Physician Assistant National Certifying Exam (PANCE) — Questions and Answers

Question 1: A clinic sees 120 patients per day and is open 5 days per week. How many patients are seen in a 4-week month?

2,400 (Correct answer)
1,800
2,200
2,000

Correct answer: 2,400

120 patients/day × 5 days/week × 4 weeks = 2,400 patients.

Question 2: What is the time window for administration of IV alteplase (tPA) in acute ischemic stroke?

Within 6 hours of symptom onset
Within 12 hours of symptom onset
Within 1 hour of symptom onset
Within 3–4.5 hours of symptom onset (Correct answer)

Correct answer: Within 3–4.5 hours of symptom onset

IV alteplase is approved for administration within 3 hours of symptom onset, with select patients eligible up to 4.5 hours based on AHA/ASA guidelines.

Question 3: A 25-year-old with asthma is awakened 4 nights per week by wheezing and uses rescue albuterol daily. Spirometry shows FEV1 of 75% predicted with 15% bronchodilator response. How is this asthma classified?

Moderate persistent asthma (Correct answer)
Mild persistent asthma
Severe persistent asthma
Mild intermittent asthma

Correct answer: Moderate persistent asthma

Daily symptoms, nighttime awakenings more than once per week, and FEV1 60-80% predicted classify asthma as moderate persistent, requiring step 3-4 therapy.

Question 4: A 58-year-old male presents with crushing chest pain radiating to the left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left circumflex artery
Right coronary artery (Correct answer)
Left anterior descending artery
Left main coronary artery

Correct answer: Right coronary artery

ST elevation in leads II, III, and aVF indicates an inferior wall STEMI, which is most commonly caused by right coronary artery (RCA) occlusion.

Question 5: A 45-year-old man has resistant hypertension despite three antihypertensives and persistent hypokalemia. The aldosterone-to-renin ratio is markedly elevated. What is the most likely diagnosis?

Renovascular hypertension
Cushing's syndrome
Primary hyperaldosteronism (Conn's syndrome) (Correct answer)
Pheochromocytoma

Correct answer: Primary hyperaldosteronism (Conn's syndrome)

Primary hyperaldosteronism causes autonomous aldosterone excess, resulting in resistant hypertension, hypokalemia, and an elevated aldosterone-to-renin ratio.

Question 6: Which type of seizure is characterized by sudden loss of muscle tone causing the patient to fall?

Tonic-clonic seizure
Absence seizure
Atonic seizure (Correct answer)
Myoclonic seizure

Correct answer: Atonic seizure

Atonic (drop) seizures involve sudden loss of postural muscle tone, causing the patient to fall abruptly without warning.

Question 7: A 65-year-old with stage IIIA non-small cell lung cancer (N2 disease, no distant metastases) is being evaluated for treatment. He has adequate pulmonary reserve. What is the preferred approach?

Surgery alone with adjuvant chemotherapy
Stereotactic body radiation therapy (SBRT) alone
Concurrent chemoradiation followed by durvalumab (Correct answer)
Palliative chemotherapy only

Correct answer: Concurrent chemoradiation followed by durvalumab

Unresectable stage III NSCLC is treated with concurrent platinum-based chemoradiation followed by consolidation durvalumab (anti-PD-L1), per the PACIFIC trial.

Question 8: A 55-year-old woman with systemic lupus erythematosus develops pericarditis. Which anti-inflammatory agent is typically added to NSAIDs to reduce recurrence?

Methotrexate
Colchicine (Correct answer)
Prednisone high-dose
Hydroxychloroquine

Correct answer: Colchicine

Colchicine added to NSAIDs significantly reduces the risk of recurrent pericarditis and is now standard first-line adjunct therapy.

Question 9: A patient presents with right lower quadrant pain, fever, and elevated WBC. CT shows a 9 cm appendix with periappendiceal fat stranding. Which is the most appropriate next step?

IV antibiotics and discharge
Urgent appendectomy (Correct answer)
Barium enema
Colonoscopy

Correct answer: Urgent appendectomy

CT findings of an enlarged appendix with periappendiceal fat stranding indicate acute appendicitis requiring urgent surgical intervention.

Question 10: What is the primary purpose of the AAPA's 'PA Scope of Practice' policy statement?

To advocate for the broadest possible PA practice authority supported by evidence (Correct answer)
To require PAs to obtain board certification in a specialty
To restrict PAs from practicing in rural areas
To set mandatory salary ranges for PAs

Correct answer: To advocate for the broadest possible PA practice authority supported by evidence

The AAPA's scope of practice policy advocates for PAs to be allowed to practice to the full extent of their education and training without unnecessary restrictions.

Question 11: A 33-year-old with HIV (CD4 count 45 cells/μL) presents with progressive dyspnea, dry cough, and bilateral perihilar ground-glass opacities on CXR. LDH is markedly elevated. What is the diagnosis?

CMV pneumonitis
Mycobacterium avium complex pulmonary disease
Pneumocystis jirovecii pneumonia (Correct answer)
Pulmonary Kaposi sarcoma

Correct answer: Pneumocystis jirovecii pneumonia

PCP classically presents in severely immunocompromised HIV patients with bilateral perihilar ground-glass opacities, elevated LDH, and an indolent progressive course.

Question 12: Which of the following findings on spirometry is most consistent with obstructive lung disease such as COPD?

FEV1 decreased, FVC normal or decreased, FEV1/FVC ratio < 0.70 (Correct answer)
FEV1 normal, FVC decreased, FEV1/FVC ratio > 0.70
FVC decreased, FEV1 normal, FEV1/FVC ratio normal
Both FEV1 and FVC decreased proportionally with normal ratio

Correct answer: FEV1 decreased, FVC normal or decreased, FEV1/FVC ratio < 0.70

Obstructive disease is defined by a post-bronchodilator FEV1/FVC ratio < 0.70, reflecting airflow limitation with air trapping causing a disproportionate reduction in FEV1.

Question 13: On thyroid examination, which technique best differentiates a thyroid mass from another neck mass?

Ask the patient to swallow and observe if the mass moves superiorly (Correct answer)
Auscultate for a bruit over the mass
Palpate for lymph nodes in the posterior triangle
Transilluminate the mass

Correct answer: Ask the patient to swallow and observe if the mass moves superiorly

Thyroid masses move upward with swallowing because the thyroid is attached to the trachea by the pretracheal fascia.

Question 14: Which pulmonary function test finding is characteristic of obstructive lung disease such as COPD?

Decreased FVC with normal FEV1/FVC ratio
Increased total lung capacity with normal FEV1/FVC
Decreased diffusing capacity with normal FEV1/FVC
Decreased FEV1/FVC ratio (<0.70) (Correct answer)

Correct answer: Decreased FEV1/FVC ratio (<0.70)

Obstructive disease is defined by a reduced FEV1/FVC ratio (<0.70 post-bronchodilator), reflecting impaired expiratory airflow due to airway obstruction.

Question 15: A 68-year-old male with a history of atrial fibrillation on warfarin requires urgent hip replacement surgery. INR is currently 2.8. What is the most appropriate perioperative anticoagulation strategy?

Proceed with surgery with INR of 2.8
Stop warfarin, bridge with low molecular weight heparin (Correct answer)
Continue warfarin and give vitamin K 1 mg orally
Switch to aspirin perioperatively

Correct answer: Stop warfarin, bridge with low molecular weight heparin

High-risk patients on warfarin undergoing major surgery require bridging with LMWH while warfarin is held to maintain some anticoagulation protection.

Question 16: What is the value of x if 3(2x − 4) = 2(x + 6)?

x = 3
x = 6 (Correct answer)
x = 5
x = 9

Correct answer: x = 6

Expanding: 6x − 12 = 2x + 12, so 4x = 24, giving x = 6.

Question 17: An 8-year-old presents with painless scrotal swelling that transilluminates. Ultrasound confirms fluid collection around the testis. What is the diagnosis?

