PANCE (Physician Assistant National Certifying Exam) — All Questions

A 14-year-old boy woke up with sudden severe left testicular pain and vomiting. The left testis is high-riding and lies horizontally, and the cremasteric reflex is absent on that side. Which is the most appropriate management?

• a.Antibiotics for presumed epididymitis and scrotal support
• b.Urgent urology consult for detorsion and exploration✓
• c.Ice, NSAIDs and follow-up in one week
• d.Ultrasound scheduled for the next outpatient day

Sudden testicular pain with a high-riding horizontal testis and absent cremasteric reflex is testicular torsion, a surgical emergency; salvage falls quickly after the first several hours, so management is prompt detorsion and surgical exploration, and imaging must not delay surgery when the diagnosis is clear. Antibiotics treat epididymitis, and delayed imaging or conservative care risks losing the testis.

A 68-year-old man has bothersome urinary hesitancy, weak stream and nocturia from benign prostatic hyperplasia. His prostate is about 50 mL. Which statement about drug therapy is correct?

• a.Both classes shrink the prostate substantially within the first week
• b.Neither class should be started until surgery has been ruled out
• c.5-alpha-reductase inhibitors act within days; alpha-blockers shrink it over months
• d.Alpha-blockers act in days; 5-alpha-reductase inhibitors shrink it over months✓

Alpha-adrenergic blockers such as tamsulosin relax prostatic smooth muscle and improve symptoms quickly, while 5-alpha-reductase inhibitors such as finasteride reduce prostate size over months and help most in larger glands; combining the two is more effective than either alone. The reverse timing is incorrect, alpha-blockers do not shrink the prostate, and medical therapy is first-line before surgery.

A 22-year-old man has a painless left scrotal mass that feels like a bag of worms when he stands, enlarges with Valsalva and decreases when he lies down. Which diagnosis is most likely?

• a.Varicocele✓
• b.Spermatocele
• c.Testicular seminoma
• d.Hydrocele

A left-sided scrotal mass that feels like a bag of worms when standing and increases with Valsalva is a varicocele, a dilation of the pampiniform venous plexus. A hydrocele is a smooth cystic swelling around the testis that transilluminates. A spermatocele is a small cyst above the testis, and a seminoma is a firm mass within the testis itself.

A 40-year-old man has sudden colicky right flank pain radiating to the groin, with microscopic hematuria. He is afebrile and has normal renal function. Which imaging study is generally preferred to confirm a urinary stone?

• a.Intravenous pyelography
• b.Contrast-enhanced CT of the abdomen
• c.Noncontrast CT of the abdomen and pelvis✓
• d.MRI of the lumbar spine

Noncontrast (helical) CT is the preferred study for suspected nephrolithiasis because it shows nearly all stones and signs of obstruction; ultrasound is an alternative when radiation should be avoided, such as in pregnancy. IV contrast can obscure stones, IV pyelography has been replaced by CT, and spine MRI evaluates radicular pain, not ureteral stones.

A 55-year-old man has fever, chills, dysuria, perineal pain and difficulty voiding. On gentle digital rectal exam the prostate is exquisitely tender, warm and boggy. Which diagnosis is most likely?

• a.Chronic pelvic pain syndrome
• b.Benign prostatic hyperplasia
• c.Acute bacterial prostatitis✓
• d.Prostate adenocarcinoma

Systemic symptoms with urinary symptoms and an exquisitely tender, boggy prostate indicate acute bacterial prostatitis, treated with antibiotics. Benign prostatic hyperplasia produces a smooth, enlarged, nontender gland without fever. Prostate cancer is typically a hard nodule without fever, and chronic pelvic pain syndrome causes long-standing pain without systemic infection.