PANCE (Physician Assistant National Certifying Exam) — All Questions

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?

• a.Inferior ST-elevation myocardial infarction
• b.Stable angina pectoris
• c.Acute pulmonary embolism
• d.Acute pericarditis✓

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 41-year-old woman is diagnosed with acute idiopathic pericarditis. She is hemodynamically stable, has no effusion on echocardiography, and has no contraindications to anti-inflammatory therapy. Which initial regimen is most appropriate?

• a.Emergency pericardiocentesis
• b.IV vancomycin and ceftriaxone
• c.Warfarin anticoagulation with a heparin bridge
• d.An NSAID or aspirin plus colchicine✓

First-line treatment of uncomplicated acute pericarditis is an NSAID (or aspirin) together with colchicine, which also lowers the recurrence rate. Anticoagulation has no role and can promote hemorrhagic effusion. Pericardiocentesis is reserved for tamponade or selected large effusions, and empiric broad-spectrum antibiotics are used only when purulent pericarditis is suspected.

After a motor vehicle collision, a patient is hypotensive with distended neck veins and muffled heart sounds. Systolic pressure falls 16 mm Hg with each inspiration. Which finding does this inspiratory fall in systolic pressure represent?

• a.Kussmaul respiration
• b.Pulsus alternans
• c.Pulsus parvus et tardus
• d.Pulsus paradoxus✓

A fall in systolic pressure of more than 10 mm Hg during inspiration is pulsus paradoxus, which with hypotension, jugular venous distention and muffled heart sounds points to cardiac tamponade. Pulsus alternans is beat-to-beat alternation in pulse strength seen in severe left ventricular dysfunction. Kussmaul respiration is deep acidotic breathing, and pulsus parvus et tardus is the weak, delayed pulse of aortic stenosis.

A 19-year-old athlete has a harsh systolic murmur at the left sternal border. The murmur becomes louder during the strain phase of a Valsalva maneuver and softer with sustained handgrip. Which condition best explains this murmur?

• a.Mitral valve prolapse with regurgitation
• b.Obstructive hypertrophic cardiomyopathy✓
• c.Ventricular septal defect
• d.Aortic stenosis

In obstructive hypertrophic cardiomyopathy, maneuvers that reduce preload such as Valsalva increase outflow obstruction and make the murmur louder, while handgrip or squatting soften it. The murmur of aortic stenosis generally softens with Valsalva because less blood crosses the valve. A ventricular septal defect murmur is holosystolic and louder with handgrip, and mitral regurgitation also increases with handgrip because afterload rises.

A 78-year-old man has exertional chest pressure and two episodes of syncope while climbing stairs. There is a harsh crescendo-decrescendo systolic murmur at the right upper sternal border radiating to both carotids, and the carotid upstroke is weak and delayed. Which test best confirms the diagnosis?

• a.Coronary artery calcium score
• b.Transthoracic echocardiography✓
• c.Exercise treadmill stress test
• d.Holter monitor for 48 hours

Exertional syncope, angina and a crescendo-decrescendo murmur radiating to the carotids with pulsus parvus et tardus suggest severe aortic stenosis, which is confirmed and graded by echocardiography. Exercise stress testing is hazardous in symptomatic severe aortic stenosis. A calcium score estimates coronary risk and does not assess the valve, and a Holter monitor looks for arrhythmias rather than valve obstruction.

A 62-year-old man with poorly controlled hypertension has abrupt, tearing chest pain radiating between the shoulder blades. CT angiography shows an intimal flap beginning in the ascending aorta. What is the definitive management?

• a.Outpatient beta-blocker titration
• b.Urgent percutaneous coronary intervention
• c.Emergency surgical repair✓
• d.Thrombolysis with alteplase

A dissection involving the ascending aorta (Stanford type A) requires emergency surgical repair because of the risk of rupture, tamponade and coronary or aortic valve involvement, with blood pressure and heart rate control as a bridge. Thrombolysis can be fatal in dissection. Beta-blockade alone is not definitive for an ascending dissection, and percutaneous coronary intervention treats coronary occlusion, not an aortic flap.