Testicular torsion
Hydrocele (Correct answer)
Epididymo-orchitis
Varicocele

Correct answer: Hydrocele

A hydrocele is a fluid collection between the tunica vaginalis layers that presents as painless scrotal swelling that transilluminates on exam.

Question 18: A 50-year-old male develops acute onset monoarthritis of the first metatarsophalangeal joint, described as exquisitely tender, red, and swollen. Synovial fluid analysis shows negatively birefringent needle-shaped crystals. What is the first-line treatment for acute attack?

Allopurinol
Colchicine or NSAIDs (Correct answer)
Febuxostat
Probenecid

Correct answer: Colchicine or NSAIDs

Acute gout attacks are treated with anti-inflammatory agents—NSAIDs, colchicine, or corticosteroids—not urate-lowering therapy which can worsen acute flares.

Question 19: A 28-year-old woman presents with a butterfly-shaped rash across her cheeks and nose, joint pain, and fatigue. ANA is positive. What is the most likely diagnosis?

Systemic lupus erythematosus (Correct answer)
Psoriasis
Dermatomyositis
Rosacea

Correct answer: Systemic lupus erythematosus

The malar (butterfly) rash, arthralgia, fatigue, and positive ANA are classic features of systemic lupus erythematosus.

Question 20: When a PA documents 'patient refused treatment,' this primarily protects against which legal concern?

Fraud and abuse allegations
Claims of abandonment or negligence (Correct answer)
HIPAA violations
Unauthorized practice of medicine

Correct answer: Claims of abandonment or negligence

Documenting patient refusal protects the PA from claims of negligence or abandonment by demonstrating the patient was informed and made an autonomous decision.

Question 21: Which of the following negative effects of beta channel blockers is NOT one of them?

Hypertension (Correct answer)
Bradycardia
Hypotension
Impotence

Correct answer: Hypertension

Beta-blockers work by blocking beta-adrenergic receptors, which leads to a decrease in heart rate, reduced myocardial contractility, and vasodilation. These actions collectively result in a *reduction* of blood pressure, making hypotension a common side effect. Therefore, hypertension is not a negative effect; instead, beta-blockers are frequently prescribed to *treat* hypertension.

Question 22: A patient with short bowel syndrome following extensive small intestine resection is at highest risk for which type of kidney stones?

Calcium phosphate stones
Uric acid stones
Struvite stones
Calcium oxalate stones (Correct answer)

Correct answer: Calcium oxalate stones

Fat malabsorption in short bowel syndrome increases free oxalate absorption (enteric hyperoxaluria), predisposing to calcium oxalate nephrolithiasis.

Question 23: Which of the following is the most appropriate initial treatment for a patient with community-acquired pneumonia requiring hospitalization who has no comorbidities and no risk factors for resistant organisms?

Azithromycin monotherapy
Vancomycin plus piperacillin-tazobactam
Levofloxacin plus metronidazole
Beta-lactam plus macrolide, or respiratory fluoroquinolone alone (Correct answer)

Correct answer: Beta-lactam plus macrolide, or respiratory fluoroquinolone alone

IDSA/ATS guidelines recommend beta-lactam plus macrolide combination or a respiratory fluoroquinolone alone for non-ICU hospitalized CAP.

Question 24: Which of the following best describes the pathophysiology of Type 2 Diabetes Mellitus?

Autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency
Peripheral insulin resistance combined with progressive beta-cell dysfunction (Correct answer)
Downregulation of hepatic glucose transporters only
Excess glucagon secretion from alpha cells as the primary mechanism

Correct answer: Peripheral insulin resistance combined with progressive beta-cell dysfunction

Type 2 DM involves both peripheral insulin resistance and progressive pancreatic beta-cell dysfunction, leading to relative insulin deficiency over time.

Question 25: A 25-year-old woman presents with optic neuritis and new-onset sensory disturbances in her extremities. MRI shows periventricular white matter lesions. What is the most likely diagnosis?

Vitamin B12 deficiency
Neuromyelitis optica
Multiple sclerosis (Correct answer)
CNS vasculitis

Correct answer: Multiple sclerosis

Multiple sclerosis classically presents in young women with relapsing-remitting neurological symptoms, optic neuritis, and periventricular demyelinating lesions on MRI.

Question 26: Wolff-Parkinson-White syndrome involves which anatomical abnormality?

Accessory conduction pathway (Bundle of Kent) bypassing the AV node (Correct answer)
Abnormal SA node automaticity
Dilated coronary sinus
Hypertrophied bundle of His

Correct answer: Accessory conduction pathway (Bundle of Kent) bypassing the AV node

WPW is caused by an accessory pathway (Bundle of Kent) that bypasses the AV node, allowing pre-excitation of the ventricles.

Question 27: What is the most common cause of osteomyelitis in adults in the United States?

Escherichia coli
Streptococcus pyogenes
Staphylococcus aureus (Correct answer)
Pseudomonas aeruginosa

Correct answer: Staphylococcus aureus

Staphylococcus aureus is the most common causative organism of osteomyelitis in adults, accounting for the majority of hematogenous and contiguous cases.

Question 28: Which organization is responsible for certifying Physician Assistants in the United States?

American Medical Association (AMA)
American Academy of PAs (AAPA)
National Commission on Certification of Physician Assistants (NCCPA) (Correct answer)
Federation of State Medical Boards (FSMB)

Correct answer: National Commission on Certification of Physician Assistants (NCCPA)

The NCCPA is the only credentialing organization for PAs in the United States, awarding the PA-C credential.

Question 29: Which organism is most commonly responsible for traveler's diarrhea?

Campylobacter jejuni
Giardia lamblia
Enterotoxigenic Escherichia coli (ETEC) (Correct answer)
Salmonella typhi

Correct answer: Enterotoxigenic Escherichia coli (ETEC)

ETEC is the leading cause of traveler's diarrhea, producing heat-labile and heat-stable enterotoxins that increase intestinal fluid secretion.

Question 30: Which type of PA practice agreement or document outlines the specific clinical duties and prescribing authority of a PA at a given practice site?

Delegation of Services Agreement (DSA) (Correct answer)
HIPAA Business Associate Agreement
National Provider Agreement
Medicare Enrollment Form 855I

Correct answer: Delegation of Services Agreement (DSA)

A Delegation of Services Agreement (also called a practice agreement or scope of practice document) defines the PA's authorized clinical activities and prescriptive authority at a specific site.

Question 31: A 72-year-old male presents with a progressive, multi-year history of exertional dyspnea and a dry, non-productive cough. Physical examination is notable for digital clubbing and fine, bibasilar inspiratory 'Velcro-like' crackles. Pulmonary function tests demonstrate a restrictive pattern. Which of the following is the most likely diagnosis?

Chronic obstructive pulmonary disease (COPD)
Congestive heart failure
Idiopathic pulmonary fibrosis (IPF) (Correct answer)
Asthma

Correct answer: Idiopathic pulmonary fibrosis (IPF)

The combination of insidious onset dyspnea in an older adult, digital clubbing, characteristic 'Velcro-like' crackles on auscultation, and a restrictive pattern on PFTs is classic for Idiopathic Pulmonary Fibrosis (IPF). COPD and asthma would show an obstructive pattern, and while heart failure can cause crackles, they are typically described as 'wet' or 'coarse', and the other features are not characteristic.

Question 32: Which diagnostic approach is most appropriate when two diagnoses on a differential have similar presentations but very different treatments?

Order the test with the highest likelihood ratio for the most dangerous diagnosis (Correct answer)
Treat empirically for the more common diagnosis
Wait for all symptoms to resolve spontaneously
Consult subspecialty immediately without further workup

Correct answer: Order the test with the highest likelihood ratio for the most dangerous diagnosis

When dangerous diagnoses must be ruled out, prioritizing tests with the highest likelihood ratios for the most life-threatening condition ensures patient safety.

