency, is the recommended first test while the patient is still eating gluten.
Why not the others: HLA testing (B) mainly helps rule celiac out; a positive result is common in the general population. O&P (C) and breath testing (D) don't evaluate celiac disease. Starting a gluten-free diet first (E) can make serology and biopsy falsely negative.
5-minute look-up: "ACG celiac guideline initial serologic test IgA tTG total IgA."
Level: Diagnosis · Source: NIDDK Celiac Disease Tests, “Serologic tests,” “IgA deficiency,” and “Genetic tests.”
Question 9
A 59-year-old man with type 2 diabetes takes metformin 1,000 mg twice daily. A1C is 7.6%, eGFR 48 mL/min/1.73 m², and urine albumin-to-creatinine ratio 420 mg/g. These kidney abnormalities have persisted for four months. BP is 128/78 mm Hg on maximum-dose lisinopril. He has no known cardiovascular disease. Which addition best slows kidney disease progression and lowers cardiovascular risk?
Reveal answer and explanation
Answer: D. In type 2 diabetes with CKD and albuminuria, an SGLT2 inhibitor with proven kidney benefit is recommended regardless of A1C to slow CKD progression and reduce cardiovascular events.
Why not the others: Glipizide (A), sitagliptin (B), and NPH (E) lower glucose but are not preferred for slowing CKD progression in this setting. Pioglitazone (C) is not preferred for kidney protection and can cause fluid retention.
5-minute look-up: "ADA Standards of Care CKD SGLT2 inhibitor albuminuria."
Level: Intervention (Complex) · Source: KDIGO 2024 CKD Guideline (PDF), Table 1, practice points 1.1.3.1–2 and recommendations 3.7.1–2; pioglitazone prescribing information, §5.1.
Question 10
A 29-year-old woman with pre-existing overt hypothyroidism due to Hashimoto thyroiditis takes levothyroxine 100 mcg daily; her TSH was 1.8 mIU/L last month. She now has a confirmed pregnancy at 5 weeks. Which is the most appropriate management?
Reveal answer and explanation
Answer: C. Thyroid hormone requirements rise early in pregnancy. For pre-existing overt hypothyroidism, ATA 2026 guidance supports increasing levothyroxine when pregnancy is confirmed and then titrating to thyroid tests, taking the prior TSH and dose into account. Two extra usual doses per week is one practical increase; check TSH in about 4 weeks and continue close monitoring through midpregnancy.
Why not the others: Waiting (A) or stopping therapy (B) risks maternal hypothyroidism during fetal brain development. Liothyronine (D) is not recommended in pregnancy. Methimazole (E) treats hyperthyroidism.
5-minute look-up: "ATA pregnancy guideline levothyroxine increase confirmed pregnancy."
Level: Intervention (Complex) · Source: ATA 2026 pregnancy and postpartum guideline, §F, overt hypothyroidism—gestational management; ATA Hypothyroidism in Pregnancy, treatment and four-week monitoring guidance.
Question 11
A 2-year-old has a temperature of 39.0 °C (102.2 °F), is pulling at the right ear, and has a bulging, erythematous right tympanic membrane. Both eyes have purulent discharge with conjunctival injection. She has had no antibiotics in the past 30 days and has no penicillin allergy. Which is the best treatment?
Reveal answer and explanation
Answer: E. Acute otitis media with purulent conjunctivitis (otitis-conjunctivitis syndrome) calls for beta-lactamase coverage. The AAP recommends amoxicillin-clavulanate in this situation instead of amoxicillin alone.
Why not the others: A temperature of 39 °C or higher marks severe AOM, so observation (A) isn't appropriate. Plain amoxicillin (B) is first-line in most cases but not with concurrent purulent conjunctivitis. Azithromycin (C) is not the recommended first choice for a child who can take beta-lactams. Ofloxacin otic drops (D) alone do not treat this infection behind an intact, bulging TM.
5-minute look-up: "AAP AOM guideline conjunctivitis amoxicillin-clavulanate."
Level: Intervention (Complex) · Source: CDC pediatric outpatient recommendations, AOM row; AAP AOM symptom severity and treatment options, severe-AOM row and alternate-treatment footnote.
Question 12
A 26-year-old who wears soft contact lenses slept in them and now has right eye pain, tearing, and photophobia. Fluorescein shows a small epithelial defect without an infiltrate. Visual acuity is normal. Which is the best management?
Reveal answer and explanation
Answer: C. Contact lens–related abrasions carry a risk of Pseudomonas keratitis, so they need an antipseudomonal topical antibiotic such as a fluoroquinolone, no lens wear, and close follow-up.
Why not the others: Patching (A) isn't recommended and is avoided in lens wearers. Tetracaine alone (B) is not an adequate treatment plan for this contact lens–related abrasion and provides no antipseudomonal coverage. Topical steroids (D) can worsen infection. Erythromycin (E) lacks reliable Pseudomonas coverage, and resuming lenses is unsafe.
5-minute look-up: "corneal abrasion contact lens wearer antipseudomonal."
Level: Intervention (Basic) · Source: Oxford University Hospitals antimicrobial guide, “Superficial trauma—corneal abrasion”; AAO Contact Lens Complications, epithelial defects; Merck Manual, treatment (September 2026); ACEP 2024 consensus, restricted topical-anesthetic use.
Question 13
A 67-year-old man has had a hot, swollen right knee for 1 day and cannot bear weight. Temperature is 38.6 °C (101.5 °F). Arthrocentesis shows cloudy fluid with 85,000 WBC/µL, 92% neutrophils, and no crystals; Gram stain is negative. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: B. A synovial WBC above 50,000/µL with a neutrophil predominance strongly raises the likelihood of septic arthritis. A negative Gram stain doesn't exclude it — stains miss many infections. This presentation requires urgent evaluation and treatment for suspected septic arthritis; a negative culture alone would not exclude infection.
Why not the others: Gout (A) and pseudogout (C) can also produce high cell counts; absent crystals do not exclude them, and even identified crystals would not exclude infection. OA (D) is less consistent with fever and this markedly inflammatory fluid. Reactive arthritis (E) usually follows a GI or GU infection, a supporting history not provided here.
5-minute look-up: "synovial fluid WBC septic arthritis likelihood ratio."
Level: Diagnosis · Source: SANJO guideline, diagnostic questions 3–5 and microbiology question 9; NIAMS reactive arthritis, overview.
Question 14
A 19-year-old falls on an outstretched hand. She has tenderness in the anatomic snuffbox. Wrist radiographs, including a scaphoid view, are normal. Which is the most appropriate next step?
Reveal answer and explanation
Answer: B. Initial radiographs miss a meaningful share of scaphoid fractures. With snuffbox tenderness, immobilize in a thumb spica and re-image — repeat radiographs in 10–14 days, or MRI for an earlier answer — because a missed fracture risks nonunion and avascular necrosis.
Why not the others: Reassurance (A) risks a missed fracture. Surgery (C) isn't indicated without a confirmed fracture and an operative indication. Six weeks of immobilization without follow-up imaging (D) leaves the diagnosis and healing unassessed. Steroid injection (E) has no role.
5-minute look-up: "occult scaphoid fracture normal x-ray thumb spica repeat imaging."
Level: Intervention (Basic) · Source: BSSH Scaphoid Fracture Standards (PDF), recommendations 5, 7 and 9; ACR Acute Hand and Wrist Trauma, Variant 2; AAOS scaphoid fracture guidance, imaging and complications.
Question 15
A 31-year-old man has a painless, indurated penile ulcer for 10 days with nontender inguinal lymphadenopathy. RPR is reactive and a treponemal test is positive. HIV testing is negative. He has no penicillin allergy. Which is the recommended treatment?
