PANCE (Physician Assistant National Certifying Exam) — All Questions

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.

A 56-year-old man with alcohol-related cirrhosis vomits large amounts of bright red blood. After airway protection and IV access, which combination is most appropriate for suspected esophageal variceal bleeding?

• a.IV vasopressin followed by urgent colonoscopy
• b.Oral propranolol and discharge home
• c.High-dose IV proton pump inhibitor as the only treatment
• d.Octreotide, antibiotics and endoscopic band ligation✓

Acute variceal hemorrhage is managed with resuscitation, a vasoactive drug such as octreotide, prophylactic antibiotics in cirrhosis, and endoscopic band ligation, with TIPS if bleeding persists. A PPI alone treats peptic ulcer bleeding, not varices. Colonoscopy looks at the wrong part of the gut, and oral nonselective beta-blockers are for prevention after stabilization, not acute hemorrhage.

A 26-year-old woman has chronic bloating, loose stools, iron-deficiency anemia and an itchy blistering rash on her elbows. She eats a regular gluten-containing diet. Which initial test is recommended?

• a.Tissue transglutaminase IgA with total IgA✓
• b.Stool ova and parasites examination
• c.Hydrogen breath test for lactose
• d.Serum gastrin level

Tissue transglutaminase IgA is the recommended initial test for celiac disease, with total IgA measured because IgA deficiency causes false-negative results; testing must be done while the patient is still eating gluten, and small-bowel biopsy confirms the diagnosis. The rash suggests dermatitis herpetiformis. Stool parasites, a lactose breath test, and gastrin do not diagnose celiac disease.

A 38-year-old woman has progressive difficulty swallowing both solids and liquids over 2 years, regurgitation of undigested food at night, and weight loss. Upper endoscopy shows no mass. Which test best establishes the diagnosis?

• a.24-hour pH monitoring
• b.Serum gastrin level
• c.Abdominal ultrasonography
• d.Esophageal manometry✓

Dysphagia to both solids and liquids from the onset with regurgitation of undigested food suggests achalasia, and esophageal manometry is the diagnostic test, showing failed relaxation of the lower esophageal sphincter and absent peristalsis. A barium swallow and endoscopy support the diagnosis and exclude cancer. pH monitoring evaluates reflux, and ultrasound and gastrin do not assess esophageal motility.