Question 33: Which logical fallacy is committed when someone argues, 'You can't trust Dr. Smith's research on smoking because he once smoked himself'?

Ad hominem (Correct answer)
False dichotomy
Straw man
Slippery slope

Correct answer: Ad hominem

An ad hominem fallacy attacks the person rather than evaluating the merits of the argument or evidence.

Question 34: Which of the following side effects is most frequently experienced after using angiotensin converting enzyme inhibitors for an extended period of time?

Cough (Correct answer)
Dyspnea
CHF
Hypertension

Correct answer: Cough

Angiotensin-converting enzyme (ACE) inhibitors prevent the breakdown of bradykinin, a potent vasodilator, which contributes to their blood pressure-lowering effect. However, the accumulation of bradykinin in the respiratory tract can irritate the airways. This irritation frequently manifests as a persistent, dry cough, which is a well-known and common side effect leading many patients to discontinue the medication.

Question 35: What is the minimum degree required to sit for the PANCE as of 2020?

Master's degree (Correct answer)
Associate's degree
Doctor of Medical Science
Bachelor of Science

Correct answer: Master's degree

ARC-PA mandated that all accredited PA programs must award a master's degree by 2020, making it the minimum requirement to graduate and sit for the PANCE.

Question 36: According to the 2021 United States Preventive Services Task Force (USPSTF) recommendations, which of the following patients is the most appropriate candidate for annual low-dose computed tomography (LDCT) screening for lung cancer?

A 65-year-old current smoker with a 25 pack-year history. (Correct answer)
An 82-year-old former smoker with a 40 pack-year history who quit 10 years ago.
A 70-year-old who quit smoking 20 years ago but had a 30 pack-year history.
A 45-year-old current smoker with a 25 pack-year history.

Correct answer: A 65-year-old current smoker with a 25 pack-year history.

The 2021 USPSTF guidelines recommend annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. The 65-year-old patient meets all three criteria (age, pack-year history, and current smoking status). The 70-year-old is ineligible because they quit more than 15 years ago. The 45-year-old is too young, and the 82-year-old is too old.

Question 37: A PA who discloses a patient's HIV status to the patient's employer without consent has violated which principle?

Autonomy
Non-maleficence
Veracity
Confidentiality (Correct answer)

Correct answer: Confidentiality

Unauthorized disclosure of protected health information violates the ethical and legal principle of confidentiality, as well as HIPAA.

Question 38: What is the purpose of a PA's National Provider Identifier (NPI)?

To track a PA's CME completion
To uniquely identify the PA in all healthcare transactions covered by HIPAA (Correct answer)
To verify a PA's DEA registration status
To assign billing rates for Medicare services

Correct answer: To uniquely identify the PA in all healthcare transactions covered by HIPAA

The NPI is a unique 10-digit identification number used in HIPAA standard electronic transactions to identify healthcare providers.

Question 39: A 55-year-old develops hemoptysis, and bronchoscopy reveals a central endobronchial mass with biopsy showing small cell lung cancer. PET/CT shows hilar lymphadenopathy only. This is classified as:

Stage IIIB NSCLC
Limited-stage SCLC (Correct answer)
Stage IIB NSCLC
Extensive-stage SCLC

Correct answer: Limited-stage SCLC

Limited-stage SCLC is confined to one hemithorax and regional nodes that can be encompassed in a radiation field; this patient's disease fits within that definition.

Question 40: Which ethical principle requires a PA to tell a patient the truth about their diagnosis?

Justice
Veracity (Correct answer)
Beneficence
Non-maleficence

Correct answer: Veracity

Veracity is the ethical principle that obligates healthcare providers to be truthful with patients about their health status and treatment.

Question 41: A 35-year-old man presents with coarse facial features, enlarged hands and feet, headaches, and bitemporal hemianopsia. IGF-1 is markedly elevated. What is the most likely diagnosis?

Prolactinoma
Acromegaly (Correct answer)
Gigantism
Cushing's disease

Correct answer: Acromegaly

Acromegaly is caused by excess GH after epiphyseal closure, leading to coarse acral features and elevated IGF-1; a pituitary tumor causes the visual field defect.

Question 42: What is the most common cause of right heart failure in the United States?

Left heart failure (Correct answer)
Pulmonary embolism
Primary pulmonary hypertension
Tricuspid stenosis

Correct answer: Left heart failure

Left heart failure is the most common cause of right heart failure due to elevated pulmonary pressures transmitted to the right ventricle.

Question 43: A 45-year-old woman presents with iron deficiency anemia and a positive fecal occult blood test. Which is the most appropriate next diagnostic step?

Upper endoscopy only
Both upper endoscopy and colonoscopy (Correct answer)
Capsule endoscopy first
Colonoscopy only

Correct answer: Both upper endoscopy and colonoscopy

In a patient with FOBT-positive iron deficiency anemia, bidirectional endoscopy (both upper and lower) is recommended to identify the source of occult GI bleeding.

Question 44: A 70-year-old woman sustains a hip fracture after a minor fall. DEXA shows a T-score of -3.1. Which bisphosphonate is FDA-approved for reducing fracture risk in postmenopausal osteoporosis?

Alendronate (Correct answer)
Colchicine
Raloxifene
Methotrexate

Correct answer: Alendronate

Alendronate is a bisphosphonate FDA-approved for treating postmenopausal osteoporosis and reducing vertebral, hip, and nonvertebral fracture risk.

Question 45: The following are examples of anterior mediastinal tumors, WITH THE EXCEPTION OF:

Thymoma
Adenoma (Correct answer)
Teratoma
Lymphoma

Correct answer: Adenoma

Common anterior mediastinal tumors are often remembered by the '4 Ts': Thymoma, Teratoma, Thyroid (ectopic), and 'Terrible' Lymphoma. Adenomas, which are benign glandular tumors, are not typically classified as a common primary tumor type specifically originating in the anterior mediastinum in this context.

Question 46: Which of the ensuing antidotes best suits the toxicity at its core?

Narcotics — flumazenil (Romazicon)
Benzodiazepines — naloxone (Narcan)
High carboxyhemoglobin — methylene blue
Acetaminophen — fomepizole (4-methylpyrazole) (Correct answer)
Ethylene glycol — ethanol (booze)

Correct answer: Acetaminophen — fomepizole (4-methylpyrazole)

Fomepizole is the antidote for toxicity caused by ethylene glycol or methanol, not acetaminophen. It is used to treat poisoning from these substances by inhibiting the enzymes that metabolize ethylene glycol and methanol into toxic byproducts.

Question 47: A PA is reviewing a study with a p-value of 0.03. At a significance level of 0.05, the correct conclusion is:

The result is not statistically significant
No conclusion can be drawn from the data
The null hypothesis is accepted because p < 0.05
The null hypothesis is rejected because p < 0.05 (Correct answer)

Correct answer: The null hypothesis is rejected because p < 0.05

When the p-value is less than the significance level (0.03 < 0.05), the null hypothesis is rejected.

Question 48: A patient on amiodarone for 18 months develops new bilateral pulmonary infiltrates and decreased DLCO. Which finding on BAL most supports amiodarone pulmonary toxicity?

Malignant cells on cytology
Hemosiderin-laden macrophages
Foamy lipid-laden macrophages (Correct answer)
Eosinophilia >25%

Correct answer: Foamy lipid-laden macrophages

Foamy macrophages containing phospholipid inclusions are characteristic of amiodarone pulmonary toxicity due to drug-induced phospholipidosis, though they are not specific.

Question 49: A patient presents with sudden severe headache, nuchal rigidity, photophobia, and fever. CSF analysis shows cloudy fluid, elevated protein, low glucose, and neutrophilic pleocytosis. What is the most appropriate immediate treatment?