Reveal answer and explanation
Answer: A. Primary syphilis is treated with a single IM dose of benzathine penicillin G 2.4 million units.
Why not the others: Three weekly doses (B) are for late latent syphilis or latent syphilis of unknown duration. The single 500-mg ceftriaxone dose (C) is not a recommended syphilis regimen. Doxycycline is an alternative for penicillin allergy and is given for 14 days, not 7 (D). Acyclovir (E) treats herpes, not syphilis.
5-minute look-up: "CDC STI treatment guidelines primary syphilis."
Level: Intervention (Basic) · Source: CDC primary and secondary syphilis guidance, recommended regimen and penicillin-allergy section; CDC latent syphilis, treatment; CDC genital herpes, first-episode regimens.
Question 16
A nonpregnant 44-year-old woman in Connecticut went hiking in June. Nine days later she has an expanding, 8-cm round erythematous patch with central clearing on her thigh and mild fatigue. She has no neurologic or cardiac findings. Which is the best management?
Reveal answer and explanation
Answer: E. Erythema migrans in an endemic area is a clinical diagnosis of early localized Lyme disease. The IDSA/AAN/ACR guideline recommends treatment without testing; doxycycline for 10 days is a recommended regimen.
Why not the others: Serology (A) is often negative this early. A single 200-mg dose (B) is prophylaxis after a qualifying tick bite, not treatment of an established rash. IV therapy (C) is not needed for localized disease. Mupirocin (D) treats impetigo.
5-minute look-up: "IDSA Lyme 2020 erythema migrans doxycycline duration."
Level: Intervention (Basic) · Source: IDSA/AAN/ACR Lyme guideline, §§IV–VII; CDC erythema migrans treatment, adult doxycycline row and duration footnote (March 27, 2026).
Question 17
A 52-year-old with alcohol use disorder has completed withdrawal management and wants help staying abstinent. He takes buprenorphine for opioid use disorder. eGFR is 90 mL/min/1.73 m²; liver enzymes are mildly elevated. Which medication is most appropriate?
Reveal answer and explanation
Answer: B. Acamprosate is a first-line option for maintaining abstinence, is cleared by the kidneys (his renal function is normal), and doesn't interact with opioid therapy.
Why not the others: Naltrexone (A) is an opioid antagonist; it would block buprenorphine and can precipitate withdrawal, so it's contraindicated while he takes an opioid. Disulfiram (C) is not first-line and works mainly with supervision and strong motivation. Prolonged benzodiazepines (D) add dependence risk. Bupropion (E) isn't an AUD treatment.
5-minute look-up: "APA alcohol use disorder guideline naltrexone acamprosate opioid."
Level: Intervention (Basic) · Source: NYSDOH/JHU Treatment of Alcohol Use Disorder, preferred pharmacotherapy, naltrexone contraindications and disulfiram sections; SAMHSA acamprosate, opioid compatibility and renal precautions.
Question 18
A 40-year-old seen for insomnia says he was recently divorced, feels hopeless, and plans to shoot himself this weekend. He owns a handgun kept at home and says, "I don't see another way." Which is the most appropriate next step?
Reveal answer and explanation
Answer: D. A specific plan, a near-term date, intent, and access to a firearm indicate acute high risk. He needs immediate emergency evaluation with continuous observation while transfer is arranged. Take steps to secure or remove access to lethal means as part of the immediate safety plan.
Why not the others: Delayed follow-up (A, C, E) does not match acute risk. No-suicide contracts (B) are not supported as a safety intervention and don't replace evaluation.
5-minute look-up: "VA/DoD suicide risk guideline acute high risk management."
Level: Intervention (Basic) · Source: NIMH Adult Outpatient Brief Suicide Safety Assessment Guide, “Suicide Plan,” “Make a safety plan,” and “Determine disposition.”
Question 19
A 35-year-old has a 4-cm fluctuant abscess on the thigh with 3 cm of surrounding erythema. Temperature is 38.4 °C (101.1 °F), HR 102/min. Community MRSA is common locally. He has no drug allergies. Which is the best management?
Reveal answer and explanation
Answer: C. Drainage is the core treatment for a purulent abscess. Because he has signs of systemic inflammation (fever and tachycardia), an antibiotic active against MRSA, such as TMP-SMX or doxycycline, is added.
Why not the others: Compresses alone (A) are inadequate for a 4-cm abscess. Drainage alone (B) is reasonable without systemic signs, but he has them. Cephalexin without drainage (D) misses both the source control and MRSA. Needle aspiration (E) is less effective than incision, and topical therapy doesn't treat systemic signs.
5-minute look-up: "IDSA SSTI purulent abscess SIRS MRSA antibiotic."
Level: Intervention (Complex) · Source: IDSA Skin and Soft Tissue Infections guideline, “Purulent Skin and Soft Tissue Infections,” recommendations II.3–4 and cutaneous-abscess evidence summary.
Question 20
A 15-year-old wakes with sudden severe left scrotal pain that began 3 hours ago, with vomiting. The left testis is high-riding with a horizontal lie, and the cremasteric reflex is absent. Which is the most appropriate next step?
Reveal answer and explanation
Answer: E. Sudden pain, a high-riding horizontal testis, and an absent cremasteric reflex make testicular torsion highly likely. Salvage falls sharply after about 6 hours, so emergent surgical exploration should not wait for imaging when the clinical picture is this clear.
Why not the others: Elevation and NSAIDs (A) and antibiotics (B) treat epididymitis. Delayed imaging (C) and observation (D) waste the salvage window.
5-minute look-up: "acute scrotum testicular torsion cremasteric reflex surgical exploration timing."
Level: Intervention (Basic) · Source: American Urological Association, Medical Student Curriculum: Acute Scrotum (amended November 2025), “Testicular Torsion”: presentation, time to detorsion, and exploration when clinical suspicion is high.
Question 21
A 63-year-old man has fatigue. Hemoglobin is 10.1 g/dL, MCV 74 fL, ferritin 8 ng/mL. He has no overt bleeding, no GI symptoms, and has never had a colonoscopy. Besides starting iron, what is the most appropriate next step?
Reveal answer and explanation
Answer: A. Unexplained iron deficiency anemia in an adult man requires evaluation for a gastrointestinal cause, including occult bleeding or malignancy. The AGA recommends bidirectional endoscopy for asymptomatic men and postmenopausal women with iron deficiency anemia.
Why not the others: A negative FIT (B) does not exclude a bleeding lesion and shouldn't gate endoscopy here. Electrophoresis (C) evaluates thalassemia, which does not explain the depleted iron stores here. Marrow biopsy (D) is unnecessary with a diagnostic ferritin. Waiting (E) risks missing a cancer.
5-minute look-up: "AGA iron deficiency anemia guideline bidirectional endoscopy men."
Level: Intervention (Basic) · Source: AGA, Gastrointestinal evaluation of iron deficiency anemia, “Key guideline recommendations,” bidirectional endoscopy in asymptomatic men and postmenopausal women.
Question 22
A 70-year-old with CKD takes lisinopril and spironolactone. Potassium is 7.1 mEq/L. ECG shows peaked T waves and a widened QRS. He is hemodynamically stable. Which medication should be given first?
Reveal answer and explanation
Answer: A. With ECG changes, the first priority is stabilizing the cardiac membrane with IV calcium, which works within minutes. Calcium does not lower potassium; potassium-shifting treatment (such as insulin with glucose) and potassium removal must also be arranged promptly.
Why not the others: Binders (B, D) and diuretics (C) do not provide the immediate cardiac membrane stabilization needed for these ECG changes. Bicarbonate (E) is not a first-line drug, especially without acidosis.
5-minute look-up: "hyperkalemia ECG changes calcium gluconate first."
