PANCE (Physician Assistant National Certifying Exam) — All Questions

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.