IV ceftriaxone and dexamethasone empirically (Correct answer)
Await culture results before starting antibiotics
Oral amoxicillin and close outpatient follow-up
IV acyclovir only

Correct answer: IV ceftriaxone and dexamethasone empirically

Bacterial meningitis is a medical emergency; empiric IV ceftriaxone and dexamethasone (to reduce inflammation) should be started immediately without waiting for culture results.

Question 50: A 16-year-old female athlete presents with stress fracture, amenorrhea for 8 months, and BMI of 16.5. What is this triad called?

Polycystic ovary syndrome triad
Turner syndrome presentation
Anorexia nervosa criteria
Female athlete triad (Correct answer)

Correct answer: Female athlete triad

The female athlete triad consists of energy deficiency (often with disordered eating), menstrual dysfunction, and low bone mineral density.

Question 51: A 60-year-old woman presents with nausea, early satiety, and bloating after meals. Her blood glucose is poorly controlled. Which condition best explains her symptoms?

Celiac disease
Peptic ulcer disease
Gastroparesis (Correct answer)
Irritable bowel syndrome

Correct answer: Gastroparesis

Gastroparesis is a common complication of long-standing diabetes mellitus and causes delayed gastric emptying with these symptoms.

Question 52: During a musculoskeletal exam, a patient has pain with passive range of motion of a joint. This finding most suggests:

Isolated tendon injury
Nerve entrapment
Muscle strain only
Pathology within the joint itself (Correct answer)

Correct answer: Pathology within the joint itself

Pain with passive range of motion implicates the joint capsule or intra-articular structures, as the examiner — not the patient's muscles — is generating the movement.

Question 53: Which physical exam maneuver increases the intensity of the murmur of hypertrophic obstructive cardiomyopathy?

Handgrip
Valsalva maneuver (Correct answer)
Squatting
Passive leg raise

Correct answer: Valsalva maneuver

Valsalva decreases preload and venous return, reducing LV size and worsening outflow obstruction in HOCM, increasing the murmur.

Question 54: A patient with liver cirrhosis and portal hypertension develops confusion, asterixis, and elevated serum ammonia. Which treatment is most appropriate?

Metronidazole PO
Lactulose (Correct answer)
Rifaximin IV
Neomycin IV

Correct answer: Lactulose

Lactulose acidifies the colon, trapping ammonia as ammonium (NH4+) and promoting its excretion, reducing serum ammonia in hepatic encephalopathy.

Question 55: What is the primary mechanism of action of digoxin in atrial fibrillation?

Blocks sodium channels in atrial cells
Directly cardioverts AF to sinus rhythm
Blocks potassium channels to prolong action potential
Enhances vagal tone to slow AV node conduction (Correct answer)

Correct answer: Enhances vagal tone to slow AV node conduction

Digoxin slows ventricular rate in AF primarily by increasing vagal tone and decreasing AV nodal conduction.

Question 56: All of the following are true with regard to the EKG findings of premature atrial contractions EXCEPT:

P waves may be present
The QRS is usually narrow
P waves are invariably absent (Correct answer)
Extra P waves may be hidden within the QRS complex or T waves

Correct answer: P waves are invariably absent

Premature atrial contractions (PACs) originate in the atria, meaning there must be an atrial depolarization event, which manifests as a P wave on an EKG. While the P wave may be abnormal in shape, hidden within other waves, or premature, its complete and invariable absence is characteristic of rhythms like atrial fibrillation, not PACs.

Question 57: What is the primary scope of practice document that guides PA practice in the United States?

State Medical Practice Act (Correct answer)
PA Practice Agreement
AAPA Guidelines for Ethical Conduct
Collaborating Physician Agreement

Correct answer: State Medical Practice Act

Each state's Medical Practice Act defines the legal scope of practice for PAs within that state.

Question 58: A beaker holds 500 mL. If 20% of the liquid evaporates and then 50 mL is added, how many mL remain?

420 mL
430 mL
450 mL (Correct answer)
440 mL

Correct answer: 450 mL

500 × 0.80 = 400 mL after evaporation; 400 + 50 = 450 mL.

Question 59: Which vaccine is contraindicated in a 6-month-old with a severe egg allergy?

DTaP
MMR
Hepatitis B
Influenza (egg-based) (Correct answer)

Correct answer: Influenza (egg-based)

Egg-based influenza vaccines contain egg protein and are contraindicated in severe egg allergy; cell-based alternatives should be used.

Question 60: Which of the following distinguishes essential tremor from Parkinson's tremor?

Essential tremor is associated with bradykinesia
Essential tremor occurs at rest; Parkinson's occurs with action
Essential tremor involves the legs primarily
Essential tremor is an action/postural tremor; Parkinson's is a resting tremor (Correct answer)

Correct answer: Essential tremor is an action/postural tremor; Parkinson's is a resting tremor

Essential tremor is a postural/action tremor that occurs during movement, while Parkinson's tremor is characteristically present at rest and suppressed by movement.

Question 61: A PA is evaluating a 30-year-old woman with episodic hypertension, headaches, palpitations, and diaphoresis. Which secondary cause of hypertension should be included on the differential?

Pheochromocytoma (Correct answer)
Cushing's syndrome
Renal artery stenosis
Primary hyperaldosteronism

Correct answer: Pheochromocytoma

The triad of episodic hypertension, headache, and diaphoresis with palpitations is classic for pheochromocytoma, a catecholamine-secreting adrenal tumor.

Question 62: A 25-year-old male is diagnosed with moderate-to-severe ileocolonic Crohn's disease. Which of the following biologic agents is often considered a first-line therapy for inducing and maintaining remission in this patient?

Mesalamine (5-ASA)
Prednisone
Metronidazole
Infliximab (an anti-TNF agent) (Correct answer)

Correct answer: Infliximab (an anti-TNF agent)

For moderate-to-severe Crohn's disease, biologic therapies such as anti-TNF agents (e.g., infliximab, adalimumab) are recommended as a first-line treatment to both induce and maintain clinical remission. [15, 29, 45] Corticosteroids like prednisone are used for short-term induction but not maintenance, while mesalamine has limited efficacy in moderate-to-severe disease. [4, 10]

Question 63: Which finding on echocardiography is most consistent with cardiac tamponade?

Mitral valve prolapse
Aortic stenosis gradient
Left ventricular hypertrophy
Diastolic collapse of the right ventricle (Correct answer)

Correct answer: Diastolic collapse of the right ventricle

Diastolic right ventricular collapse is the classic echocardiographic sign of cardiac tamponade due to elevated pericardial pressure.

Question 64: During glycolysis, which molecule serves as both a substrate and an allosteric activator of phosphofructokinase-1 (PFK-1)?

Citrate
AMP (Correct answer)
Glucose-6-phosphate
ATP

Correct answer: AMP

AMP allosterically activates PFK-1, signaling low cellular energy and promoting glycolysis, while high ATP inhibits PFK-1 to prevent excess glucose breakdown.

Question 65: A 55-year-old male with a history of poorly controlled hypertension presents with a headache and confusion. His blood pressure is measured at 220/130 mmHg. Fundoscopic examination reveals papilledema. Which of the following is the most appropriate immediate step in management?

Administer oral clonidine and discharge home with follow-up
Admit to the ICU and initiate an intravenous antihypertensive infusion (Correct answer)
Schedule an outpatient cardiology consultation for the following week
Prescribe a high-dose oral diuretic and recheck blood pressure in 24 hours

Correct answer: Admit to the ICU and initiate an intravenous antihypertensive infusion

This patient is presenting with a hypertensive emergency, defined as severely elevated blood pressure (typically >180/120 mmHg) with evidence of end-organ damage (in this case, papilledema indicating hypertensive encephalopathy). The standard of care is immediate admission to an ICU for continuous monitoring and a controlled reduction of blood pressure using an intravenous antihypertensive agent like nicardipine or labetalol.

Question 66: A patient on warfarin for AF has an INR of 8.5 with active major bleeding. What is the most appropriate immediate treatment?