Level: Intervention (Basic) · Source: Lindner et al., KDIGO acute hyperkalemia conference summary, “Cellular membrane stabilization,” “Potassium shift,” and “Potassium elimination.”
Question 23
A 68-year-old has sudden right hemiparesis and aphasia; he was last known well 2 hours ago. Noncontrast CT shows no hemorrhage, glucose is 132 mg/dL, and NIHSS is 12. BP is 202/112 mm Hg. He is otherwise eligible for IV thrombolysis. What is the most appropriate approach to his blood pressure?
Reveal answer and explanation
Answer: B. BP must be below 185/110 mm Hg before IV thrombolysis and kept below 180/105 mm Hg for 24 hours afterward. Arrival BP above that threshold is not a contraindication if it can be safely lowered with IV agents.
Why not the others: Thrombolysis at this BP (A) raises hemorrhage risk. Aggressive lowering to 140/90 (C) can worsen ischemia and isn't the target. Withholding therapy (D) is wrong when BP can be controlled. Immediate-release nifedipine (E) causes unpredictable drops.
5-minute look-up: "AHA ASA acute ischemic stroke BP before thrombolysis 185/110."
Level: Intervention (Complex) · Source: 2026 AHA/ASA acute ischemic stroke guideline (PDF), §4.3, recommendations 5 and 7–8, PDF p35; 2025 AHA/ACC High Blood Pressure slide set, Table 27, slide 154 (IV stroke agents).
Question 24
A 27-year-old is 6 weeks from her last menstrual period with mild pelvic pain. She is hemodynamically stable. hCG is 1,900 mIU/mL and rising less than expected. Transvaginal ultrasound shows a 2.5-cm left tubal gestational sac containing a yolk sac, separate from the ovary, with no embryonic cardiac activity; there is no intrauterine pregnancy or free fluid. CBC, creatinine, and liver enzymes are normal. She is not breastfeeding, has no other contraindications to methotrexate, and can return reliably for follow-up. After counseling about medical and surgical options, she chooses medical treatment. Which is the most appropriate management?
Reveal answer and explanation
Answer: D. The extrauterine yolk sac confirms a tubal ectopic pregnancy. She is stable, has a small unruptured ectopic without embryonic cardiac activity, a low initial hCG, no methotrexate contraindications, and reliable follow-up. A single-dose methotrexate protocol with serial hCG until it reaches the laboratory’s nonpregnant range is appropriate; an inadequate hCG decline may require further treatment.
Why not the others: D&C (A) evaluates intrauterine tissue, not a tubal pregnancy. Laparotomy (B) is for instability or rupture. Monitoring without hCG (C) is unsafe. Misoprostol (E) is used for intrauterine pregnancy loss.
5-minute look-up: "ACOG tubal ectopic pregnancy methotrexate candidates."
Level: Intervention (Basic) · Source: ACOG Practice Bulletin No. 193, Tubal Ectopic Pregnancy (reaffirmed 2025), “Transvaginal Ultrasonography,” medical-management eligibility, and Boxes 1–2; accessible bulletin text (PDF), appendix pp. 49, 55–62 and 74 (PDF pp. 55, 61–68 and 80).
Question 25
A 58-year-old Spanish-speaking woman with limited English proficiency comes to a clinic covered by Section 1557 to discuss a new diagnosis and consent for colonoscopy. Her 14-year-old bilingual son offers to interpret. A qualified medical interpreter is available by video. The patient has not asked for her son to interpret. Which is the most appropriate action?
Reveal answer and explanation
Answer: B. When interpretation is needed, Section 1557 rules require a covered provider to offer a qualified interpreter. A minor child may be used only temporarily during an emergency involving an imminent threat when no qualified interpreter is immediately available; a qualified interpreter who arrives must confirm or supplement the communication. This routine consent discussion does not meet that exception, and qualified video interpretation is available now.
Why not the others: Relying on her minor son (A) is prohibited in this nonemergency setting. Bilingual ability alone does not establish the front-desk employee's qualifications (C). Gestures and English materials (D) don't give meaningful access. A month's delay (E) is unnecessary when a qualified interpreter is available today.
5-minute look-up: "45 CFR 92.201 language assistance minor child interpreter."
Level: Emergent topic · Source: 45 CFR §92.201, (a)–(c), (e)(3)–(4), (f), and (h): qualified interpretation, minor-child exception and video services.
Practice Quarter 2
Question 26
A 67-year-old has heart failure with reduced ejection fraction (LVEF 30%), NYHA class II. He takes sacubitril-valsartan, metoprolol succinate at target dose, and dapagliflozin. BP is 112/70 mm Hg, potassium 4.3 mEq/L, eGFR 58 mL/min/1.73 m². Which addition is most appropriate?
Reveal answer and explanation
Answer: E. He's on three of the four foundational HFrEF drug classes. A mineralocorticoid receptor antagonist is recommended for NYHA II–IV when eGFR is above 30 and potassium is below 5.0 mEq/L — both true — to reduce mortality and hospitalization.
Why not the others: Digoxin (A) may reduce hospitalization but doesn't lower mortality and isn't the next step. Diltiazem (B) is harmful in HFrEF. A thiazide (C) treats congestion or BP, not prognosis. Switching to an ACE inhibitor (D) is a step down from an ARNI.
5-minute look-up: "2022 AHA ACC HFSA HFrEF MRA eGFR potassium."
Level: Intervention (Complex) · Source: 2022 AHA/ACC/HFSA Heart Failure guideline slide set (PDF), slide 75 (MRA eligibility/monitoring), slide 85 (diltiazem), slide 94 (digoxin).
Question 27
A 55-year-old has BP 228/134 mm Hg with headache, confusion, and bilateral papilledema. Creatinine is 2.4 mg/dL (1.0 mg/dL six months ago). CT shows no stroke, and there is no evidence of aortic dissection; she is not pregnant. Which is the most appropriate initial management?
Reveal answer and explanation
Answer: B. Severe hypertension with new target-organ damage (encephalopathy and papilledema) is a hypertensive emergency. Without a compelling condition such as aortic dissection, SBP should come down by no more than 25% in the first hour with a titratable IV agent, then to below 160/100 mm Hg over the next 2–6 hours if stable.
Why not the others: Oral therapy with delayed follow-up (A) undertreats an emergency. Rapid normalization (C) risks cerebral, coronary, and renal ischemia. Immediate-release nifedipine (D) causes unpredictable drops. Delaying treatment (E) allows ongoing organ injury.
5-minute look-up: "hypertensive emergency no compelling condition 25% first hour."
Level: Intervention (Basic) · Source: 2025 AHA/ACC High Blood Pressure guideline slide set, slides 144–146 (emergency targets), Tables 26–27 (IV agents).
Question 28
A 62-year-old man had an MI 2 years ago and an ischemic stroke last year. He takes atorvastatin 80 mg with good adherence and tolerates it well. LDL-C is 88 mg/dL. Which is the most appropriate next step?
Reveal answer and explanation
Answer: C. Two major ASCVD events place him at very high risk. The 2026 ACC/AHA dyslipidemia guideline sets an LDL-C goal below 55 mg/dL for very-high-risk ASCVD and recommends adding ezetimibe and/or a PCSK9 monoclonal antibody to maximally tolerated statin therapy, based on the additional LDL reduction needed and patient preference. Ezetimibe is the best option listed; further intensification may be needed to reach goal.
Why not the others: An LDL-C of 88 (A) is well above goal. Rosuvastatin 5 mg (B) is a moderate-intensity dose — a downgrade from atorvastatin 80 mg. Niacin (D) and fenofibrate (E) haven't reduced ASCVD events when added to statins.
5-minute look-up: "2026 ACC/AHA dyslipidemia very high risk LDL goal ezetimibe."