A 14-year-old is found to have blood pressure of 150/90 mm Hg in the right arm. Femoral pulses are weak and delayed compared with the radial pulses, and leg blood pressure is lower than arm pressure. Which diagnosis is most likely?

• a.Renal artery stenosis
• b.Coarctation of the aorta✓
• c.Patent ductus arteriosus
• d.Tetralogy of Fallot

Upper-extremity hypertension with diminished, delayed femoral pulses and a lower leg pressure is the classic presentation of coarctation of the aorta. A patent ductus arteriosus gives a continuous machine-like murmur and bounding pulses rather than an arm-leg gradient. Renal artery stenosis raises pressure in all four limbs, and tetralogy of Fallot presents with cyanosis in infancy.

A 70-year-old woman with atrial fibrillation and a ventricular rate of 160/min is confused, has a blood pressure of 72/40 mm Hg, and is cool and clammy. Which is the most appropriate immediate treatment?

• a.Oral metoprolol and reassess in 1 hour
• b.Start apixaban and discharge home
• c.Immediate unsynchronized defibrillation
• d.Synchronized electrical cardioversion✓

Atrial fibrillation with rapid ventricular response causing hypotension and altered mental status is unstable and is treated with synchronized cardioversion. Oral rate control acts too slowly for a patient in shock. Anticoagulation matters for stroke prevention but does not correct the instability, and unsynchronized shocks are for pulseless ventricular tachycardia or ventricular fibrillation because an unsynchronized shock can induce ventricular fibrillation.

A monitored patient suddenly becomes unresponsive. The monitor shows a wide-complex regular tachycardia at 200/min and no carotid pulse is palpable. CPR has been started. What is the next step?

• a.Transcutaneous pacing
• b.IV adenosine 6 mg rapid push
• c.Synchronized cardioversion at 50 joules
• d.Defibrillation✓

Pulseless ventricular tachycardia is a shockable arrest rhythm and is treated with CPR and defibrillation as soon as possible. Synchronized cardioversion is for ventricular tachycardia with a pulse, because synchronization can delay the shock in a pulseless patient. Adenosine is for stable narrow-complex reentrant tachycardia, and pacing treats bradycardia.

A 58-year-old man has 40 minutes of crushing chest pain. ECG shows ST elevation in leads II, III and aVF with ST depression in I and aVL. Which region of the myocardium is most likely affected?

• a.Anterior wall
• b.Posterior wall only
• c.Inferior wall✓
• d.Lateral wall

ST elevation in leads II, III and aVF localizes an infarction to the inferior wall, usually from right coronary artery occlusion, and the ST depression in I and aVL is reciprocal. Anterior infarction shows elevation in the precordial leads V1 to V4. Lateral infarction shows elevation in I, aVL, V5 and V6, and an isolated posterior infarct shows ST depression in V1 to V3 rather than inferior elevation.

A 29-year-old man who injects heroin has 5 days of fever, a new holosystolic murmur at the left lower sternal border that increases with inspiration, and multiple nodular infiltrates on chest radiograph. Before antibiotics are started, what should be obtained?

• a.A sputum Gram stain and culture
• b.Serum procalcitonin only
• c.Three sets of blood cultures✓
• d.A single urine culture and urinalysis

Suspected infective endocarditis requires at least three sets of blood cultures drawn before antibiotics, because persistent bacteremia is a major diagnostic criterion and guides therapy. Injection drug use favors right-sided (tricuspid) disease, fitting a murmur that increases with inspiration and septic pulmonary emboli. A urine culture, procalcitonin, or a sputum Gram stain cannot identify the organism on the valve.

A 31-year-old woman with chronic hypertension controlled on lisinopril tells you she is 6 weeks pregnant. Which change to her antihypertensive regimen is most appropriate?

• a.Continue lisinopril and also add losartan
• b.Continue lisinopril at the same dose
• c.Stop lisinopril and switch to labetalol✓
• d.Stop all antihypertensives until delivery

ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy because of fetal renal toxicity, so lisinopril should be stopped and replaced with a pregnancy-compatible agent such as labetalol. Adding losartan combines two contraindicated drugs. Continuing lisinopril exposes the fetus, and stopping all treatment leaves chronic hypertension uncontrolled.