Fresh frozen plasma alone
4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K (Correct answer)
Vitamin K 10 mg IV only
Hold warfarin and recheck INR tomorrow

Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus IV vitamin K

Life-threatening warfarin-related bleeding requires rapid reversal with 4F-PCC for immediate effect plus IV vitamin K for sustained reversal.

Question 67: A 6-week-old male presents with projectile non-bilious vomiting after feeds and an olive-shaped mass in the epigastrium. What is the diagnosis?

Pyloric stenosis (Correct answer)
Malrotation with volvulus
Intussusception
Duodenal atresia

Correct answer: Pyloric stenosis

Hypertrophic pyloric stenosis presents in males aged 3–6 weeks with projectile non-bilious vomiting and a palpable pyloric mass (olive), leading to hypochloremic metabolic alkalosis.

Question 68: The Fick principle is used to calculate cardiac output. Which formula correctly represents it?

CO = VO2 / (CaO2 - CvO2) (Correct answer)
CO = HR × SV
CO = MAP / SVR
CO = (CaO2 - CvO2) / VO2

Correct answer: CO = VO2 / (CaO2 - CvO2)

The Fick principle states cardiac output equals oxygen consumption divided by the arteriovenous oxygen content difference.

Question 69: Which medication used for osteoporosis requires patients to remain upright for at least 30 minutes after ingestion?

Alendronate (Correct answer)
Denosumab
Teriparatide
Raloxifene

Correct answer: Alendronate

Oral bisphosphonates like alendronate can cause esophageal irritation and must be taken with water while remaining upright to prevent esophagitis.

Question 70: In a patient with metabolic alkalosis, which compensatory mechanism would you expect?

Hyperventilation to eliminate CO2
Decreased aldosterone secretion
Increased renal bicarbonate excretion only
Hypoventilation to retain CO2 (Correct answer)

Correct answer: Hypoventilation to retain CO2

Metabolic alkalosis is compensated by hypoventilation, which retains CO2 and increases carbonic acid to buffer the elevated pH.

Question 71: A patient's ECG shows a prolonged PR interval, but all P waves are conducted. What rhythm is this?

Second-degree AV block Mobitz I
Second-degree AV block Mobitz II
First-degree AV block (Correct answer)
Third-degree AV block

Correct answer: First-degree AV block

First-degree AV block is defined by a PR interval >200 ms with all P waves conducted to the ventricles.

Question 72: Which PA has the higher pay?

General Pediatrics
Pediatric Subspecialty (Correct answer)

Correct answer: Pediatric Subspecialty

A Pediatric Subspecialty PA typically earns more than a General Pediatrics PA because specialized expertise generally commands higher compensation. Focused, advanced training in a subspecialty raises earning potential compared to general practice.

Question 73: Which of the following best describes the PA profession's scope of practice in the United States?

Defined solely by federal law and is uniform in all states
Determined by the supervising physician's preference only
Defined by state law, clinical training, and institutional policy (Correct answer)
Limited to emergency medicine and primary care settings only

Correct answer: Defined by state law, clinical training, and institutional policy

PA scope of practice is determined by a combination of state law, the PA's education and experience, the supervising physician's delegation, and institutional policies.

Question 74: A 40-year-old presents with painless lymphadenopathy in the right supraclavicular region. What is this finding classically called and what does it suggest?

Virchow's node — suggests right-sided thoracic or cervical malignancy (Correct answer)
Virchow's node — suggests left-sided abdominal malignancy
Delphian node — suggests thyroid malignancy
Sister Mary Joseph node — suggests abdominal malignancy

Correct answer: Virchow's node — suggests right-sided thoracic or cervical malignancy

The right supraclavicular node (Virchow's on the right side) drains the thorax, lungs, and esophagus and its enlargement suggests right-sided thoracic or mediastinal malignancy.

Question 75: A 30-year-old with cystic fibrosis presents with increased sputum production and worsening FEV1. Sputum culture grows Pseudomonas aeruginosa. Which antibiotic combination is most appropriate for an acute exacerbation?

Vancomycin and metronidazole
Amoxicillin-clavulanate and doxycycline
Azithromycin and trimethoprim-sulfamethoxazole
Piperacillin-tazobactam and tobramycin (Correct answer)

Correct answer: Piperacillin-tazobactam and tobramycin

Anti-pseudomonal beta-lactam plus an aminoglycoside provides synergistic coverage against Pseudomonas in CF exacerbations and helps prevent resistance.

Question 76: If a train travels 240 miles at 60 mph, then returns the same distance at 40 mph, what is the average speed for the entire trip?

48 mph (Correct answer)
52 mph
45 mph
50 mph

Correct answer: 48 mph

Average speed = total distance / total time = 480 / (4 + 6) = 48 mph.

Question 77: During oxidative phosphorylation, the chemiosmotic gradient drives ATP synthesis through which complex?

Complex III (cytochrome bc1)
Complex I (NADH dehydrogenase)
Complex IV (cytochrome c oxidase)
Complex V (ATP synthase) (Correct answer)

Correct answer: Complex V (ATP synthase)

Complex V (ATP synthase) uses the proton-motive force generated by the electron transport chain to synthesize ATP from ADP and inorganic phosphate.

Question 78: A PA applies the principle of parsimony (Occam's Razor) in formulating a diagnosis. What does this principle suggest?

Multiple diagnoses must always be considered simultaneously
The rarest diagnosis should be prioritized
The most expensive test should be ordered first
One unifying diagnosis should explain all of the patient's findings when possible (Correct answer)

Correct answer: One unifying diagnosis should explain all of the patient's findings when possible

Occam's Razor in clinical reasoning favors a single unifying diagnosis over multiple separate diagnoses when the clinical evidence supports it.

Question 79: A 4-week-old male infant presents with a 1-week history of non-bilious, projectile vomiting immediately after feeding. The mother reports he seems hungry all the time. On physical examination, an olive-sized mass is palpated in the epigastric region. What is the most appropriate next step to confirm the diagnosis?

Barium upper GI series
Abdominal ultrasound (Correct answer)
Abdominal X-ray
Empiric trial of thickened feeds

Correct answer: Abdominal ultrasound

The history and physical exam findings are classic for hypertrophic pyloric stenosis. Abdominal ultrasound is the preferred, most sensitive, and specific imaging modality to confirm the diagnosis. [13, 23, 24] It is non-invasive, avoids radiation exposure, and allows for direct measurement of the pyloric muscle thickness and channel length. [25, 28]

Question 80: In the coagulation cascade, which factor is shared between the intrinsic and extrinsic pathways at the common pathway junction?

Factor XII
Factor IX
Factor X (Correct answer)
Factor VII

Correct answer: Factor X

Factor X is activated by both the intrinsic pathway (via IXa/VIIIa) and the extrinsic pathway (via VIIa/TF) and initiates the common coagulation pathway.

Question 81: Which finding is MOST characteristic of constrictive pericarditis on physical exam?

Loud S1 heart sound
Pulsus alternans
Friction rub that disappears with leaning forward
Kussmaul's sign (JVD increasing with inspiration) (Correct answer)

Correct answer: Kussmaul's sign (JVD increasing with inspiration)

Kussmaul's sign — paradoxical rise in JVP during inspiration — is a classic finding in constrictive pericarditis.

Question 82: A patient with Crohn's disease involving the terminal ileum is at greatest risk for deficiency of which nutrient?

Folate
Iron
Vitamin B12 (Correct answer)
Calcium

Correct answer: Vitamin B12

Vitamin B12 (cobalamin) is exclusively absorbed in the terminal ileum; Crohn's disease in this location impairs its absorption.

Question 83: A patient with Type 2 DM on metformin develops lactic acidosis after a hospitalization for cardiac catheterization with contrast. Which medication is most likely responsible?