Level: Intervention (Complex) · Source: 2026 ACC/AHA Dyslipidemia guideline slide set, Table 6/slide 66 (statin intensity), slides 112–116 (very-high-risk secondary prevention).
Question 29
A 70-year-old with COPD (post-bronchodilator FEV₁ 45% of predicted) uses a single-inhaler LAMA/LABA with good technique. He had two moderate exacerbations needing oral prednisone in the past year. Blood eosinophils are 340 cells/µL. Which is the most appropriate change?
Reveal answer and explanation
Answer: A. For exacerbations despite LABA + LAMA, GOLD recommends escalating to LABA + LAMA + ICS when blood eosinophils are 100 cells/µL or more; the benefit is greatest at 300 or more, as here.
Why not the others: GOLD discourages LABA/ICS without a LAMA in COPD (B). Theophylline (C) adds toxicity with little benefit. Long-term oral steroids (D) cause serious harm. Removing maintenance therapy (E) is a step backward.
5-minute look-up: "GOLD 2026 follow-up exacerbations LABA LAMA eosinophils ICS."
Level: Intervention (Complex) · Source: GOLD 2026 Pocket Guide (PDF), Figures 3.9–3.10, printed pp. 28–29/PDF pp. 31–32: follow-up therapy and factors favoring ICS.
Question 30
A 2-year-old has a barking cough and hoarse voice that began last night after 2 days of runny nose. She has inspiratory stridor at rest and mild suprasternal retractions, SpO₂ 96%, and looks nontoxic. Which is the best treatment?
Reveal answer and explanation
Answer: D. This is moderate croup (stridor at rest with retractions). A single dose of dexamethasone reduces severity and return visits, and nebulized epinephrine gives rapid relief of airway swelling; observe for at least two hours after epinephrine for recurrent stridor or respiratory distress as its effect wears off.
Why not the others: Albuterol (A) treats lower-airway bronchospasm, not subglottic edema. Croup is viral, so antibiotics (B) don't help. Imaging (C) isn't needed for a typical presentation and shouldn't delay care. Mist (E) hasn't been shown to work.
5-minute look-up: "croup moderate stridor at rest dexamethasone nebulized epinephrine."
Level: Intervention (Basic) · Source: Canadian Paediatric Society, Acute management of croup in the emergency department (updated March 6, 2026), Table 2 and “Corticosteroids,” “Epinephrine,” and “Other therapies.”
Question 31
A 61-year-old with years of heartburn now has 3 months of progressive difficulty swallowing solids and has lost 6 kg (13 lb) without trying. He takes omeprazole daily. Which is the most appropriate next step?
Reveal answer and explanation
Answer: C. Progressive solid-food dysphagia and unintentional weight loss are alarm features for malignancy or stricture. Guidelines call for prompt upper endoscopy rather than escalating empiric therapy.
Why not the others: More acid suppression (A, B) delays diagnosis. A barium study (D) can't biopsy and doesn't replace endoscopy here. pH monitoring (E) does not replace prompt endoscopic evaluation of these alarm features.
5-minute look-up: "ACG GERD guideline alarm symptoms endoscopy dysphagia weight loss."
Level: Intervention (Complex) · Source: ASGE 2025 GERD guideline, Table 1 and alarm-symptom recommendation.
Question 32
A 9-year-old has 18 hours of abdominal pain with right lower quadrant tenderness, a temperature of 38.1 °C (100.6 °F), and WBC 14,000/µL. He is stable, without guarding or rebound tenderness. The clinical assessment places him at intermediate risk for appendicitis. Which is the best initial imaging study?
Reveal answer and explanation
Answer: E. For a child at intermediate clinical risk for appendicitis, right lower quadrant ultrasound is an appropriate initial test and avoids ionizing radiation. If ultrasound is nondiagnostic and concern persists, MRI or contrast-enhanced CT is an appropriate next study.
Why not the others: CT (A) is accurate but exposes a child to radiation as a first step. Plain films (B) are rarely diagnostic. An upper GI series (C) evaluates malrotation. HIDA (D) evaluates the gallbladder.
5-minute look-up: "ACR Suspected Appendicitis–Child intermediate clinical risk ultrasound."
Level: Diagnosis · Source: ACR Appropriateness Criteria, Suspected Appendicitis–Child, Variant 2 (intermediate-risk initial imaging), Variant 4 (nondiagnostic ultrasound).
Question 33
A 72-year-old develops six watery stools a day after a week of clindamycin. WBC is 11,000/µL and creatinine 1.0 mg/dL (her baseline). C. difficile testing is positive. This is her first episode. Which treatment is preferred?
Reveal answer and explanation
Answer: B. For this first, non-severe episode, the IDSA/SHEA 2021 focused update favors fidaxomicin when available; oral vancomycin is an acceptable alternative.
Why not the others: Metronidazole (A) is now reserved for non-severe cases when the preferred drugs aren't available. IV vancomycin (C) is not the appropriate route for treating intraluminal CDI. Antimotility drugs alone (D) don't treat the infection. FMT (E) is not initial treatment for this uncomplicated first episode.
5-minute look-up: "IDSA SHEA 2021 C difficile initial episode fidaxomicin."
Level: Intervention (Basic) · Source: SHEA/IDSA 2021 CDI focused update, recommendationI/resource comment; SHEA/IDSA 2017 guideline, adult treatmentXXIX (dose and limited-access metronidazole).
Question 34
A 32-year-old woman has 2 months of weight loss, tremor, palpitations, and heat intolerance. She has a diffuse, nontender goiter and bilateral proptosis with lid retraction. TSH is below 0.01 mIU/L and free T4 is elevated. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: D. Thyrotoxicosis with a diffuse goiter and orbitopathy (proptosis) strongly supports Graves disease.
Why not the others: Toxic multinodular goiter (A) is nodular and occurs in older patients without eye disease. Subacute thyroiditis (B) causes a tender thyroid. Painless thyroiditis (C) has no orbitopathy and low uptake. Factitious disease (E) produces a small gland and low thyroglobulin, not proptosis.
5-minute look-up: "ATA hyperthyroidism guideline Graves orbitopathy diagnosis."
Level: Diagnosis · Source: ATA, Graves’ Disease, “How is Graves’ disease diagnosed?”; ATA, Thyroid Eye Disease, “What is thyroid eye disease?”; Endotext, Subacute Thyroiditis (PDF), differential diagnosis, pp2–3 (updated January 7, 2026).
Question 35
A 24-year-old with type 1 diabetes has glucose 486 mg/dL, venous pH 7.14, bicarbonate 9 mEq/L, beta-hydroxybutyrate 6.2 mmol/L, potassium 3.1 mEq/L, and creatinine 1.3 mg/dL. IV isotonic fluids have been started. What is the next step?
Reveal answer and explanation
Answer: C. Insulin drives potassium into cells. Starting it with a potassium of 3.1 risks dangerous hypokalemia and arrhythmia. The 2024 hyperglycemic crises consensus says to replace potassium first and delay insulin until potassium exceeds 3.5 mmol/L.
Why not the others: Immediate insulin (A) is the error this question tests. Bicarbonate (B) is not indicated at pH 7.14. Basal insulin alone (D) doesn't treat DKA. Dextrose (E) is added when glucose falls below about 250 mg/dL.
5-minute look-up: "2024 hyperglycemic crises consensus potassium below 3.5 delay insulin."
Level: Intervention (Complex) · Source: Umpierrez et al., 2024 hyperglycaemic-crises consensus, treatment sections “Potassium,” “Bicarbonate” and “Insulin.”
Question 36
A 19-year-old has had a sore throat for 5 days that is now severe on the right, with trismus and a muffled "hot potato" voice. The right peritonsillar area bulges and the uvula is deviated to the left. Which is the most appropriate management?