A 66-year-old man with heart failure with reduced ejection fraction takes sacubitril/valsartan, carvedilol and spironolactone. Adding which drug class would most likely further reduce his risk of death and hospitalization?

• a.Digoxin
• b.Additional loop diuretic
• c.SGLT2 inhibitor✓
• d.Nondihydropyridine calcium channel blocker

SGLT2 inhibitors are one of the four core guideline-directed medication classes for HFrEF, alongside an ARNI or ACE inhibitor/ARB, an evidence-based beta-blocker and a mineralocorticoid receptor antagonist. Digoxin may improve symptoms and reduce hospitalizations but has no proven survival benefit. Nondihydropyridine calcium channel blockers depress contractility and are avoided in HFrEF, and loop diuretics relieve congestion without improving survival.

A 55-year-old man has a blood pressure of 212/128 mm Hg, new confusion, and papilledema. How is this presentation classified?

• a.Hypertensive urgency
• b.White coat hypertension
• c.Isolated systolic hypertension
• d.Hypertensive emergency✓

Severe hypertension accompanied by acute target-organ damage, here encephalopathy and papilledema, defines a hypertensive emergency that needs controlled IV blood pressure lowering. Hypertensive urgency is severe elevation without acute organ damage. Isolated systolic hypertension requires a normal diastolic pressure, and white coat hypertension is elevation confined to the clinical setting.

A 22-year-old woman noticed a single 4-cm oval, pink, scaly patch on her trunk. Ten days later, many smaller oval lesions appeared on her back, aligned along skin cleavage lines in a Christmas tree pattern. Which diagnosis is most likely?

• a.Secondary syphilis
• b.Guttate psoriasis
• c.Tinea versicolor
• d.Pityriasis rosea✓

A herald patch followed by smaller oval lesions oriented along cleavage lines in a Christmas tree distribution is classic pityriasis rosea. Tinea versicolor causes hypo- or hyperpigmented macules with fine scale and no herald patch. Guttate psoriasis produces small drop-like plaques after streptococcal infection, and secondary syphilis classically involves the palms and soles; syphilis serology is still reasonable when the picture is atypical.

Nine days after starting a new anticonvulsant, a 40-year-old man develops fever, painful dusky macules with epidermal detachment over about 35% of his body surface area, and oral and conjunctival erosions. Besides admission to a burn or intensive care unit, which step is most important?

• a.Apply high-potency topical steroids
• b.Start empiric oral acyclovir
• c.Stop the suspected drug immediately✓
• d.Continue the drug and add an antihistamine

Epidermal detachment over more than 30% of body surface area with mucosal erosions after a new drug is toxic epidermal necrolysis; immediate withdrawal of the causative drug and intensive supportive care are the core of management. Continuing the drug worsens outcome. Acyclovir treats herpes infection, not a drug reaction, and topical steroids do not address a process that is detaching the epidermis.

A 30-year-old man has intense itching that is worst at night. Examination shows small papules and short linear burrows in the finger web spaces, on the wrists and along the waistline. His partner has similar symptoms. Which management is most appropriate?

• a.Oral cephalexin for him and his household contacts
• b.Topical permethrin for him and close contacts✓
• c.Oral terbinafine for him only
• d.Topical hydrocortisone for him only

Nocturnal itching with burrows in the web spaces, wrists and waistline and a symptomatic contact indicate scabies, treated with a topical scabicide such as permethrin with simultaneous treatment of close contacts to prevent reinfestation. Terbinafine treats dermatophytes, hydrocortisone only suppresses itch, and cephalexin treats bacterial skin infection rather than mite infestation.

A 68-year-old farmer has several rough, sandpaper-like, scaly pink papules on his forehead and the backs of his hands. Which statement best describes the significance of these lesions?

