Pance Questions 1

Question 1

1. A 46-year-old man arrives at your family practice office as a new patient since he just moved to the area. His only complaint is soreness in his legs for the past few weeks. He says that his previous primary care provider had recently started him on several new medications. Which of the following medications is likely causing his reported symptom?
   a. Lisinopril
   b. Atorvastatin
   c. Naproxen
   d. Niacin

Answer 1

1. B: Atorvastatin.

This medication is an HMG-CoA reductase inhibitor and is used to treat hypercholesterolemia. Myalgias are a common side effect. More rarely, the statin medications can cause rhabdomyolysis, which may present with renal dysfunction. Niacin is also a medication used to manage cholesterol, but flushing is more common side effect.

Question 2

2. A 64-year-old African-American man with no prior history of cancer asks if he should have a blood test to check for prostate cancer. Since your practice uses the most recent United States Preventive Services Task Force (USPSTF) guidelines, what do you do?
   a. Order a prostate-specific antigen (PSA) test since he is older than 55 years
   b. Do not order a PSA test since he is African American and at lower risk for prostate cancer
   c. Order a PSA test since his brother had prostate cancer
   d. Do not order a PSA test since the harm outweighs the benefit of screening

Answer 2

2. D: Not order a PSA test since the harm outweighs the benefit of screening. The USPSTF recommends against PSA-based screening for prostate cancer. African Americans and those with a family history of prostate cancer are at a higher risk of developing prostate cancer. There are other organizations that do recommend screening for prostate cancer with the PSA test.

Question 3

3. A 25-year-old woman arrives in your urgent care facility with a bright red left sclera. She denies any eye trauma. The review of symptoms is negative besides the patient reporting constipation. How do you treat this patient?
   a. Prescribe antibiotics for 1 week.
   b. Refer her to an ophthalmologist for further evaluation.
   c. Advise her that the condition will likely resolve on its own. d. Give a steroid shot today to reduce inflammation.

Answer 3

3. C: Advise her that the condition will likely resolve on its own.

Based on the information given, this patient likely has a subconjunctival haemorrhage. They are usually caused by coughing, sneezing, or straining. They generally clear up on their own in a couple of weeks.

Question 4

4. A 43-year-old woman with a history of cocaine dependence presents to your office complaining of stress. She says that for the past 3 months, she has been worrying excessively about her job, finances, relationships, and other daily matters. She denies a depressed mood. She would like to start a medication to help with her symptoms. What is a reasonable choice of medication to start?
   a. Buspirone
   b. Clonazepam
   c. Bupropion
   d. Doxepin

Answer 4

4. A: Buspirone. Buspirone is an anti-anxiety medication that is taken daily to reduce symptoms of generalized anxiety. Clonazepam is in the benzodiazepine class of medications and is usually used on an as-needed, short-term basis. It is generally avoided in patients with a history of substance dependence because of its potential for abuse. While bupropion and doxepin may also relieve anxiety symptoms, they are primarily used to treat depression.

Question 5

5. A 56-year-old woman arrives with an itchy rash that has been present for several weeks. On exam, you find small, flat, purplish papules spread primarily over her forearms and back. You decide to do a biopsy, but in the meantime before the results come back, the patient wants to know if she is contagious. What do you tell her based on your suspected diagnosis at this time?
   a. Not contagious anymore since it started several weeks ago
   b. Contagious for the next 2 to 4 days as she starts antibiotics
   c. Not contagious since this is an autoimmune condition
   d. Contagious until the rash is completely cleared

Answer 5

5. C: Not contagious since this is an autoimmune condition. The condition described is lichen planus, which is thought to be an autoimmune condition that is T cell-mediated. It is usually characterized by the “Ps”—pruritic, polygonal, planar, purple, papules/plaques. Lesions can also occur on the oral mucosa. A biopsy can confirm the diagnosis, and it is treated with steroids.