Reveal answer and explanation
Answer: A. Unilateral peritonsillar swelling with uvular deviation away from the side, trismus, and a muffled voice indicate a peritonsillar abscess. Treatment is drainage — needle aspiration or incision — plus antibiotics, with analgesia and hydration.
Why not the others: Antibiotics alone (B) are inadequate for this abscess with trismus and a muffled voice. Immediate tonsillectomy (C) is reserved for selected patients. Testing alone (D, E) delays needed drainage.
5-minute look-up: "peritonsillar abscess management needle aspiration antibiotics."
Level: Intervention (Basic) · Source: University of Iowa, Peritonsillar Abscess Management, “Evaluation,” “Management” and “Drainage Procedure” (updated 2023); Galioto, Peritonsillar Abscess, “Treatment—Drainage” (2017).
Question 37
A 66-year-old woman develops sudden severe right eye pain, headache, nausea, and halos around lights after a film in a dark theater. Which examination finding is most expected?
Reveal answer and explanation
Answer: E. Dim light dilates the pupil and can close a narrow angle, causing acute angle-closure glaucoma. Expect a red eye, a fixed mid-dilated pupil, corneal edema (haze), and a firm globe from very high intraocular pressure. It needs emergency treatment.
Why not the others: A curtain (A) suggests retinal detachment. A cherry-red spot (B) fits central retinal artery occlusion, which is painless. Dendrites (C) indicate herpes simplex keratitis. Subconjunctival hemorrhage (D) is painless and benign.
5-minute look-up: "acute angle closure glaucoma signs mid-dilated pupil corneal edema."
Level: History & Physical · Source: NHS Highland, Acute Angle Closure Glaucoma, “Signs and symptoms” (reviewed February 16, 2026); Royal College of Ophthalmologists, Management of Angle-Closure Glaucoma (PDF), §4.1 and §4.4(y), pp. 10–11 and 20–23 (2022).
Question 38
A 70-year-old man has acute podagra. He has stage 4 CKD (eGFR 22 mL/min/1.73 m²) and no diabetes. His estimated creatinine clearance is 24 mL/min. He took a standard low-dose colchicine flare course 5 days ago with incomplete relief. He takes no allopurinol. Which is the most appropriate treatment for this flare?
Reveal answer and explanation
Answer: C. Colchicine, NSAIDs, and glucocorticoids are all first-line for gout flares, chosen by comorbidities. In advanced CKD, NSAIDs increase kidney risk, and a colchicine flare-treatment course should not be repeated within 2 weeks in severe renal impairment. An oral glucocorticoid is the best option listed.
Why not the others: Indomethacin (A) is risky in advanced CKD. Repeating colchicine after only 5 days (B) conflicts with the label's minimum 2-week interval in severe renal impairment. Allopurinol without flare treatment (D) doesn't treat the attack, and 300 mg is too high a starting dose in CKD. Probenecid (E) is not flare therapy and is generally avoided in moderate-to-severe CKD.
5-minute look-up: "ACR 2020 gout flare treatment CKD glucocorticoid."
Level: Intervention (Basic) · Source: ACR 2020 gout guideline (PDF), “Gout flare management,” Table 6 and “Uricosurics”; colchicine prescribing information, §§2.5 and 8.6, severe renal impairment.
Question 39
A 68-year-old woman has bilateral knee osteoarthritis that limits walking despite a supervised exercise program and weight loss. She had a peptic ulcer bleed 2 years ago and has hypertension. Which is the most appropriate next medication?
Reveal answer and explanation
Answer: D. The ACR/Arthritis Foundation guideline strongly recommends topical NSAIDs for knee osteoarthritis and suggests using them before oral NSAIDs. Low systemic absorption matters for someone with a prior ulcer bleed and hypertension.
Why not the others: Oral NSAIDs (A) raise GI bleeding and BP risk for her. Tramadol (B) is conditionally recommended at most, with dependence and fall risks. Glucosamine (C) is recommended against. Long-term oral prednisone (E) is not a recommended treatment for knee OA.
5-minute look-up: "ACR 2019 osteoarthritis guideline topical NSAID knee."
Level: Intervention (Basic) · Source: ACR/Arthritis Foundation 2019 osteoarthritis guideline (PDF), pharmacologic recommendations for topical NSAIDs, tramadol and glucosamine (published 2020).
Question 40
A 26-year-old has fever, sore throat, a diffuse rash, and lymphadenopathy 2 weeks after condomless sex with a new partner. A fourth-generation HIV-1/2 antigen/antibody immunoassay is reactive. The HIV-1/HIV-2 antibody differentiation immunoassay is negative. What is the next step?
Reveal answer and explanation
Answer: B. A reactive antigen/antibody screen with a negative differentiation assay may reflect acute HIV or a false-positive screen. HIV-1 RNA testing distinguishes these possibilities; p24 antigen can become detectable before antibodies.
Why not the others: Calling it negative (A) can miss acute HIV. Western blot (C) is no longer part of the algorithm. Waiting 6 months (D) delays diagnosis and treatment. CD4 count (E) stages known infection; it doesn't diagnose it.
5-minute look-up: "CDC HIV laboratory testing algorithm differentiation negative NAT."
Level: Diagnosis · Source: NIH, Early (Acute and Recent) HIV Infection, “Diagnosing Acute HIV Infection” (reviewed 2024).
Question 41
A 74-year-old with COPD has had fever, myalgia, and cough for 3 days during influenza season. A rapid molecular test is positive for influenza A. SpO₂ is 94%, and she is being managed as an outpatient. Estimated creatinine clearance is 76 mL/min. Which is the best management?
Reveal answer and explanation
Answer: E. Antiviral treatment is recommended for outpatients at high risk of complications — age 65 or older and chronic lung disease both qualify — even when started more than 48 hours after symptom onset.
Why not the others: The 48-hour cutoff (A) should not be used to withhold treatment from this high-risk patient. Adamantanes (B) are not recommended because of widespread resistance among circulating influenza A viruses. Azithromycin (C) doesn't treat influenza. Vaccination (D) doesn't treat current infection.
5-minute look-up: "CDC influenza antiviral high risk outpatient more than 48 hours."
Level: Intervention (Basic) · Source: CDC, Influenza Antiviral Medications: Summary for Clinicians, “Priority Groups,” Table 2 and Table 3 (updated March 10, 2026).
Question 42
A 78-year-old woman has generalized anxiety disorder for 9 months. She has fallen twice this year and takes oxycodone for chronic back pain. Her anxiety remains functionally limiting despite an adequate course of cognitive behavioral therapy, and buspirone was ineffective. Which medication is most appropriate?
Reveal answer and explanation
Answer: A. An SSRI or SNRI is first-line for GAD. In an older adult, start low and titrate. Sertraline is used off label for GAD in the United States. SSRIs also require caution in people with falls: review other CNS-active medicines and monitor sodium and balance.
Why not the others: Benzodiazepines (B, E) increase falls, cognitive impairment, and — with an opioid — respiratory depression; the AGS Beers Criteria advise avoiding them in older adults, and FDA warns against combining them with opioids. Diphenhydramine (C) and amitriptyline (D) are strongly anticholinergic and on the Beers list.
5-minute look-up: "Beers criteria benzodiazepines older adults falls opioids."
Level: Intervention (Complex) · Source: NICE CG113, Generalised Anxiety Disorder and Panic Disorder in Adults, “Drug treatment,” recommendations 1.2.23–1.2.24 and 1.2.26 (updated 2020); AGS 2023 Beers Criteria pocket guide (PDF), Tables 1–4, especially “History of falls or fractures,” printed pp. 12–14; U.S. sertraline prescribing information, §§1 and 5.8 (revised 2026); FDA opioid safety labeling communication, benzodiazepine/CNS-depressant interaction table (2025).
