PANCE (Physician Assistant National Certifying Exam) — All Questions

For 3 weeks, a 42-year-old man has had low mood most of the day, loss of interest in his hobbies, insomnia, poor concentration, fatigue and feelings of worthlessness nearly every day, impairing his work. He has never had a manic episode. Which diagnosis is most likely?

• a.Adjustment disorder with depressed mood
• b.Bipolar II disorder
• c.Persistent depressive disorder
• d.Major depressive disorder✓

Five or more depressive symptoms, including depressed mood or loss of interest, nearly every day for at least 2 weeks with functional impairment meets criteria for major depressive disorder. Persistent depressive disorder requires at least 2 years of symptoms. Adjustment disorder does not meet full criteria for another disorder, and bipolar II requires a hypomanic episode.

A 26-year-old woman has had four sudden episodes of racing heart, chest tightness, trembling and fear of dying that peaked within minutes and occurred without a trigger. Cardiac evaluation is normal. For the past 2 months she has avoided driving for fear of another attack. Which is an appropriate first-line treatment?

• a.A stimulant such as methylphenidate
• b.An SSRI and/or cognitive behavioral therapy✓
• c.Long-term alprazolam as sole therapy
• d.A first-generation antipsychotic

Recurrent unexpected panic attacks followed by at least a month of worry or behavior change is panic disorder, treated first-line with an SSRI, cognitive behavioral therapy, or both. Benzodiazepines can help short term but carry dependence risk and are not preferred as long-term monotherapy. Antipsychotics are not indicated, and stimulants can provoke panic.

Ten days after a violent assault, a 31-year-old man has intrusive memories, nightmares, avoidance of the area, and hypervigilance. Which diagnosis best fits at this time?

• a.Post-traumatic stress disorder
• b.Acute stress disorder✓
• c.Generalized anxiety disorder
• d.Adjustment disorder with anxiety

Trauma-related intrusion, avoidance and arousal symptoms occurring within the first month after the event are diagnosed as acute stress disorder; PTSD can be diagnosed only when symptoms last longer than 1 month. Adjustment disorder applies to stressors that do not produce this trauma symptom pattern, and generalized anxiety requires 6 months of diffuse worry.

A 50-year-old man who drinks a fifth of vodka daily is admitted for a hip fracture. On hospital day 2 he is tremulous, sweating, anxious and tachycardic, with a CIWA-Ar score of 18. Which is the first-line medication class?

• a.Benzodiazepines✓
• b.Haloperidol alone
• c.Beta-blockers alone
• d.Naltrexone

Benzodiazepines are first-line for alcohol withdrawal because they are cross-tolerant with alcohol and prevent progression to seizures and delirium tremens; symptom-triggered dosing is guided by the CIWA-Ar. Haloperidol can lower the seizure threshold and does not treat withdrawal, beta-blockers only mask autonomic signs, and naltrexone is for relapse prevention after withdrawal.

A 34-year-old woman seeks evaluation for inattention, disorganization and restlessness at work. To diagnose ADHD in an adult, which historical feature is required?

• a.Several symptoms present before age 12✓
• b.Symptoms beginning after age 30
• c.A prior diagnosis of a learning disorder
• d.Symptoms in only one setting

DSM-5-TR requires that several inattentive or hyperactive-impulsive symptoms were present before age 12 and occur in two or more settings, even when ADHD is first recognized in adulthood. New symptoms beginning in the 30s suggest another cause. Symptoms confined to one setting do not meet criteria, and a learning disorder may coexist but is not required.

Four days after starting haloperidol, a 28-year-old man becomes confused and develops a temperature of 40.1 °C, lead-pipe rigidity, fluctuating blood pressure and a markedly elevated creatine kinase. What is the most important immediate step?

• a.Start an SSRI
• b.Add a long-acting injectable antipsychotic
• c.Increase the haloperidol dose for agitation
• d.Stop the antipsychotic; cool and support✓

Fever, rigidity, autonomic instability, altered mental status and elevated creatine kinase after an antipsychotic indicate neuroleptic malignant syndrome; the drug is stopped immediately with rapid cooling and aggressive supportive care, adding agents such as dantrolene or bromocriptine in severe cases. More or additional antipsychotics worsen it, and an SSRI does not treat it and raises concern for serotonin syndrome.

A 20-year-old man spends 3 hours a day washing his hands because of intrusive fears of contamination that he recognizes are excessive. Which psychotherapy is most effective for this condition?

• a.Supportive counseling only
• b.Eye movement desensitization
• c.Psychodynamic psychotherapy
• d.Exposure and response prevention✓

Intrusive obsessions with time-consuming compulsions define obsessive-compulsive disorder, and the psychotherapy of choice is exposure and response prevention, a form of CBT, often combined with an SSRI or clomipramine. Psychodynamic and supportive approaches alone are less effective for OCD, and EMDR is used for trauma-related disorders.