Question 6

6. What would you expect to hear on exam when listening to the heart of a patient with known severe aortic stenosis?
   a. High-pitched murmur during diastole
   b. Crescendo-decrescendo ejection murmur
   c. Holosystolic murmur at the apex
   d. Rumbling diastolic murmur at the apex

Answer 6

6. B: Crescendo-decrescendo ejection murmur. Aortic stenosis is a narrowing of the aortic valve between the left ventricle and the aorta. The murmur is heard when blood is flowing from the heart to the rest of the body. Aortic regurgitation is when blood is flowing in the wrong direction from the aorta back into the left ventricle, and it can sound high-pitched. A holosystolic murmur is heard with mitral regurgitation when blood is flowing in the wrong direction from the left ventricle to the left atrium. Mitral stenosis is a narrowing of the valve between the left atrium and left ventricle, and the rumbling murmur would occur during diastole.

Question 7

7. A 72-year-old woman with a history of congestive heart failure (CHF) and hypertension arrives in the emergency department with shortness of breath. Her breath sounds are clear, but you notice an irregularly irregular rhythm with auscultation. What does her electrocardiogram (ECG) likely show?
   a. Myocardial infarction
   b. Pericardial effusion
   c. Atrial fibrillation
   d. Aortic stenosis

Answer 7

7. C: Atrial fibrillation. This arrhythmia is caused by disorganized atrial activity. The patient has risks factors such as advanced age and underlying heart problems. A patient with myocardial infarction may present with shortness of breath, along with other symptoms like chest pain; however, the heart rhythm is not characteristically irregularly irregular. Pericardial effusion would present with diminished heart sounds due to the fluid surrounding the heart. Patients with aortic stenosis may have normal ECGs or ventricular hypertrophy.

Question 8

8. A 24-year-old woman reports intermittent stomach cramping, diarrhea, and constipation, which has been present for the past 5 years. She has tried cutting out wheat from her diet but did not notice any different in her symptoms. She has had a colonoscopy and endoscopy that had normal results. What is the most likely diagnosis?
   a. Celiac disease
   b. Crohn disease
   c. Irritable bowel syndrome
   d. Ulcerative colitis

Answer 8

8. C: Irritable bowel syndrome. IBS is a condition characterized by diarrhea and/or constipation. It has no clear cause but is common, especially in younger patients. Celiac disease is a condition in which the body reacts to the ingestion of gluten (which includes wheat), so this patient would have likely seen a reduction in her symptoms with changes in her diet. Crohn disease and ulcerative colitis are inflammatory bowel diseases that would likely show evidence of lesions on the studies performed.

Question 9

9. A 35-year-old woman has fatigue and generalized weakness. She is mildly tachycardic with cool skin, but otherwise the exam is normal. You suspect she is anemic and would like to figure out the cause. Which of the following is NOT a test you would typically order for an initial work-up?
   a. Complete blood cell count (CBC)
   b. Fecal occult blood testing
   c. Complete metabolic panel (CMP)
   d. Bone marrow biopsy

Answer 9

9. D: Bone marrow biopsy. Anemia can be acute or chronic. In women of childbearing age, anemia can be due to iron-deficiency and treated with supplementation and diet changes. A CBC can help determine the cause of anemia, along with additional iron studies that may be necessary. It is important to evaluate for active bleeding and clinical stability. Stool studies can show occult bleeding from the GI tract. A bone marrow biopsy may be indicated at some point, but it is not a first step due to its invasiveness.

Question 10

10. A 46-year-old man arrives in the emergency department with confusion. He had previously been diagnosed with AIDS but has not recently been taking antiretrovirals or prophylactic antibiotics. A ring-enhancing lesion is seen on head computed tomography (CT). What is causing his current presentation?
    a. Toxoplasmosis
    b. Kaposi sarcoma
    c. Pneumocystis jiroveci
    d. Mycobacterium avium complex

Answer 10

10. A: Toxoplasmosis. This is an infection that can present with a range of symptoms, but the disease occurs mostly in immunocompromised patients. The other answer choices can also occur in AIDS patients. Kaposi sarcoma usually presents as cutaneous lesions. Pneumocystis jiroveci and Mycobacterium avium complex infections usually involve the lungs.