Question 43
A 29-year-old has had several documented major depressive episodes. Two years ago she had 6 days of unusually elevated mood and increased energy for most of each day, needing only 3 hours of sleep while feeling rested, racing thoughts, and starting many new projects. Coworkers noticed, but it didn't cause marked problems at work, and she wasn't hospitalized or psychotic. She has never had a manic episode, and the episodes were not caused by substances or a medical condition. She has been depressed again for 3 weeks. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: D. A hypomanic episode (at least 4 days, observable by others, without marked impairment, hospitalization, or psychosis) plus major depressive episodes and no history of mania defines bipolar II disorder.
Why not the others: Bipolar I (A) requires a full manic episode with marked impairment, hospitalization, or psychosis. A history of hypomania excludes unipolar MDD (B). Cyclothymia (C) involves subthreshold symptoms without full major depressive episodes. Persistent depressive disorder (E) requires chronic depressive symptoms for at least 2 years and does not account for this hypomanic episode.
5-minute look-up: "DSM-5-TR hypomanic episode criteria bipolar II."
Level: Diagnosis · Source: SAMHSA, Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health (PDF), Table 3.8, p.89, and Table 3.23, pp. 128–129 (2016); Veterans Affairs Canada, Bipolar and Related Disorders, DSM-5-TR criteria for hypomania and bipolar II disorder (reviewed 2025).
Question 44
A 52-year-old has a 9-mm mole on the back with asymmetry, an irregular border, and several shades of brown and black. It has grown over the past year. Which is the best initial management?
Reveal answer and explanation
Answer: C. For a lesion suspicious for melanoma, a narrow excisional biopsy (1–3 mm margins) that includes the full depth is preferred so the pathologist can measure Breslow thickness, which drives staging and the final margins.
Why not the others: Cryotherapy (A) destroys tissue without a diagnosis. A superficial shave (B) can transect the lesion and understage it. Wide excision before diagnosis (D) can disrupt later sentinel node mapping. Monitoring (E) delays diagnosis of a changing, suspicious lesion.
5-minute look-up: "AAD melanoma guideline biopsy narrow margins."
Level: Intervention (Basic) · Source: AAD guideline, Primary Cutaneous Melanoma (PDF), “Biopsy techniques” and Table VI; “Timing of excision in relation to SLNB” (2019).
Question 45
A 34-year-old started lamotrigine 2 weeks ago. She now has fever, painful dusky targetoid macules and blisters on the trunk, oral erosions, and conjunctivitis. Detached or detachable skin involves about 6% of body surface area, and the Nikolsky sign is positive. Which is the most likely diagnosis?
Reveal answer and explanation
Answer: A. A new high-risk drug, fever, mucosal involvement at two or more sites, and epidermal detachment under 10% of body surface area support the diagnosis of Stevens-Johnson syndrome. Stop the drug and arrange urgent specialty care.
Why not the others: EM minor (B) has typical targets on the extremities without significant mucosal disease or detachment and usually follows HSV. SSSS (C) typically spares mucosa and most often affects young children. Bullous pemphigoid (D) usually causes tense, itchy blisters in older adults; mucosal involvement can occur but is less common. TEN (E) with this macular pattern involves more than 30% of body surface area; 10–30% is SJS/TEN overlap.
5-minute look-up: "SJS TEN body surface area classification 10% 30%."
Level: Diagnosis · Source: Creamer et al., U.K. SJS/TEN guideline, §§7.1–7.2 (2016); DermNet, SJS/TEN, “Clinical features,” “Diagnosis” and “Treatment”; DermNet, Bullous Pemphigoid, “Clinical features.”
Question 46
A 38-year-old has right flank pain. CT shows a 5-mm stone in the distal right ureter with mild hydronephrosis. He is afebrile, pain is controlled with ketorolac, creatinine is normal, and urinalysis shows no infection. Which is the best management?
Reveal answer and explanation
Answer: E. For an uncomplicated distal ureteral stone 10 mm or smaller, the 2026 AUA guideline supports offering an alpha-blocker (medical expulsive therapy) with analgesia and follow-up imaging to confirm passage.
Why not the others: Urgent decompression (A) is for obstruction with infection or kidney failure. Immediate ureteroscopy (B) is not required in this uncomplicated presentation; it remains an option through shared decision-making or if observation fails. Antibiotics (C) aren't needed without infection. Allopurinol (D) is not acute stone-expulsion therapy.
5-minute look-up: "AUA surgical management of stones medical expulsive therapy distal ureter."
Level: Intervention (Basic) · Source: Pearle et al., AUA 2026 Surgical Management of Kidney and Ureteral Stones, Part I (PDF), “Treatment of Patients With Ureteral Stones,” p.116 (DOI 10.1097/JU.0000000000004842); EAU Urolithiasis guideline, medical expulsive therapy and ureteral-stone management.
Question 47
A 45-year-old has had sudden right facial weakness for 36 hours, including the forehead. She can't fully close the right eye. The rest of the neurologic exam is normal, and there is no rash or vesicles. Which is the best management?
Reveal answer and explanation
Answer: D. This isolated peripheral facial weakness involving the forehead is most consistent with Bell palsy. Oral corticosteroids started within 72 hours improve recovery. Protect the eye (lubricants, taping at night) because closure is incomplete.
Why not the others: Antivirals alone (A) aren't recommended. Routine imaging (B) isn't needed for a typical presentation. Surgical decompression (C) is not the initial treatment; evidence is insufficient for a guideline recommendation. Withholding steroids (E) lowers the chance of full recovery.
5-minute look-up: "AAO-HNS Bell's palsy guideline steroids 72 hours antiviral alone."
Level: Intervention (Basic) · Source: AAO-HNSF Bell’s Palsy guideline fact sheet, key action statements 1,3,4,5A,6 and 8 (2013).
Question 48
A 22-year-old has lower abdominal pain, mucopurulent cervical discharge, cervical motion tenderness, and adnexal tenderness. Temperature is 38.0 °C (100.4 °F). She weighs 65 kg, is not pregnant, tolerates oral intake, and ultrasound shows no tubo-ovarian abscess. Which outpatient regimen is recommended?
Reveal answer and explanation
Answer: A. The CDC 2021 recommended outpatient regimen for pelvic inflammatory disease is ceftriaxone 500 mg IM once plus 14 days of doxycycline and metronidazole, covering gonorrhea, chlamydia, and anaerobes.
Why not the others: Single-dose azithromycin (B) is not a PID regimen. Ceftriaxone alone (C) misses chlamydia and anaerobes. Single-dose metronidazole (D) does not provide the recommended PID coverage or duration. Nitrofurantoin (E) treats cystitis.
5-minute look-up: "CDC 2021 PID outpatient regimen ceftriaxone doxycycline metronidazole."
Level: Intervention (Basic) · Source: CDC, Pelvic Inflammatory Disease, “Intramuscular or Oral Treatment,” regimen/weight footnote and “Follow-Up” (STI Treatment Guidelines 2021).
Question 49
A 68-year-old with type 2 diabetes has taken metformin for 12 years. She reports fatigue. Hemoglobin is 10.8 g/dL with an MCV of 112 fL. Which examination finding is most likely to accompany her anemia?
Reveal answer and explanation
Answer: A. Long-term metformin use is associated with vitamin B12 deficiency, which causes macrocytic anemia and dorsal column dysfunction — reduced vibration and proprioception. Diabetic neuropathy can look similar, so check B12 (and methylmalonic acid if borderline) before attributing it to diabetes.
Why not the others: Koilonychia (B), blue sclerae (D), and pagophagia (E) point to iron deficiency, a microcytic anemia. Splenomegaly with jaundice (C) suggests hemolysis.
