PANCE (Physician Assistant National Certifying Exam) — All Questions

A 67-year-old man arrives 50 minutes after sudden right arm and face weakness and difficulty speaking. Glucose is 112 mg/dL. Before any thrombolytic is considered, which study must be done first?

• a.Carotid duplex ultrasound
• b.Lumbar puncture
• c.Noncontrast CT of the head✓
• d.Electroencephalogram

In suspected acute stroke, noncontrast head CT (or MRI) is done immediately to exclude intracranial hemorrhage before thrombolysis. Lumbar puncture has no place in initial stroke evaluation and is contraindicated before thrombolysis. Carotid imaging is part of the later work-up, and an EEG is not used to decide on reperfusion.

A 48-year-old woman has a sudden, severe headache that peaked within seconds while lifting a box, described as the worst of her life. Noncontrast head CT 8 hours later is normal. What is the next step?

• a.Start aspirin 325 mg daily
• b.Discharge with a triptan for presumed migraine
• c.Repeat CT in 1 week
• d.Lumbar puncture for xanthochromia✓

A thunderclap headache raises concern for subarachnoid hemorrhage; if noncontrast CT is negative, lumbar puncture looking for xanthochromia and red blood cells is the next step. Treating it as migraine or waiting a week risks missing an aneurysmal bleed with high rebleeding mortality. Aspirin is contraindicated until hemorrhage is excluded.

A 30-year-old woman has drooping eyelids and double vision that are worse in the evening and after reading, and her jaw tires while chewing. Strength improves after rest. Reflexes and sensation are normal. Which test is most appropriate to confirm the diagnosis?

• a.Serum creatine kinase
• b.Serum acetylcholine receptor antibodies✓
• c.Lumbar puncture to look for oligoclonal bands
• d.Nerve conduction velocity for demyelination

Fatigable ptosis, diplopia and bulbar weakness that improve with rest suggest myasthenia gravis, and serum acetylcholine receptor antibodies are the key confirmatory test, with electrodiagnostic studies and chest imaging for thymoma to follow. Demyelinating slowing points to Guillain-Barre or CIDP, oligoclonal bands support multiple sclerosis, and creatine kinase is elevated in myopathies, not neuromuscular junction disease.

Two weeks after a diarrheal illness, a 35-year-old man develops ascending symmetric leg weakness and absent ankle and knee reflexes. He is admitted. Which measurement is most important to monitor frequently for early complications?

• a.Erythrocyte sedimentation rate
• b.Serum sodium
• c.Forced vital capacity✓
• d.Peak expiratory flow

Ascending weakness with areflexia after a Campylobacter-type illness suggests Guillain-Barre syndrome; forced vital capacity is measured every 6 to 8 hours because respiratory muscle weakness can require intubation. Peak flow reflects airway obstruction rather than neuromuscular weakness. Sodium and ESR do not track respiratory failure.

A 66-year-old man has a slowly progressive tremor of the right hand that is most obvious when his hand rests in his lap and lessens when he reaches for a cup. He has cogwheel rigidity and slowed finger tapping. Which medication is the most effective symptomatic treatment?

• a.Oral donepezil
• b.Oral haloperidol
• c.Oral propranolol
• d.Carbidopa-levodopa✓

A resting tremor with rigidity and bradykinesia is Parkinson disease, and carbidopa-levodopa is the most effective symptomatic therapy. Propranolol treats essential tremor, which is an action tremor. Haloperidol blocks dopamine and worsens parkinsonism, and donepezil treats cognitive symptoms of Alzheimer disease.

A 34-year-old man has attacks of excruciating stabbing pain behind the right eye lasting 45 minutes, with tearing, a runny nostril and drooping of the right eyelid. They occur nightly for several weeks. He paces during attacks. Which acute treatment is appropriate?

• a.High-flow oxygen by nonrebreather mask✓
• b.Oral propranolol twice daily
• c.Daily oral amitriptyline
• d.Oral acetaminophen and rest

Short, severe unilateral orbital attacks with ipsilateral autonomic features, occurring in bouts, are cluster headache; acute treatment is high-flow oxygen or a parenteral triptan. Acetaminophen is too slow and weak for these attacks. Propranolol and amitriptyline are migraine or tension-type preventives, and verapamil is the usual cluster preventive.

A 19-year-old college student has fever, severe headache, neck stiffness and confusion. A head CT is planned before lumbar puncture because he has a depressed level of consciousness. What should be done before the CT?

• a.Blood cultures, then antibiotics and dexamethasone✓
• b.Give oral amoxicillin and observe
• c.Withhold antibiotics until CT and LP results return
• d.Start IV acyclovir alone

When bacterial meningitis is suspected and lumbar puncture will be delayed for imaging, blood cultures are drawn and empiric antibiotics with dexamethasone are started before the CT, because delaying therapy worsens outcome. Waiting for results is dangerous. Oral amoxicillin is inadequate, and acyclovir alone treats herpes encephalitis but not bacterial meningitis.

A 52-year-old man with a known lumbar disk herniation has new bilateral leg weakness, numbness of the perineum and inner thighs, and urinary retention. What is the most appropriate next step?

• a.Emergency MRI of the lumbar spine✓
• b.Physical therapy referral
• c.Oral steroids and follow-up in 2 weeks
• d.Outpatient MRI in 4 to 6 weeks

Saddle anesthesia, bilateral leg weakness and urinary retention indicate cauda equina syndrome, which requires immediate MRI (or CT myelography if MRI is unavailable) and urgent surgical decompression. Physical therapy and delayed imaging are appropriate for uncomplicated radiculopathy, and a course of oral steroids with delayed follow-up risks permanent bowel, bladder and motor loss.