• a.Benign lesions needing no follow-up
• b.Lesions caused by papillomavirus infection
• c.Precursors of squamous cell carcinoma✓
• d.Early in situ lesions of malignant melanoma

Rough, scaly papules on chronically sun-exposed skin are actinic keratoses, premalignant lesions with a risk of progression to squamous cell carcinoma, so they are treated or monitored. They are not merely cosmetic, they are not a melanocytic precursor to melanoma, and they are caused by ultraviolet damage rather than papillomavirus.

An 80-year-old woman has several weeks of itching followed by large tense bullae on her trunk and flexural areas. Rubbing the skin next to a blister does not shear off the epidermis, and her oral mucosa is spared. Which diagnosis is most likely?

• a.Bullous impetigo
• b.Dermatitis herpetiformis
• c.Bullous pemphigoid✓
• d.Pemphigus vulgaris

Tense bullae in an older adult with a negative Nikolsky sign and little or no mucosal involvement characterize bullous pemphigoid, a subepidermal blistering disease. Pemphigus vulgaris produces flaccid, easily ruptured bullae with painful oral erosions and a positive Nikolsky sign. Dermatitis herpetiformis causes grouped itchy vesicles on extensor surfaces, and bullous impetigo is a localized staphylococcal infection.

A 32-year-old woman has weight loss, heat intolerance and palpitations. She has a diffusely enlarged, nontender thyroid, bilateral proptosis, and thickened skin over the shins. TSH is suppressed and free T4 is elevated. Which diagnosis is most likely?

• a.Subacute granulomatous thyroiditis
• b.Graves disease✓
• c.Hashimoto thyroiditis
• d.Toxic multinodular goiter

Hyperthyroidism with a diffuse goiter, exophthalmos and infiltrative dermopathy is specific for Graves disease, which is caused by antibodies that stimulate the TSH receptor. Toxic multinodular goiter produces a nodular gland without eye disease or dermopathy. Subacute thyroiditis causes a painful, tender thyroid, and Hashimoto thyroiditis usually leads to hypothyroidism.

A 74-year-old man with known coronary artery disease is diagnosed with primary hypothyroidism (TSH 38 mIU/L, low free T4). How should levothyroxine be started?

• a.At a low dose, titrated gradually✓
• b.At a high loading dose given IV
• c.Only after a trial of liothyronine (T3)
• d.At the full weight-based dose on day one

In older patients and those with coronary disease, levothyroxine is started at a low dose (for example 25 mcg daily) and increased gradually, about every 6 weeks, because rapid replacement raises myocardial oxygen demand and can provoke angina or arrhythmia. Full-dose initiation is reasonable in younger healthy patients but not here. T3 is not a standard first step, and IV loading is reserved for myxedema coma.

A 36-year-old woman has fatigue, weight loss, salt craving and darkening of her palmar creases and gums. Labs show sodium 128 mEq/L and potassium 5.9 mEq/L. Which test is most useful to confirm the suspected diagnosis?

• a.Plasma free metanephrines
• b.Overnight dexamethasone suppression test
• c.Serum aldosterone-to-renin ratio
• d.ACTH (cosyntropin) stimulation test✓

Hyperpigmentation, hyponatremia and hyperkalemia suggest primary adrenal insufficiency, confirmed by a low cortisol response to ACTH (cosyntropin) stimulation together with an elevated plasma ACTH. The dexamethasone suppression test screens for cortisol excess, metanephrines screen for pheochromocytoma, and the aldosterone-to-renin ratio screens for primary hyperaldosteronism, which causes hypokalemia rather than hyperkalemia.

A 45-year-old woman has central obesity, wide purple abdominal striae, proximal muscle weakness, easy bruising and new hypertension. She takes no glucocorticoids. Which is an appropriate initial screening test?

• a.Random morning serum ACTH
• b.Fasting serum insulin level
• c.Late-night salivary cortisol✓
• d.Serum TSH and free T4

Suspected endogenous Cushing syndrome is screened with a test of cortisol excess: late-night salivary cortisol, 24-hour urinary free cortisol, or a low-dose dexamethasone suppression test. ACTH is measured after hypercortisolism is confirmed, to separate ACTH-dependent from independent causes. Thyroid tests and insulin levels do not establish cortisol excess.

