PANCE (Physician Assistant National Certifying Exam)

A 34-year-old man has 3 days of sharp substernal chest pain that worsens when he lies flat or breathes deeply and eases when he sits up and leans forward. A scratchy sound is heard at the left sternal border. ECG shows diffuse ST elevation with PR depression. Which diagnosis is most likely?

1. AInferior ST-elevation myocardial infarction
2. BStable angina pectoris
3. CAcute pulmonary embolism
4. DAcute pericarditisCorrect

Why: Pain relieved by sitting up and leaning forward, a friction rub, and diffuse ST elevation with PR depression are the classic findings of acute pericarditis. An inferior STEMI produces regional ST elevation in II, III and aVF with reciprocal change, not a diffuse pattern with PR depression. Pulmonary embolism causes pleuritic pain and dyspnea but not a positional rub with diffuse ST elevation, and stable angina is exertional pressure that settles with rest.

A 44-year-old woman has 8 hours of constant right upper quadrant pain after a fatty meal, fever of 38.4 °C, and a positive Murphy sign. Bilirubin is normal. Which initial imaging study is most appropriate?

1. AUpper endoscopy with biopsy
2. BRight upper quadrant ultrasoundCorrect
3. CBarium swallow study
4. DPlain abdominal radiograph

Why: Right upper quadrant pain, fever and a Murphy sign suggest acute cholecystitis, and abdominal ultrasound is the initial imaging test because it shows gallstones, wall thickening and pericholecystic fluid. Plain films miss most gallstones. Endoscopy and barium studies examine the upper gut lumen and do not assess the gallbladder.