Question 11

11. A 9-year-old boy has an itchy right ear. On exam, you see discharge and pain is elicited with palpation of the tragus. There is no evidence of cellulitis. The patient reports that he has been doing a lot of swimming. How would you treat this patient?
    a. Give a steroid injection.
    b. Prescribe topical antibiotics and steroids.
    c. Prescribe oral antibiotics.
    d. Give an antibiotic injection.

Answer 11

11. .B: Prescribe topical antibiotics and steroids Otitis externa is an infection of the ear canal and is diagnosed by history and inspection. It is often called “swimmer’s ear.” It can be caused by bacteria or fungi. Treatment is with topical antibiotics and steroids. A cotton wick may also be used. Oral antibiotics may be necessary when cellulitis is present.

Question 12

12. You are examining a 6 month old and are only able to palpate one testis in the scrotum. You discuss surgical intervention with the mother. What are the risks if the condition is left untreated?
    a. Possible concurrent inguinal hernia
    b. Decreased fertility
    c. Increased risk of testicular cancer
    d. All of the above

Answer 12

12. D: All of the above. The condition described is cryptorchidism, which is the failure of one or both testes to descend into the scrotum. It is more common in preterm infants. In most cases, the testis will spontaneously descend, but otherwise surgery should be done around the age of 6 months.

Question 13

13. An 11-year-old boy arrives in urgent care after falling out of a tree and reaching out to break his fall. On exam, you note tenderness in the “anatomical snuff box” area. You decide to do an x-ray. Which of the following bones do you suspect may be fractured?
    a. Hamate
    b. Triquetrum
    c. Scaphoid
    d. Pisiform

Answer 13

13. C: Scaphoid. This wrist bone is located on the radial side, whereas the other wrist bones listed are more medial. Scaphoid fractures usually occur with hyperextension, as seen during a fall. A common complication is avascular necrosis. Initial x-rays may be normal and require MRI, or suspected scaphoid fractures can be treated with a thumb spica splint.

Question 14

14. A 10-year-old boy arrives in your office for a routine checkup. He is found to have a body mass index (BMI) higher than the 95th percentile. There is a history of cardiovascular disease and hypertension in the family. Which of the following tests should you order first?
    a. CBC and C-reactive protein (CRP)
    b. ECG
    c. Liver function tests (LFTs) and lipid panel
    d. Polysomnography

Answer 14

14. C: LFTs and lipid panel. The epidemic of childhood obesity is due to multiple factors including genetics, diseases, medications, activity level, and diet/nutrition. The rate of childhood obesity is highest between ages 10 and 11 years. A fasting lipid profile is recommended for children between the ages of 2 and 10 years with a family history of dyslipidemia, cardiovascular disease, hypertension, diabetes, and obesity. Oral glucose tolerance testing should begin at age 10 for any child at increased risk for metabolic syndrome. For children with a body mass index (BMI) in the 95th percentile or higher, they should have LFTs, fasting glucose, and insulin and lipid profiles.

Question 15

15. What part of the brain is abnormal in a 72-year-old patient who has a stooped posture, shuffling gait, pill-rolling tremor, and small handwriting?
    a. Pineal body
    b. Medulla oblongata
    c. Cerebellar peduncle
    d. Substantia nigra

Answer 15

15. D: Substantia nigra. The patient described has Parkinson disease, which is a degenerative CNS disorder in which dopamine-producing cells in the substantia nigra are lost. The cause of this cell death is unknown. The substantia nigra is part of the midbrain. High levels of melanin in the dopaminergic cells give them a darker appearance. Levodopa is used as a treatment in Parkinson disease because it is a metabolic precursor to dopamine