A 38-year-old man has episodes of pounding headache, sweating and palpitations with blood pressure up to 230/120 mm Hg. Plasma free metanephrines are markedly elevated and CT shows a 4-cm adrenal mass. Before surgery, how should his blood pressure be managed?

• a.Alpha-blockade first, then a beta-blocker✓
• b.A beta-blocker first, then alpha-blockade
• c.A beta-blocker alone
• d.A thiazide diuretic alone

In pheochromocytoma, alpha-adrenergic blockade (for example phenoxybenzamine or doxazosin) is started first, and a beta-blocker is added only afterward to control tachycardia. Starting a beta-blocker first leaves alpha-mediated vasoconstriction unopposed and can precipitate a hypertensive crisis. Diuretics worsen the volume contraction these patients already have.

A 19-year-old with type 1 diabetes presents with diabetic ketoacidosis. Glucose is 540 mg/dL, pH 7.12, and serum potassium 3.0 mEq/L. IV 0.9% saline has been started. What is the next step before starting an insulin infusion?

• a.Give IV sodium bicarbonate
• b.Give IV dextrose 50%
• c.Replace potassium to at least 3.3 mEq/L✓
• d.Start insulin immediately at a high rate

Insulin drives potassium into cells, so in DKA insulin is held until serum potassium is at least 3.3 mEq/L to avoid life-threatening hypokalemia and arrhythmia. Bicarbonate is considered only for very severe acidosis (pH below about 7.0). Starting insulin with a potassium of 3.0 is dangerous, and dextrose is added later when glucose falls, not before insulin.

A 28-year-old woman has amenorrhea and galactorrhea. Prolactin is markedly elevated, pregnancy test is negative, TSH is normal, and MRI shows a 7-mm pituitary adenoma. What is the usual first-line treatment?

• a.External-beam pituitary radiation
• b.Octreotide
• c.Cabergoline✓
• d.Transsphenoidal surgery

A prolactin-secreting microadenoma is usually treated first with a dopamine agonist, and cabergoline is preferred over bromocriptine because it is better tolerated. Octreotide is a somatostatin analog used for acromegaly. Surgery is an option in selected patients or when medication fails or is not tolerated, and radiation is reserved for refractory tumors.

A 64-year-old woman develops severe right eye pain, blurred vision with colored halos around lights, headache and vomiting after sitting in a dark movie theater. The eye is red, the cornea hazy, and the pupil fixed and mid-dilated. What is the most appropriate course?

• a.Urgent pressure-lowering therapy and ophthalmology referral✓
• b.Dilate the pupil to examine the optic nerve and fundus fully
• c.Topical antibiotic drops for presumed bacterial conjunctivitis
• d.Prescribe artificial tears and review in one week

Sudden painful red eye with halos, a hazy cornea and a fixed mid-dilated pupil is acute angle-closure glaucoma, an emergency treated immediately with pressure-lowering medications and ophthalmology referral for laser iridotomy. Delaying care risks permanent optic nerve damage. Pupillary dilation can worsen angle closure, and conjunctivitis does not cause a fixed pupil or corneal haze.

A 71-year-old man with atrial fibrillation suddenly loses vision in his left eye without pain. Funduscopy shows a pale, opaque retina with a cherry-red spot at the fovea. Which diagnosis is most likely?

• a.Acute angle-closure glaucoma attack
• b.Central retinal vein occlusion
• c.Rhegmatogenous retinal detachment
• d.Central retinal artery occlusion✓

Sudden painless monocular vision loss with a pale retina and a cherry-red spot, usually from an embolus, is central retinal artery occlusion. Central retinal vein occlusion shows diffuse retinal hemorrhages and dilated veins. Angle-closure glaucoma is painful with a red eye, and retinal detachment is preceded by flashes, floaters and a curtain-like field defect.

A 58-year-old with severe myopia reports new flashes of light, a shower of floaters, and a dark curtain moving across the upper part of the vision in one eye over the past day. What is the most appropriate next step?