5-minute look-up: "metformin vitamin B12 deficiency neuropathy ADA monitoring."
Level: History & Physical · Source: NIH Office of Dietary Supplements, Vitamin B12, “Assessing Vitamin B12 Status” and “Metformin”; Merck Manual Professional, Vitamin B12 Deficiency, “Symptoms and Signs” and “Diagnosis” (reviewed June 2026).
Question 50
A 60-year-old without diabetes has chronic kidney disease with an eGFR of 42 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 520 mg/g. He takes maximum-dose losartan. BP is 126/78 mm Hg, potassium 4.6 mEq/L, and serum bicarbonate 24 mEq/L. Which addition best slows kidney disease progression?
Reveal answer and explanation
Answer: C. KDIGO 2024 recommends an SGLT2 inhibitor for adults with CKD and eGFR of 20 or more with albuminuria of 200 mg/g or more, with or without diabetes, on top of maximally tolerated RAS blockade.
Why not the others: Combining an ACE inhibitor with an ARB (A) increases hyperkalemia and AKI without benefit. Stopping the ARB (B) removes proven protection; an eGFR of 42 isn't a reason to stop. Bicarbonate (D) is for metabolic acidosis, which he doesn't have. A thiazide (E) may help blood pressure when needed, but it is not the recommended addition for this albuminuric CKD indication.
5-minute look-up: "KDIGO 2024 CKD SGLT2 inhibitor without diabetes albuminuria 200."
Level: Intervention (Complex) · Source: KDIGO 2024 CKD guideline (PDF), Recommendation 3.7.2 (SGLT2), Recommendation 3.6.4 (avoid dualRAS blockade), Practice Point 3.6.7 (continueACEi/ARB), Recommendation 3.4.1 (BP), and Practice Point 3.10.1 (metabolic acidosis).
Review your answers
Count how many of your first answers were correct before reading an explanation, and keep the number attempted beside it. In timed practice, include an opened question that times out without a selection as incorrect; keep questions you never opened separate. If you reveal an explanation before attempting a question, leave that question out of your score for this run. That result tells you how you did on these 50 questions — nothing more. It isn't a PANRE-LA scale score and doesn't predict a pass: NCCPA scores PANRE-LA on a 1000–1500 scale that adjusts for the difficulty of the questions each PA receives.
A single miss in a system with only a few questions is one data point, not a weak area. Look at what you missed instead: the threshold, contraindication, or first-line choice the explanation names. Then log it.
| Question | Concept to review | The rule or clue that decides it | Source and next review |
|---|---|---|---|
| Q35 (example) | Potassium before insulin in DKA | Potassium below 3.5 mmol/L: replace it and hold insulin | 2024 hyperglycemic crises consensus; recheck before your next quarter |
Copy the table to paper or a note on your device. Log Castleport question numbers and general concepts only — never write down, paste, or reconstruct real PANRE-LA questions.
Answer key
| Q | Ans | Organ system | Level | Q | Ans | Organ system | Level |
|---|---|---|---|---|---|---|---|
| 1 | D | Cardiovascular | Int (Complex) | 26 | E | Cardiovascular | Int (Complex) |
| 2 | E | Cardiovascular | Int (Basic) | 27 | B | Cardiovascular | Int (Basic) |
| 3 | E | Cardiovascular | Diagnosis | 28 | C | Cardiovascular | Int (Complex) |
| 4 | B | Pulmonary | Int (Complex) | 29 | A | Pulmonary | Int (Complex) |
| 5 | C | Pulmonary | Int (Basic) | 30 | D | Pulmonary | Int (Basic) |
| 6 | D | Pulmonary | Diagnosis | 31 | C | GI/Nutrition | Int (Complex) |
| 7 | B | GI/Nutrition | Int (Basic) | 32 | E | GI/Nutrition | Diagnosis |
| 8 | A | GI/Nutrition | Diagnosis | 33 | B | GI/Nutrition | Int (Basic) |
| 9 | D | Endocrine | Int (Complex) | 34 | D | Endocrine | Diagnosis |
| 10 | C | Endocrine | Int (Complex) | 35 | C | Endocrine | Int (Complex) |
| 11 | E | EENT | Int (Complex) | 36 | A | EENT | Int (Basic) |
| 12 | C | EENT | Int (Basic) | 37 | E | EENT | History & Physical |
| 13 | B | Musculoskeletal | Diagnosis | 38 | C | Musculoskeletal | Int (Basic) |
| 14 | B | Musculoskeletal | Int (Basic) | 39 | D | Musculoskeletal | Int (Basic) |
| 15 | A | Infectious Diseases | Int (Basic) | 40 | B | Infectious Diseases | Diagnosis |
| 16 | E | Infectious Diseases | Int (Basic) | 41 | E | Infectious Diseases | Int (Basic) |
| 17 | B | Psychiatry/Behavioral | Int (Basic) | 42 | A | Psychiatry/Behavioral | Int (Complex) |
| 18 | D | Psychiatry/Behavioral | Int (Basic) | 43 | D | Psychiatry/Behavioral | Diagnosis |
| 19 | C | Dermatologic | Int (Complex) | 44 | C | Dermatologic | Int (Basic) |
| 20 | E | Genitourinary | Int (Basic) | 45 | A | Dermatologic | Diagnosis |
| 21 | A | Hematologic | Int (Basic) | 46 | E | Genitourinary | Int (Basic) |
| 22 | A | Renal | Int (Basic) | 47 | D | Neurologic | Int (Basic) |
| 23 | B | Neurologic | Int (Complex) | 48 | A | Reproductive | Int (Basic) |
| 24 | D | Reproductive | Int (Basic) | 49 | A | Hematologic | History & Physical |
| 25 | B | Emergent Topics | Emergent topic | 50 | C | Renal | Int (Complex) |
The 5-minute open-book method
Five minutes is plenty for a question you mostly know and tight for one you don't. This routine keeps lookups from eating the clock. It's our method, not NCCPA guidance.
- Before you open the question (no clock yet). NCCPA shows the content category — and whether there's an image — before you open each question. If it's a system you're shaky on, skim that system's blueprint list or your go-to reference first. If there's an image and you're on a phone, switch to a bigger screen.
- First 60 seconds: answer from your own head. Read the last line of the stem first so you know the task (diagnosis? next step? drug?). Pick a provisional answer.
- Minutes 1–3: one targeted lookup. Search the decision, not the disease: "AF anticoagulation threshold," not "atrial fibrillation." Use a few discrete keywords — NCCPA allows that, and prohibits typing, pasting, screenshotting, or uploading substantial parts of a question, its options, or its rationale into any search engine or AI tool. The look-up line under each question above shows the shape of a good keyword search.
- Minute 4: confirm against the options. Check the specific thing that separates your top two choices — a threshold, a contraindication, a first-line drug.
- By 4:30: select an answer. If time runs out, NCCPA records a selected answer as submitted; an unselected question counts as wrong. Never leave it blank.
Set up two screens (or a laptop plus a phone) with your references already open before you start a sitting. Then work Quarter 1 above with a 5-minute timer per question and note which questions pushed past three minutes — those are useful topics to rehearse.
The category preview and reference-use rules above come from NCCPA’s PANRE-LA FAQ and PANRE-LA Agreement (PDF). The timing routine is an editorial study method.
How PANRE-LA scoring works
- Your score comes from your best eight quarters. NCCPA starts calculating pass/fail after you've participated in eight quarters. If you haven't reached the passing score, it recalculates after each later quarter using your best eight, through the end of the three years.
- The passing score is 1150 on a 1000–1500 scale. It's a scale score adjusted for the difficulty of the questions you received, so there's no fixed percent correct that guarantees a pass. You don't need to "pass" each quarter.