Question 16

16. A 26-year-old man reports a slightly painful and itchy red bump on the outside of his lip. His review of systems is otherwise otherwise negative. On exam, you see a small cluster of vesicles on the vermillion border. How do you counsel this patient?
    a. Advise him to be cautious because this condition can spread with or without active lesions
    b. Provide education about how this is linked to his previous chickenpox infection
    c. Tell him that this condition can only be spread by contact with blood
    d. Relieve his concerns by letting him know that the infection does not recur

Answer 16

16. A: Advise him to be cautious because this condition can spread with or without active lesions. Based on the information given, this patient has herpes simplex virus (HSV). Oral lesions are usually caused by HSV type 1, and virus shedding can occur with close contact. Diagnosis is often clinical but a Tzanck smear can confirm diagnosis. The duration of an eruption can be decreased with antivirals. HSV can appear similar to the herpes zoster virus; however, this condition is usually found in a dermatomal pattern and more painful.

Question 17

17. A 57-year-old man was recently admitted to the hospital with shortness of breath, cough, and night sweats. His sputum smear shows acid-fast bacilli. All of the following are risk factors for the development of this disease EXCEPT:
    a. Being a health care worker
    b. Working in a chemical factory
    c. Living in the same household as someone with this disease
    d. Living in poverty

Answer 17

17. B: Working in a chemical factory. This would not necessarily increase someone’s risk of acquiring tuberculosis (TB). This mycobacterium infection is spread by inhalation, and is enhanced by overcrowding or close contact. Other risk factors for acquiring TB include being homeless, being in jail or prison, living in an institution, and having HIV.

Question 18

18. Which of the following medications stimulates pancreatic beta cell insulin secretion, thus lowering plasma glucose level?
    a. Acarbose
    b. Metformin
    c. Pioglitazone
    d. Glyburide

Answer 18

18. D: Glyburide. This medication is a sulfonylurea drug, which is an insulin secretagogue. Acarbose works by inhibiting intestinal enzymes so that carbohydrates are digested more slowly. Metformin is a biguanide that acts as an insulin sensitizer by decreasing hepatic glucose production. Pioglitazone falls under the thiazolidinedione class, which decreases peripheral insulin resistance.

Question 19

19. A temporal artery biopsy can confirm the diagnosis of which condition listed below?
    a. Polyarteritis nodosa
    b. Takayasu arteritis
    c. Giant cell arteritis
    d. Polymyalgia rheumatica

Answer 19

19. C: Giant cell arteritis. Giant cell arteritis is also known as temporal arteritis and is a chronic inflammatory disease. It usually occurs in older adults and may present with symptoms such as headache, changes in vision, pain in the temple area, fever, and fatigue. An elevated ESR or CRP can increase suspicion for the diagnosis, which can then be verified through biopsy. It is treated with prednisone. Polymyalgia rheumatica is a condition that is associated with giant cell arteritis; it may present with similar symptoms and also include elevated ESR, but biopsy is normal.

Question 20

20. A newborn has been in the intensive care unit (ICU) because of cyanotic spells and poor growth. A systolic murmur is heard with auscultation and a boot-shaped heart is seen on x-ray. What is the most likely diagnosis?
    a. Tetralogy of Fallot
    b. Persistent truncus arteriosus
    c. Transposition of the great arteries
    d. Hypoplastic left heart syndrome

Answer 20

20. A: Tetralogy of Fallot. This congenital heart condition consists of four abnormalities: ventricular septal defect, right ventricular outflow obstruction, right ventricular hypertrophy, and an overriding aorta. Although medications can be given to help with cyanotic spells, definitive treatment of the condition is by surgery.

Question 21

21. A previously healthy 2 year old is brought to the emergency department with recurrent and worsening abdominal pain. During your exam, the child passes stool that looks like currant jelly. You note abdominal tenderness and guarding. What are you most concerned about?
    a. Pyloric stenosis
    b. Meconium ileus
    c. Necrotizing enterocolitis
    d. Intussusception

Answer 21

21. D: Intussusception. This condition is when part of the intestine “telescopes” into another part. It usually occurs between 3 months and 3 years of age. It can lead to bowel obstruction or ischemia if not treated. Pyloric stenosis usually presents with projectile vomiting. Meconium ileus and necrotizing enterocolitis occur in neonates.