• a.Same-day ophthalmology evaluation✓
• b.Oral prednisone and neurology follow-up
• c.Warm compresses and lid hygiene
• d.Reassurance and routine eye exam in 3 months

New flashes, many new floaters and a curtain-like shadow indicate retinal detachment, which needs urgent ophthalmologic evaluation because prompt repair preserves vision. Routine follow-up risks progression to the macula. Steroids are not a treatment for detachment, and warm compresses are for blepharitis or chalazion.

A 7-year-old with a recent sinus infection has a swollen, red left upper eyelid, fever, pain with eye movement, proptosis and reduced visual acuity. Which is the most appropriate next step?

• a.Topical erythromycin ointment only
• b.Warm compresses and follow-up in 2 days
• c.CT of the orbits and IV antibiotics✓
• d.Oral amoxicillin-clavulanate at home

Proptosis, painful or restricted eye movement and reduced vision distinguish orbital cellulitis from preseptal cellulitis; it needs imaging (CT or MRI) to look for abscess and hospital IV antibiotics. Outpatient oral antibiotics suit mild preseptal cellulitis with normal eye movement and vision. Warm compresses and topical ointment do not treat a deep orbital infection.

A 3-year-old with no drug allergies has 2 days of fever and ear pain. The left tympanic membrane is bulging and erythematous with decreased mobility. The child has not taken antibiotics in the past month. If antibiotics are prescribed, which is generally preferred?

• a.Oral ciprofloxacin
• b.Topical ofloxacin drops
• c.Azithromycin
• d.High-dose amoxicillin✓

Acute otitis media with a bulging tympanic membrane is generally treated, when antibiotics are chosen, with high-dose amoxicillin, which covers resistant pneumococcus. Fluoroquinolones are not first-line oral therapy in young children. Macrolides have high pneumococcal resistance, and topical drops are used for otitis externa or a draining tube, not an intact bulging drum.

A 19-year-old has severe sore throat, fever, drooling, difficulty opening the mouth and a muffled voice. The right tonsillar pillar bulges and the uvula is deviated to the left. Which management is most appropriate?

• a.Oral penicillin alone and reassess in 10 days
• b.Rapid strep test and throat lozenges
• c.Tonsillectomy at a scheduled future date
• d.Drainage of the abscess plus antibiotics✓

Trismus, a hot potato voice and a unilateral tonsillar bulge with uvular deviation are the signs of a peritonsillar abscess, which needs drainage by needle aspiration or incision plus antibiotics. Antibiotics alone do not treat an established abscess, and a strep test with lozenges ignores it. Tonsillectomy may be considered later for recurrence but does not replace urgent drainage.

A 45-year-old woman has recurrent attacks of spinning vertigo lasting several hours, with fullness, roaring tinnitus and muffled hearing in the right ear. Audiometry shows low-frequency sensorineural hearing loss on the right. Which diagnosis is most likely?

• a.Otosclerosis
• b.Benign paroxysmal positional vertigo
• c.Meniere disease✓
• d.Vestibular neuronitis

Episodic vertigo lasting hours with fluctuating sensorineural hearing loss, tinnitus and aural fullness is Meniere disease. BPPV causes brief vertigo lasting seconds with head position change and no hearing loss. Vestibular neuronitis is a single prolonged attack without hearing loss, and otosclerosis causes a gradual conductive loss without vertigo attacks.

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?

• a.Upper endoscopy with biopsy
• b.Right upper quadrant ultrasound✓
• c.Barium swallow study
• d.Plain abdominal radiograph

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.

A 67-year-old man with known gallstones has fever with rigors, jaundice and right upper quadrant pain. Blood pressure is stable. After starting IV antibiotics and fluids, which intervention is most important?

• a.Oral ursodiol therapy
• b.Biliary drainage, usually by ERCP✓
• c.Hepatitis serologies and observation
• d.Elective cholecystectomy in 6 weeks

Fever, jaundice and right upper quadrant pain (the Charcot triad) indicate acute cholangitis from an obstructed common bile duct, which needs antibiotics and timely biliary decompression, usually by ERCP. Delayed cholecystectomy alone does not relieve the ductal obstruction. Viral hepatitis does not explain rigors with an obstructing stone, and ursodiol dissolves stones far too slowly for an infection.