Glipizide
Sitagliptin
Metformin (Correct answer)
Pioglitazone

Correct answer: Metformin

Metformin can cause lactic acidosis, especially when combined with IV contrast, renal impairment, or hypoxic states; it should be held before contrast procedures.

Question 84: A 34-year-old male complains of recurrent episodes of excruciating, unilateral pain behind his right eye, which he describes as a 'hot poker' sensation. The attacks last for 60-90 minutes and occur several times a day for weeks at a time. During these episodes, he also experiences right-sided nasal congestion and tearing from his right eye. Which of the following is the most likely diagnosis?

Tension-type headache
Trigeminal neuralgia
Migraine with aura
Cluster headache (Correct answer)

Correct answer: Cluster headache

This patient's presentation is classic for a cluster headache. Key features include the severe, unilateral, periorbital pain of relatively short duration, occurring in cyclical 'clusters'. The associated ipsilateral autonomic symptoms (lacrimation, nasal congestion) are also characteristic of this headache syndrome. [3, 16, 17] Migraines are typically throbbing and last longer. Tension headaches are bilateral and pressing. Trigeminal neuralgia involves brief, electric shock-like pains in the distribution of the trigeminal nerve.

Question 85: A 55-year-old smoker presents with progressive dyspnea, barrel chest, and decreased breath sounds bilaterally. Spirometry shows FEV1/FVC of 0.58. Which pathophysiologic mechanism best explains the air trapping?

Alveolar flooding with proteinaceous fluid
Bronchial wall thickening from eosinophilic inflammation
Increased surfactant production reducing surface tension
Loss of elastic recoil causing dynamic airway collapse (Correct answer)

Correct answer: Loss of elastic recoil causing dynamic airway collapse

In emphysema, destruction of alveolar walls reduces elastic recoil, causing small airways to collapse during exhalation and trapping air distally.

Question 86: A 50-year-old woman presents with dyspnea and a loud S2 with fixed splitting. What is the most likely diagnosis?

Ventricular septal defect
Atrial septal defect (Correct answer)
Patent ductus arteriosus
Pulmonary stenosis

Correct answer: Atrial septal defect

Fixed wide splitting of S2 that does not vary with respiration is pathognomonic for an atrial septal defect.

Question 87: Which finding on physical examination is most consistent with a complete rotator cuff tear?

Positive apprehension sign
Tenderness over the acromioclavicular joint
Painful arc between 60–120 degrees of abduction
Inability to initiate abduction with preserved passive range of motion (Correct answer)

Correct answer: Inability to initiate abduction with preserved passive range of motion

A complete rotator cuff tear results in inability to initiate active abduction while passive range of motion remains intact due to loss of musculotendinous continuity.

Question 88: A 45-year-old man presents with sudden severe tearing chest pain radiating to the back. BP is 180/100 in the right arm and 140/80 in the left arm. What is the most likely diagnosis?

Esophageal rupture
Acute STEMI
Aortic dissection (Correct answer)
Pulmonary embolism

Correct answer: Aortic dissection

Asymmetric blood pressures combined with tearing back pain are classic for aortic dissection.

Question 89: A patient with a known pulmonary embolism develops sudden worsening of hypoxemia despite anticoagulation. Which mechanism most directly causes hypoxemia in acute PE?

Right-to-left intracardiac shunting
Ventilation-perfusion mismatch with increased dead space (Correct answer)
Hypoventilation from respiratory muscle fatigue
Diffusion impairment across the alveolar-capillary membrane

Correct answer: Ventilation-perfusion mismatch with increased dead space

PE creates high V/Q areas (dead space) where ventilation occurs without perfusion, and can also cause atelectasis leading to low V/Q areas, both worsening oxygenation.

Question 90: A 38-year-old woman with antiphospholipid syndrome has a right lower lobe pulmonary infarction confirmed on V/Q scan. She completes 3 months of anticoagulation. What is the recommended long-term management?

Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3 (Correct answer)
Repeat 3-month course of anticoagulation if another clot occurs
Switch to low-dose aspirin for long-term secondary prevention
Discontinue anticoagulation and monitor with periodic V/Q scans

Correct answer: Indefinite anticoagulation with a vitamin K antagonist targeting INR 2-3

Antiphospholipid syndrome with thrombosis requires indefinite anticoagulation with a VKA (warfarin) targeting INR 2-3 due to very high recurrence risk.

Question 91: A PA student must read a 180-page textbook chapter in 3 hours. At what rate must they read?

60 pages/hour (Correct answer)
50 pages/hour
55 pages/hour
65 pages/hour

Correct answer: 60 pages/hour

180 pages ÷ 3 hours = 60 pages per hour.

Question 92: Which pharmacokinetic parameter describes the fraction of an administered drug that reaches systemic circulation unchanged?

Bioavailability (F) (Correct answer)
Clearance (CL)
Volume of distribution (Vd)
Half-life (t½)

Correct answer: Bioavailability (F)

Bioavailability (F) quantifies the proportion of an administered dose that reaches systemic circulation, accounting for first-pass metabolism and absorption.

Question 93: A 24-year-old female presents for a routine physical exam. On cardiac auscultation, a mid-systolic click followed by a late systolic murmur is heard best at the apex. The murmur is accentuated when she stands up from a squatting position. What is the most likely valvular abnormality?

Aortic stenosis
Tricuspid regurgitation
Mitral regurgitation
Mitral valve prolapse (Correct answer)

Correct answer: Mitral valve prolapse

A mid-systolic click is the pathognomonic finding for mitral valve prolapse. The click is caused by the sudden tensing of the chordae tendineae as the valve leaflets prolapse into the left atrium during systole. Maneuvers that decrease venous return and left ventricular volume, such as standing, cause the click and murmur to occur earlier in systole and become more prominent.

Question 94: Which type of hypersensitivity reaction is mediated by IgE antibodies and mast cell degranulation?

Type II (cytotoxic)
Type III (immune complex)
Type I (immediate hypersensitivity) (Correct answer)
Type IV (delayed-type)

Correct answer: Type I (immediate hypersensitivity)

Type I hypersensitivity involves IgE-mediated mast cell and basophil degranulation, releasing histamine and other mediators causing anaphylaxis, asthma, and allergic rhinitis.

Question 95: A 55-year-old male presents to the emergency department with an acute onset of pleuritic chest pain and dyspnea. He returned from an international flight yesterday. His heart rate is 115 bpm, and his O2 saturation is 90% on room air. A D-dimer is elevated. According to diagnostic algorithms for suspected pulmonary embolism (PE), what is the most appropriate next step for this hemodynamically stable patient?

Lower extremity venous duplex ultrasound
Chest X-ray
Ventilation/perfusion (V/Q) scan
CT pulmonary angiography (CTPA) (Correct answer)

Correct answer: CT pulmonary angiography (CTPA)

In a patient with a high clinical pretest probability for pulmonary embolism and an elevated D-dimer, CT pulmonary angiography (CTPA) is the diagnostic imaging modality of choice. It is readily available and provides definitive visualization of the pulmonary arteries. While a chest X-ray is often obtained to rule out other pathologies, it cannot confirm a PE. A V/Q scan is an alternative if CTPA is contraindicated. A lower extremity ultrasound can diagnose a DVT but cannot rule out a PE.

Question 96: A neonate presents at 24 hours of life with bilious vomiting. Abdominal X-ray shows a 'double bubble' sign. What is the most likely diagnosis?

Meconium ileus
Hirschsprung's disease
Pyloric stenosis
Duodenal atresia (Correct answer)

Correct answer: Duodenal atresia

The double bubble sign on X-ray (air in stomach and proximal duodenum) is pathognomonic for duodenal atresia.

Question 97: Which of the following DON'T add to the causes of atrial fibrillation?

