PANCE (Physician Assistant National Certifying Exam) — All Questions

A 58-year-old man has sudden, exquisite pain and swelling of the first metatarsophalangeal joint overnight. Joint aspiration shows needle-shaped crystals that are negatively birefringent under polarized light. Which diagnosis is most likely?

• a.Septic arthritis
• b.Gout✓
• c.Pseudogout
• d.Osteoarthritis

Needle-shaped, negatively birefringent monosodium urate crystals confirm gout, which classically strikes the first metatarsophalangeal joint. Pseudogout shows rhomboid, weakly positively birefringent calcium pyrophosphate crystals. Septic arthritis is diagnosed by Gram stain and culture, and osteoarthritis has noninflammatory fluid without crystals.

A 66-year-old woman with diabetes has 2 days of fever and a hot, swollen, painful right knee that she cannot bend. There was no trauma. What is the most important next step?

• a.Intra-articular corticosteroid injection today
• b.Oral NSAIDs and follow-up in 1 week
• c.Joint aspiration for cell count and culture✓
• d.MRI of the knee before any invasive procedure

An acutely hot, swollen joint with fever must be aspirated to exclude septic arthritis; synovial fluid usually shows a white count above 50,000/µL with neutrophil predominance, and Gram stain and culture identify the organism. MRI delays diagnosis. NSAIDs alone may mask a joint-destroying infection, and injecting a steroid into a possibly infected joint is harmful.

A 12-year-old boy with obesity has a 3-week limp and pain in the left knee and anterior thigh. On exam, flexing the left hip causes it to rotate externally, and internal rotation is limited. Knee exam is normal. What is the most appropriate immediate step?

• a.Non-weight-bearing and hip radiographs✓
• b.Knee MRI and physical therapy
• c.Ibuprofen and return to sports as tolerated
• d.Reassure; this is growing pains

Knee or thigh pain with loss of internal rotation of the hip in an obese early adolescent suggests slipped capital femoral epiphysis; the patient should not bear weight until it is excluded or treated, and hip radiographs including a frog-leg lateral view confirm it before surgical screw fixation. Focusing on the knee misses referred hip pain, and reassurance or return to sports risks further slippage.

During a newborn examination, the examiner adducts the flexed hip and applies gentle posterior pressure, and the femoral head is felt to slip out of the acetabulum. Which maneuver was performed?

• a.FABER test
• b.Ortolani maneuver
• c.Barlow maneuver✓
• d.Galeazzi test

The Barlow maneuver detects an unstable hip that can be pushed out of the acetabulum with adduction and posterior pressure. The Ortolani maneuver is the reverse: abduction with anterior lift that relocates a dislocated hip with a clunk. The Galeazzi sign compares knee heights with the hips flexed, and the FABER test assesses sacroiliac or hip pathology in older patients.

A 25-year-old man had a closed tibial shaft fracture casted 6 hours ago. He now has severe leg pain that is out of proportion to the injury, is unrelieved by opioids, and worsens sharply with passive toe flexion. Distal pulses are palpable. Which is the definitive treatment?

• a.Higher-dose IV opioids and reassessment
• b.Doppler ultrasound for deep vein thrombosis
• c.Elevation of the leg above heart level
• d.Fasciotomy✓

Pain out of proportion to the injury and pain with passive stretch are early signs of acute compartment syndrome; the cast should be removed and definitive treatment is prompt fasciotomy, often after measuring compartment pressure. Palpable pulses do not exclude it because pulselessness is late. Elevating the limb above heart level reduces perfusion, more opioids only mask progression, and a DVT study does not address the problem.

A 24-year-old man has 6 months of low back pain and stiffness that is worse in the morning and after rest, improves with exercise, and wakes him in the second half of the night. Pelvic radiographs show bilateral sacroiliitis. Which test result would most support the diagnosis?

• a.HLA-B27 positive✓
• b.Anti-dsDNA antibody positive
• c.Rheumatoid factor positive
• d.Serum uric acid elevated

Inflammatory back pain in a young man that improves with activity, with sacroiliitis on imaging, suggests ankylosing spondylitis, which is strongly associated with HLA-B27. Rheumatoid factor supports rheumatoid arthritis, which spares the sacroiliac joints, anti-dsDNA supports lupus, and an elevated uric acid supports gout.

A 67-year-old woman has hand pain that worsens with use. Examination shows bony, hard enlargements of the distal interphalangeal joints, and her metacarpophalangeal joints are normal. Which diagnosis is most likely?

• a.Systemic lupus erythematosus
• b.Psoriatic arthritis
• c.Osteoarthritis✓
• d.Rheumatoid arthritis

Hard, bony enlargements of the distal interphalangeal joints are Heberden nodes, a hallmark of osteoarthritis, and pain worse with use fits a degenerative process. Rheumatoid arthritis causes symmetric soft-tissue swelling of the wrists, MCP and PIP joints and typically spares the DIP joints. Psoriatic arthritis can involve the DIP joints but causes inflammatory swelling with nail or skin changes, and lupus arthritis is nonerosive and not bony.

A 69-year-old woman has a DXA scan showing a femoral neck T-score of -2.7. How is her bone density classified?

• a.Osteopenia
• b.Osteoporosis✓
• c.Osteomalacia
• d.Normal bone density

A T-score of -2.5 or lower defines osteoporosis. Osteopenia (low bone mass) is a T-score between -1.0 and -2.5, and normal is -1.0 or higher. Osteomalacia is defective mineralization, usually from vitamin D deficiency, and is not defined by the T-score.

A 72-year-old woman has 6 weeks of aching and morning stiffness in both shoulders and hips lasting over an hour, with difficulty getting out of bed. Muscle strength is normal and the ESR is 78 mm/h. Which response to treatment would most strongly support the suspected diagnosis?

• a.Rapid improvement with low-dose prednisone✓
• b.Improvement with allopurinol
• c.No improvement with any dose of glucocorticoid
• d.Improvement only after high-dose IV methylprednisolone

Proximal pain and stiffness of the shoulder and hip girdles in an adult over 50, with normal strength and a high ESR, suggest polymyalgia rheumatica; a dramatic, rapid response to low-dose prednisone supports the diagnosis. Needing high-dose IV steroids suggests another process such as giant cell arteritis with threatened vision. Allopurinol lowers urate for gout, and lack of steroid response argues against PMR.

A 13-year-old soccer player has anterior knee pain that worsens with running and kneeling. There is a tender, prominent bump over the tibial tubercle, and the knee joint is otherwise normal. What is the usual treatment?

• a.Surgical excision of the tubercle
• b.Rest, activity modification and analgesics✓
• c.IV antibiotics for osteomyelitis
• d.Long leg cast for 8 weeks

Painful swelling of the tibial tubercle in an active adolescent is Osgood-Schlatter disease, which is managed with analgesics, rest and activity modification and is usually self-limited as the growth plate closes. Surgery is rarely needed, casting is not routine, and osteomyelitis would present with fever and systemic signs.