PANCE (Physician Assistant National Certifying Exam) — All Questions
14 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.
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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.