A 50-year-old man has severe epigastric pain radiating to the back and vomiting after a weekend of heavy drinking. Serum lipase is 5 times the upper limit of normal. Which statement about confirming the diagnosis is correct?

• a.Lipase must be above 10 times normal to qualify
• b.Pain plus lipase above 3 times normal is sufficient✓
• c.An elevated amylase is also needed with the lipase
• d.Contrast CT is needed to confirm it in each patient

Acute pancreatitis is diagnosed when at least two of three criteria are met: characteristic abdominal pain, amylase or lipase above three times the upper limit of normal, and characteristic imaging findings. With typical pain and a lipase five times normal, imaging is not needed for diagnosis. Amylase adds nothing when lipase already qualifies, and the threshold is three times normal, not ten.

A 16-year-old has periumbilical pain that began yesterday and moved to the right lower quadrant, with anorexia and nausea. He has tenderness and rebound at the point one third of the way from the anterior superior iliac spine to the umbilicus. Which diagnosis is most likely?

• a.Meckel diverticulum bleeding
• b.Acute appendicitis✓
• c.Mesenteric adenitis
• d.Sigmoid diverticulitis

Periumbilical pain that migrates to the right lower quadrant, anorexia, and tenderness at the McBurney point are the classic sequence of acute appendicitis. Mesenteric adenitis follows a viral illness and lacks the migration pattern and peritoneal signs. Sigmoid diverticulitis causes left lower quadrant pain in older adults, and a bleeding Meckel diverticulum presents with painless rectal bleeding.

A 4-week-old firstborn boy has projectile nonbilious vomiting after every feed and is hungry again right away. A small firm mass is felt in the epigastrium. Which metabolic abnormality is most expected?

• a.Hypochloremic, hypokalemic metabolic alkalosis✓
• b.Respiratory alkalosis with hyperkalemia
• c.Anion gap metabolic acidosis
• d.Hyperchloremic metabolic acidosis

Hypertrophic pyloric stenosis presents at about 3 to 6 weeks with projectile nonbilious vomiting, a hungry infant, and an olive-like mass; loss of gastric hydrochloric acid produces hypochloremic, hypokalemic metabolic alkalosis. The diagnosis is confirmed by ultrasound. Hyperchloremic acidosis follows bicarbonate loss such as diarrhea, an anion gap acidosis reflects added acids, and neither results from losing gastric acid; hyperkalemia is not expected either.

A 9-month-old has episodes of inconsolable crying with drawing up of the legs every 15 to 20 minutes, with lethargy in between. A sausage-shaped mass is felt in the right upper abdomen and rectal exam shows heme-positive stool. Ultrasound confirms the diagnosis. In a stable infant without peritonitis, what is the usual first treatment?

• a.Air or contrast enema reduction✓
• b.Oral rehydration and observation
• c.Nasogastric decompression alone
• d.Emergency laparotomy

Intermittent colicky pain, lethargy, a sausage-shaped mass and blood in the stool indicate ileocolic intussusception; in a stable child without perforation or peritonitis, air (or contrast) enema reduction is the first treatment. Laparotomy is reserved for failed enema reduction, perforation or peritonitis. Rehydration or nasogastric decompression alone does not reduce the telescoped bowel.

A 40-year-old with dyspepsia and no alarm features has not taken a proton pump inhibitor, bismuth or antibiotics in the past month. Which is an appropriate noninvasive test for active Helicobacter pylori infection?

• a.Serum H. pylori IgG antibody after treatment
• b.Urea breath test✓
• c.Fecal occult blood test
• d.Upper GI barium series

The urea breath test and stool antigen test detect active H. pylori infection noninvasively and can also confirm eradication. Serum IgG stays positive long after cure, so it cannot show active infection or eradication. A barium study and fecal occult blood testing do not identify the organism.