Pulmonary disease
Hypothyroidism (Correct answer)
Ischemia
Rheumatic heart disease

Correct answer: Hypothyroidism

Hypothyroidism is generally associated with bradycardia and a *decreased* risk of atrial fibrillation (AFib), or at least is not a direct cause. In contrast, hyperthyroidism (thyrotoxicosis) is a well-established cause of AFib due to increased adrenergic tone and myocardial excitability. Pulmonary disease, ischemia, and rheumatic heart disease are all recognized risk factors for developing AFib.

Question 98: Which cell type produces surfactant in the lung?

Type II pneumocytes (Correct answer)
Goblet cells
Clara cells
Type I pneumocytes

Correct answer: Type II pneumocytes

Type II pneumocytes synthesize and secrete pulmonary surfactant, which reduces alveolar surface tension and prevents collapse.

Question 99: A 44-year-old woman presents with transient migratory pulmonary infiltrates, peripheral eosinophilia of 18%, and wheezing. IgE is markedly elevated. Sputum contains eosinophils and fungal hyphae. What is the diagnosis?

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
Löffler syndrome from Ascaris migration
Allergic bronchopulmonary aspergillosis (ABPA) (Correct answer)
Chronic eosinophilic pneumonia

Correct answer: Allergic bronchopulmonary aspergillosis (ABPA)

ABPA presents with asthma, migratory infiltrates, peripheral eosinophilia, markedly elevated total IgE, and Aspergillus-specific IgE/IgG with central bronchiectasis.

Question 100: A 45-year-old woman has a positive straight leg raise (SLR) test at 40°. This finding is most consistent with:

Piriformis syndrome
Hip flexor strain
L4-S1 nerve root compression (lumbar disc herniation) (Correct answer)
Sacroiliac joint dysfunction

Correct answer: L4-S1 nerve root compression (lumbar disc herniation)

A positive SLR at less than 60° (reproduction of radicular pain, not just tightness) strongly suggests L4-S1 nerve root irritation from disc herniation.

Question 101: Which one of the following conditions is NOT a long-term side effect of essential hypertension?

Renal failure
Diabetes
Asthma (Correct answer)
Neuropathy

Correct answer: Asthma

Essential hypertension, if left unmanaged over time, can lead to severe long-term complications affecting various organ systems, including renal failure, neuropathy due to vascular damage, and an increased risk of cardiovascular disease and diabetes. Asthma, however, is a chronic inflammatory disease of the airways and is not a direct long-term side effect or complication that develops as a result of essential hypertension.

Question 102: A 40-year-old woman presents with moon facies, central obesity, purple striae, and easy bruising. 24-hour urinary free cortisol is markedly elevated. What is the most likely diagnosis?

Primary hyperaldosteronism
Cushing's syndrome (Correct answer)
Acromegaly
Addison's disease

Correct answer: Cushing's syndrome

Cushing's syndrome results from chronic excess cortisol and presents with moon facies, buffalo hump, purple striae, and central obesity.

Question 103: The AAPA's 'Optimal Team Practice' initiative primarily advocates for which change in PA practice?

Expanding PA prescribing to Schedule II substances nationwide
Requiring PAs to obtain doctoral-level training
Removing the legal requirement for a supervisory relationship with a physician (Correct answer)
Standardizing PA salaries across all specialties

Correct answer: Removing the legal requirement for a supervisory relationship with a physician

Optimal Team Practice advocates for modernizing state laws to remove the mandatory supervisory physician requirement, allowing PAs to practice as full team members.

Question 104: A 3-year-old boy presents with painless scrotal swelling that transilluminates. Ultrasound confirms fluid around the testis with no blood flow abnormality. What is the most likely diagnosis?

Inguinal hernia
Epididymo-orchitis
Hydrocele (Correct answer)
Testicular torsion

Correct answer: Hydrocele

A painless, transilluminating scrotal mass in a child is a hydrocele, caused by accumulation of fluid within the tunica vaginalis.

Question 105: Which benzodiazepine is safest in elderly patients due to its lack of active metabolites and shorter half-life?

Chlordiazepoxide
Clonazepam
Diazepam
Lorazepam (Correct answer)

Correct answer: Lorazepam

Lorazepam undergoes direct glucuronidation with no active metabolites and is preferred in elderly patients per the Beers Criteria considerations.

Question 106: A patient presents with acute onset of right lower quadrant pain, fever, and anorexia. On exam, there is rebound tenderness at McBurney's point. Which lab finding most supports the diagnosis of acute appendicitis?

Leukocytosis with left shift (Correct answer)
Elevated serum bilirubin
Elevated serum lipase
Thrombocytopenia

Correct answer: Leukocytosis with left shift

Leukocytosis with a left shift (increased band neutrophils) is the most consistent laboratory finding in acute appendicitis.

Question 107: A 55-year-old man with Type 2 DM, HbA1c 9.5%, BMI 34, and established cardiovascular disease is on metformin and a sulfonylurea. Which additional agent provides the most proven cardiovascular mortality benefit?

Sitagliptin (DPP-4 inhibitor)
Pioglitazone
Glargine insulin
Empagliflozin (SGLT2 inhibitor) (Correct answer)

Correct answer: Empagliflozin (SGLT2 inhibitor)

SGLT2 inhibitors such as empagliflozin have demonstrated significant cardiovascular mortality reduction in patients with established cardiovascular disease and Type 2 DM.

Question 108: A 58-year-old male presents with progressive difficulty swallowing solids, then liquids, and an 18 lb weight loss over 3 months. What is the most likely diagnosis?

Zenker's diverticulum
Achalasia
GERD with stricture
Esophageal carcinoma (Correct answer)

Correct answer: Esophageal carcinoma

Progressive dysphagia starting with solids then progressing to liquids combined with significant weight loss in an older adult is the classic presentation of esophageal carcinoma.

Question 109: Which finding is most consistent with acute mesenteric ischemia?

Pain relieved by eating
Pain out of proportion to physical examination findings (Correct answer)
Gradual onset pain with nausea only
Rebound tenderness with a rigid abdomen from onset

Correct answer: Pain out of proportion to physical examination findings

Acute mesenteric ischemia classically presents with severe abdominal pain that is disproportionately worse than the relatively benign physical exam findings early in the course.

Question 110: A 70-year-old presents with progressive resting tremor, bradykinesia, and cogwheel rigidity. What is the most likely diagnosis?

Parkinson's disease (Correct answer)
Essential tremor
Wilson's disease
Huntington's disease

Correct answer: Parkinson's disease

Parkinson's disease presents with the classic triad of resting tremor, bradykinesia, and rigidity, typically beginning unilaterally in older adults.

Question 111: A researcher wants to determine the median of the following data set: 7, 3, 12, 5, 9. What is the median?

9
3
7 (Correct answer)
5

Correct answer: 7

Ordered: 3, 5, 7, 9, 12 — the middle value is 7.

Question 112: A 63-year-old former asbestos worker presents with a right pleural effusion. Thoracentesis shows an exudate with predominantly lymphocytes and low glucose. CT shows pleural thickening. What is the most likely diagnosis to exclude urgently?

Malignant pleural mesothelioma (Correct answer)
Tuberculosis pleuritis
Benign asbestos pleural effusion
Empyema necessitans

Correct answer: Malignant pleural mesothelioma

Asbestos-exposed patients with exudative lymphocytic pleural effusion and pleural thickening must have malignant mesothelioma excluded as a priority due to its poor prognosis and latency of 20-50 years.

Question 113: Bell's palsy involves dysfunction of which cranial nerve?

CN X (Vagus)
CN IX (Glossopharyngeal)
CN V (Trigeminal)
CN VII (Facial) (Correct answer)

Correct answer: CN VII (Facial)

Bell's palsy is idiopathic peripheral CN VII (facial nerve) palsy causing ipsilateral upper and lower facial weakness, distinguishing it from central causes which spare the forehead.

Question 114: A patient with hypertension develops a blood pressure of 210/120 mmHg with headache and papilledema. How should this be managed?

