PANCE (Physician Assistant National Certifying Exam) — All Questions

A 63-year-old woman with a 40 pack-year smoking history has chronic cough and exertional dyspnea. Which spirometry finding confirms persistent airflow limitation consistent with COPD?

• a.Post-bronchodilator FEV1/FVC below 0.70✓
• b.Pre-bronchodilator FEV1 above 80% predicted
• c.A normal FEV1/FVC with reduced total lung capacity
• d.A 20% rise in FEV1 after albuterol with a normal ratio

GOLD defines persistent airflow limitation in COPD as a post-bronchodilator FEV1/FVC below 0.70, and the FEV1 percent predicted then grades severity. An FEV1 above 80% alone does not establish obstruction. A normal ratio with reduced total lung capacity indicates restriction, and a large bronchodilator response with a normal ratio fits asthma rather than fixed obstruction.

A 22-year-old stabbing victim has worsening respiratory distress, blood pressure 76/44 mm Hg, distended neck veins, absent breath sounds and hyperresonance over the left chest, and tracheal deviation to the right. What is the most appropriate immediate step?

• a.Portable chest radiograph to confirm
• b.Endotracheal intubation first
• c.Needle decompression of the left chest✓
• d.CT of the chest with contrast

Hypotension, jugular venous distention, absent breath sounds, hyperresonance and tracheal shift indicate tension pneumothorax, which is treated immediately with needle decompression (followed by a chest tube) without waiting for a radiograph. Imaging first delays life-saving decompression, and positive-pressure ventilation before decompression can worsen the tension physiology.

Thoracentesis in a patient with a new pleural effusion shows a pleural fluid-to-serum protein ratio of 0.6 and a pleural fluid-to-serum LDH ratio of 0.7. How is this effusion classified?

• a.Hemothorax by definition
• b.Exudate✓
• c.Chylothorax by definition
• d.Transudate

By Light's criteria, an effusion is exudative if any one criterion is met: fluid-to-serum protein ratio above 0.5, fluid-to-serum LDH ratio above 0.6, or fluid LDH above two thirds of the serum upper limit of normal. Both ratios here exceed their cut-offs. Transudates meet none of the criteria, while chylothorax and hemothorax are defined by triglyceride and hematocrit measurements, not these ratios.

A 2-year-old has a barking, seal-like cough, hoarse voice and inspiratory stridor at rest that began at night after 2 days of a runny nose. Which treatment is most appropriate?

• a.IV ceftriaxone and admission
• b.Emergency surgical tracheostomy
• c.Nebulized albuterol alone
• d.Dexamethasone and racemic epinephrine✓

A barking cough with stridor after a viral prodrome is croup, usually caused by parainfluenza virus; stridor at rest indicates at least moderate disease, treated with a glucocorticoid such as dexamethasone plus nebulized racemic epinephrine. Albuterol targets lower-airway bronchospasm, antibiotics and admission are not needed for a typical viral laryngotracheitis, and surgical airways are not indicated for typical croup.

An unvaccinated 4-year-old has abrupt high fever, drooling, muffled voice and inspiratory stridor and is sitting upright leaning forward. A lateral neck radiograph, if obtained, would most likely show which finding?

• a.An enlarged epiglottis (thumb sign)✓
• b.Subglottic narrowing (steeple sign)
• c.Hyperinflated lungs with air trapping
• d.A widened retropharyngeal soft-tissue space

Rapid-onset fever, drooling, dysphagia, stridor and a tripod posture suggest epiglottitis, which shows an enlarged epiglottis (thumb sign) on a lateral neck film; the airway must be secured in a controlled setting and the child should not be agitated. The steeple sign is croup. A widened retropharyngeal soft-tissue space suggests retropharyngeal abscess, and hyperinflation suggests asthma or foreign-body obstruction lower in the airway.

A 5-month-old in January has 3 days of runny nose followed by cough, tachypnea, diffuse wheezes and crackles. Oxygen saturation is 95% on room air and she is feeding adequately. Which is the mainstay of management?

• a.Oral amoxicillin for 10 days
• b.Oral prednisolone for 5 days
• c.Scheduled nebulized albuterol every 4 hours
• d.Supportive care: suctioning and hydration✓

Viral bronchiolitis, most often from RSV, is managed with supportive care: hydration, nasal suctioning and oxygen only if needed, and most children can be treated at home. Corticosteroids and antibiotics are not recommended for typical bronchiolitis, and bronchodilators are not routinely recommended (AAP 2014 guideline), though they are sometimes tried.

A 32-year-old Black woman has a dry cough, tender red nodules on her shins and painful ankles. Chest radiograph shows bilateral hilar lymphadenopathy. Biopsy of a lymph node would most likely show which finding?

• a.Caseating granulomas with acid-fast bacilli
• b.Noncaseating granulomas✓
• c.Reed-Sternberg cells
• d.Ferruginous bodies

Bilateral hilar adenopathy with erythema nodosum and arthritis is typical of sarcoidosis, whose hallmark is noncaseating granulomas. Caseating granulomas with acid-fast bacilli indicate tuberculosis. Reed-Sternberg cells indicate Hodgkin lymphoma, and ferruginous bodies indicate asbestos exposure.

A 64-year-old heavy smoker has a central lung mass and a serum sodium of 121 mEq/L. He appears euvolemic, with a serum osmolality of 255 mOsm/kg and inappropriately concentrated urine. Which tumor type is most likely?

• a.Bronchial carcinoid tumor
• b.Small cell lung carcinoma✓
• c.Adenocarcinoma of the lung
• d.Hamartoma

SIADH causing euvolemic hypotonic hyponatremia with concentrated urine is a classic paraneoplastic syndrome of small cell lung carcinoma, a central tumor strongly linked to smoking. Adenocarcinoma is usually peripheral and less associated with SIADH. Carcinoid tumors more often cause flushing or Cushing syndrome, and hamartomas are benign and not paraneoplastic.

A 50-year-old man with obesity has loud snoring, witnessed apneas, morning headaches and daytime sleepiness. Which test is used to confirm the diagnosis?

• a.Polysomnography✓
• b.Pulmonary function testing
• c.Overnight pulse oximetry alone
• d.Arterial blood gas at rest

Suspected obstructive sleep apnea is confirmed by a sleep study, either laboratory polysomnography or a qualifying home sleep apnea test, which measures the apnea-hypopnea index; positive airway pressure is the main treatment. Oximetry alone is not sufficient for diagnosis, and pulmonary function tests and a resting blood gas do not measure sleep-related breathing events.

A 6-month-old has poor weight gain, frequent greasy foul-smelling stools, and two episodes of pneumonia. The newborn screen was positive for an elevated immunoreactive trypsinogen. Which test confirms the suspected diagnosis?

• a.Barium swallow
• b.Stool culture for pathogens
• c.Sweat chloride test✓
• d.Serum immunoglobulin levels

Failure to thrive, steatorrhea and recurrent lung infections suggest cystic fibrosis, which is confirmed by an elevated sweat chloride on two occasions or identification of two disease-causing CFTR variants. Immunoglobulin levels evaluate immunodeficiency, a stool culture looks for infection, and a barium swallow evaluates swallowing or anatomy, not CFTR function.