Question 22

22. A 17-year-old soccer player arrives after a game with knee pain. He says that another player ran into him. On exam, you note swelling and joint line tenderness. McMurray test is positive. Lachman test is negative. Based on this history and exam, what is your diagnosis? a. Osteoarthritis
    b. Anterior cruciate ligament tear
    c. Lateral collateral ligament tear
    d. Meniscus tear

Answer 22

22. D: Meniscus tear. This type of injury would elicit a positive McMurray test, in which the examiner can feel a “click” in the knee while extending and rotating the leg. Anterior cruciate ligament (ACL) and lateral collateral ligament (LCL) tears are possible given the mechanism of injury in this patient, but these injuries alone would not have a positive McMurray test. An ACL tear would have a positive Lachman test, which is where anterior motion can be felt while pulling upwards on the tibia compared with the femur.

Question 23

23. What would you expect to find in the cerebrospinal fluid (CSF) from a lumbar puncture of a patient with acute bacterial meningitis?
    a. Elevated pressure, neutrophils 2000/mcL, glucose 80 mg/dL, protein 40 mg/dL
    b. Normal pressure, neutrophils 2000/mcL, glucose 40 mg/dL, protein 100 mg/dL
    c. Elevated pressure, neutrophils 2000/mcL, glucose 40 mg/dL, protein 100 mg/dL
    d. Decreased pressure, neutrophils 2000/mcL, glucose 80 mg/dL, protein 40 mg/dL

.

Answer 23

23. C: Elevated pressure, neutrophils > 2000/mcL, glucose < 40 mg/dL, protein > 100 mg/dL. In adults, bacterial meningitis is usually caused by pneumococci. The bacteria draw neutrophils into the CSF space. Pressure is increased because of release of metabolites that damage cell membranes. Glucose is usually lower because it is being consumed by bacteria and neutrophils.

Question 24

24. You are examining an ECG that shows dropped P waves. What is the most likely diagnosis?
    a. Sick sinus syndrome
    b. Wandering atrial pacemaker
    c. Wolff-Parkinson-White syndrome
    d. None of the above

Answer 24

24. A: Sick sinus syndrome, also known as sinus node dysfunction, refers to any condition where the atrial rate is abnormal. Patients may present with weakness, dizziness, or palpitations. Dropped P waves can trigger escape beats from other parts of the heart. Treatment is by pacemaker. Wandering atrial pacemaker, also known as multifocal atrial rhythm, would show varied P waves. Wolff-Parkinson-White syndrome would show short PR intervals and delta waves.

Question 25

25. During an annual physical, a 50-year-old man has in-office blood pressure readings of 145/92 and 143/89, taken 5 minutes apart. He has previously tried diet and exercise with no change in blood pressure. He does not have a history of kidney problems or heart attack. According to the Joint National Committee, which medication should he be started on?
    a. Metoprolol
    b. Nifedipine
    c. Hydrochlorothiazide
    d. Lisinopril

Answer 25

25. C: Hydrochlorothiazide. This man is considered to have stage 1 hypertension, which is systolic between 140-159 mm Hg or diastolic between 90-99 mm Hg. Thiazide-type diuretics are recommended initially for most patients. Patients with stage 2 hypertension will likely require two medications for blood pressure control. In patients with certain medical problems, other drugs are initially recommended. For example, an ACE inhibitor or angiotensin receptor blocker would be advised instead for a patient with chronic kidney disease.

PANCE Exam Secrets Test Prep Team. PANCE Practice Questions (Second Set): PANCE Practice Tests & Exam Review for the Physician Assistant National Certifying Examination . Mometrix Test Preparation. Kindle Edition.