- Unanswered questions count as wrong. If you participate in a quarter but don't answer all 25, the unanswered ones are scored incorrect. There's no penalty for guessing. If you meet the first- and second-year participation requirements but complete fewer than eight quarters, final scoring still uses eight quarters, with unanswered questions from the missing quarters scored incorrect.
- If time runs out with an answer selected, that answer is recorded as submitted.
- One question each quarter is unscored. It covers acceptable test-taking behavior under NCCPA policy and is there for education only.
- Repeat topics help you. From the second quarter on, five questions each quarter revisit topics you've seen before. When a topic repeats, the better of your two responses counts.
- Once you pass, you're done. You're exited from PANRE-LA and can't take more quarters.
- If you haven't passed by the end of year 9, you have up to three attempts to pass the traditional PANRE in year 10 before certification expires.
These rules are described in NCCPA’s performance guide, PANRE-LA FAQ, and operational policy (PDF) (participation, pp. 3–4; scoring, p. 9).
PANRE-LA at a glance
| Item | What NCCPA says |
|---|---|
| Who it's for | Currently certified PAs, as an alternative to the proctored PANRE. It can't be used to regain lapsed certification. |
| Applying | In year 6 of the 10-year cycle, through the NCCPA Portal. PAs due to recertify in 2030 apply July 1 – December 18, 2026. |
| When questions run | Years 7–9: 12 quarters available; you can finish after 8 if you meet the passing standard |
| Participation | At least one quarter in year 7 and one in year 8; completing eight of the 12 available quarters leaves up to four to skip |
| Per quarter | 25 questions, 5 minutes each |
| Format | Multiple choice, most with five options; content category shown before each question |
| References | Printed or online references allowed, including AI-enabled tools, using discrete keywords only; consulting other people is not |
| Feedback | Immediate: correct answer, explanation, and references after each question |
| Fee | $350 (same as PANRE) |
| CME | 2 Category 1 Self-Assessment credits per quarter in which you answer all 25 (3 with NCCPA's 50% self-assessment bonus, for NCCPA requirements only) |
| Accommodations | Approved extended time per question (1.5× or 2×), based on NCCPA’s accommodation review |
| Also required | Keep meeting CME and certification maintenance fee requirements, or you'll be withdrawn |
Sources: NCCPA PANRE-LA information, PANRE-LA FAQ, and Key Dates.
How this set maps to the PANRE/PANRE-LA blueprint
PANRE and PANRE-LA share one blueprint, effective January 2023 — different from the PANCE blueprint. It assigns a percentage to each organ system and a performance expectation to each disease: History & Physical, Diagnosis, Intervention (Basic), or Intervention (Complex).
| Organ system | Blueprint share | Questions here |
|---|---|---|
| Cardiovascular System | 12% | 6 |
| Gastrointestinal System and/or Nutrition | 10% | 5 |
| Pulmonary System | 10% | 5 |
| Endocrine System | 8% | 4 |
| Eyes, Ears, Nose, and Throat | 8% | 4 |
| Musculoskeletal System | 8% | 4 |
| Infectious Diseases | 7% | 4 |
| Psychiatry/Behavioral Science | 7% | 4 |
| Dermatologic System | 5% | 3 |
| Genitourinary System | 5% | 2 |
| Neurologic System | 5% | 2 |
| Reproductive System | 5% | 2 |
| Hematologic System | 4% | 2 |
| Renal System | 4% | 2 |
| Emergent Topics (Legal, Ethical, DEI) | 2% | 1 |
The official blueprint (PDF) supplies the percentages above. A 50-question set produces fractional targets for the 5% and 7% categories, so the allocation rounds those counts while keeping 50 questions total. Together, the two practice quarters cover all 15 categories; each quarter is a fixed practice group, not a personalized NCCPA quarter. The level tags describe the task in each practice question and are our editorial classifications. They do not certify NCCPA’s condition-specific testing limits. On the real exam, from the second quarter onward, 20 questions follow the blueprint distribution and 5 revisit topics from earlier quarters.
Where to practice next
- Re-answer the questions in your review log a week or two later, 5 minutes each, before checking the explanation again.
- NCCPA's free sample questions: the official sample PANRE/PANRE-LA questions (PDF) (PDF) show NCCPA's own item style with critiques. The PANRE-LA tutorial video, linked from the PANRE-LA section of NCCPA's Maintain Certification page, shows the real interface.
- Check your quarter dates on NCCPA Key Dates and put each quarter's closing date on your calendar.
PANRE-LA practice test FAQ
Is there an official free PANRE-LA practice test? NCCPA publishes free PANRE/PANRE-LA sample questions with critiques (PDF) and a tutorial linked from its PANRE-LA information page. This page supplies 50 independent, unofficial practice questions.
Can I use UpToDate, Google, or my own notes during PANRE-LA? Yes. NCCPA allows printed or online references. You must work alone, somewhere no one else can see the questions, and you may not share exam content with anyone, during the exam or after.
Can I use an AI chatbot? Yes, within limits. NCCPA's FAQ permits online resources that use AI, but only with discrete keywords from the question. Typing, pasting, dictating, screenshotting, or uploading substantial parts of a question, its answer options, or its rationale into any search engine or chatbot is prohibited — during the quarter or after.
What happens if I miss a quarter's deadline? You can skip quarters, but you must participate in at least one quarter in year 7 and one in year 8 or you'll be withdrawn. If you open a quarter and don't finish, the unanswered questions count as wrong. NCCPA doesn't extend quarter deadlines. If you have not passed at the end of the process and missed a quarter because of personal health issues, NCCPA allows a request for an exception covering up to two additional quarters in the following year; approval is not automatic. See the PANRE-LA FAQ, “If I missed a quarter, can I make it up?” and Exceptions to Policy.
Are these real PANRE-LA questions? No. Every question here was written by Castleport Test Prep. NCCPA treats sharing or reproducing PANRE-LA content as irregular behavior, and we don't use recalled or shared exam items.
Sources and independence
- NCCPA. Maintain Certification — PANRE-LA (recertification route, format, feedback, fee and CME).
- NCCPA. PANRE/PANRE-LA Performance Guide (scale, passing score and test assembly).
- NCCPA. Content Blueprint for PANRE and PANRE-LA (PDF), effective January 2023 (pp. 1–2, weights and performance expectations; pp. 3–14, conditions).
- NCCPA. Key Dates (cohort-specific application windows and quarter dates).
- NCCPA. PANRE-LA Operational Policies, Procedures, and Authorization (PDF), July 1, 2025 (pp. 1–2, eligibility and later PANRE attempts; pp. 2–4, accommodations and participation; p. 5, CME; p. 6, fee; pp. 7–8, exceptions; p. 9, scoring).
- NCCPA. PANRE-LA Agreement (PDF), July 1, 2025 (pp. 1–2, independent work, discrete keywords, AI-enabled tools and exam security).
- NCCPA. FAQs — PANRE-LA (question format, reference limits, unscored behavior question, repeat topics and missed quarters).
- NCCPA. Sample PANRE/PANRE-LA Questions (PDF) (official sample items and critiques).
- Clinical references for each question are linked beneath its explanation.
Last verified: November 6, 2026 (NCCPA rules, scoring, fee, reference-use limits, blueprint, application dates, and the clinical sources cited for this set; verification date in Asia/Manila). Clinical guidelines change; the source links identify the editions used.
Written by the Castleport Test Prep Editorial Team. Questions are original and written to the guidelines cited beneath each one; they have not been reviewed by a practicing PA or physician. How we check sources · Report an error
Castleport Test Prep is an independent exam prep publisher. It is not affiliated with, endorsed by, or approved by the National Commission on Certification of Physician Assistants (NCCPA). Exam and credential names identify their subjects; trademarks belong to their respective owners.