Oral labetalol and discharge
Sublingual nifedipine
IV nitroprusside with continuous BP monitoring (Correct answer)
Furosemide IV bolus only

Correct answer: IV nitroprusside with continuous BP monitoring

Hypertensive emergency with end-organ damage requires IV antihypertensives with controlled, gradual BP reduction.

Question 115: A 5-year-old with sickle cell disease presents with sudden onset of left-sided weakness and slurred speech. What is the immediate next step?

Lumbar puncture
Hydroxyurea therapy
Exchange transfusion (Correct answer)
IV hydration and pain management

Correct answer: Exchange transfusion

Acute stroke in sickle cell disease requires urgent exchange transfusion to rapidly reduce HbS levels below 30%.

Question 116: A 67-year-old woman with rheumatoid arthritis presents with acute monoarthritis of the right knee. Which diagnosis must be excluded emergently?

Septic arthritis (Correct answer)
Gout flare
Osteoarthritis exacerbation
Reactive arthritis

Correct answer: Septic arthritis

Septic arthritis is a joint-destroying emergency that must be excluded by synovial fluid analysis whenever acute monoarthritis is present, especially in immunocompromised patients.

Question 117: A patient on rifampin for tuberculosis has a subtherapeutic oral contraceptive effect. What is the mechanism?

Competitive binding at estrogen receptors
Increased renal estrogen excretion
Induction of CYP3A4 increasing estrogen metabolism (Correct answer)
Inhibition of estrogen absorption in the gut

Correct answer: Induction of CYP3A4 increasing estrogen metabolism

Rifampin is a potent CYP3A4 inducer that accelerates estrogen and progestin metabolism, reducing plasma contraceptive concentrations.

Question 118: A patient with new-onset heart failure has an ejection fraction of 35%. Which combination of medications has been shown to reduce mortality?

Nitrates + hydralazine alone
ACE inhibitor + beta-blocker + aldosterone antagonist (Correct answer)
ARB + calcium channel blocker
Digoxin + furosemide

Correct answer: ACE inhibitor + beta-blocker + aldosterone antagonist

The combination of ACE inhibitor (or ARB/ARNI), beta-blocker, and aldosterone antagonist forms the evidence-based cornerstone of HFrEF therapy.

Question 119: Which physical exam finding is most specific for medial meniscus tear?

Positive McMurray test with medial joint line pain (Correct answer)
Positive valgus stress test
Positive anterior drawer test
Positive Lachman test

Correct answer: Positive McMurray test with medial joint line pain

The McMurray test with clicking and medial joint line pain during knee extension from a flexed position is most specific for a medial meniscus tear.

Question 120: A 25-year-old male athlete presents with sudden severe headache described as 'the worst headache of his life' after exertion. CT head is negative. What is the next most appropriate step?

MRI brain with contrast
Reassure and discharge
Start sumatriptan
Lumbar puncture (Correct answer)

Correct answer: Lumbar puncture

A thunderclap headache with a negative CT requires lumbar puncture to rule out subarachnoid hemorrhage, as CT misses up to 2% of cases in the first 6 hours.

Question 121: Which phase of pharmacokinetics involves the chemical transformation of a drug, typically in the liver?

Absorption
Distribution
Excretion
Metabolism (biotransformation) (Correct answer)

Correct answer: Metabolism (biotransformation)

Metabolism (biotransformation) refers to enzymatic modification of drugs, primarily by cytochrome P450 enzymes in the liver, to facilitate elimination.

Question 122: Which of the following is the most common cause of primary hypothyroidism in the United States?

Subacute thyroiditis
Iodine deficiency
Hashimoto's thyroiditis (Correct answer)
Surgical thyroidectomy

Correct answer: Hashimoto's thyroiditis

Hashimoto's thyroiditis is an autoimmune condition and the most common cause of primary hypothyroidism in iodine-sufficient countries.

Question 123: A 65-year-old with COPD has a barrel chest. Which physical exam finding would you also expect?

Decreased AP diameter
Elevated diaphragm on percussion
Hyperresonance to percussion (Correct answer)
Increased tactile fremitus

Correct answer: Hyperresonance to percussion

Air trapping in COPD leads to hyperinflation, causing hyperresonance to percussion and an increased AP:lateral diameter ratio (barrel chest).

Question 124: A 40-year-old male presents with episodic hypertension, diaphoresis, and palpitations. 24-hour urine shows elevated metanephrines and catecholamines. What is the next best imaging study?

Nuclear medicine MIBG scan
MRI adrenals without contrast
CT chest
CT abdomen/pelvis with contrast (Correct answer)

Correct answer: CT abdomen/pelvis with contrast

CT abdomen/pelvis with contrast is the first-line imaging for pheochromocytoma after biochemical confirmation to localize the tumor.

Question 125: A 75-year-old female is being treated for heart failure with reduced ejection fraction (HFrEF). Which of the following medication classes has been shown to improve mortality in patients with HFrEF and should be considered a cornerstone of therapy?

Calcium channel blockers
Digoxin
Loop diuretics
Beta-blockers (Correct answer)

Correct answer: Beta-blockers

Beta-blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) are one of the primary classes of medications, along with ACE inhibitors/ARBs/ARNIs, that have been proven to reduce mortality and hospitalizations in patients with HFrEF. Loop diuretics manage symptoms but do not improve mortality. Digoxin can reduce hospitalizations but does not have a mortality benefit. Most calcium channel blockers are not recommended in HFrEF.

Question 126: A T-score of -2.8 on DEXA scan indicates which diagnosis according to WHO criteria?

Severe osteoporosis with fracture
Osteopenia
Normal bone density
Osteoporosis (Correct answer)

Correct answer: Osteoporosis

A T-score of -2.5 or below indicates osteoporosis per WHO criteria; a T-score between -1.0 and -2.5 indicates osteopenia.

Question 127: Which type of shock is characterized by low PCWP, low SVR, and high cardiac output?

Hypovolemic shock
Distributive (septic) shock (Correct answer)
Cardiogenic shock
Obstructive shock

Correct answer: Distributive (septic) shock

Distributive shock (e.g., sepsis) features vasodilation causing low SVR and compensatory high CO with low filling pressures.

Question 128: A 55-year-old obese man with a history of Barrett's esophagus undergoes surveillance endoscopy showing high-grade dysplasia. What is the most appropriate management?

Increased PPI dose and repeat biopsy in 1 year
Endoscopic eradication therapy or esophagectomy (Correct answer)
H. pylori eradication
Nissen fundoplication alone

Correct answer: Endoscopic eradication therapy or esophagectomy

High-grade dysplasia in Barrett's esophagus carries significant risk of progression to adenocarcinoma and requires endoscopic eradication or surgical resection.

Question 129: A patient taking high-dose NSAIDs develops a peptic ulcer. Which H. pylori-negative, NSAID-associated mechanism is responsible?

Increased parietal cell mass
Increased gastrin secretion
Direct mucosal acid burn
Inhibition of prostaglandin synthesis (Correct answer)

Correct answer: Inhibition of prostaglandin synthesis

NSAIDs inhibit COX-1, reducing prostaglandin synthesis, which normally maintains the gastric mucosal protective barrier.

Question 130: Which of the following is the Rocky Mountain spotted fever-causing organism?

Bordetella pertussis
Corynebacterium
Rickettsia siberica
Rickettsia rickettsii (Correct answer)

Correct answer: Rickettsia rickettsii

Rocky Mountain spotted fever (RMSF) is a serious bacterial infection transmitted to humans through the bite of infected ticks. The specific causative agent for this disease is the bacterium *Rickettsia rickettsii*. This organism infects the endothelial cells lining blood vessels, leading to vasculitis and the characteristic rash associated with RMSF.

Question 131: A 52-year-old with obstructive sleep apnea refuses CPAP. Which consequence of untreated OSA poses the greatest cardiovascular risk?

Peripheral chemoreceptor desensitization to hypoxia
Repetitive hypoxemia and sympathetic surges causing systemic hypertension (Correct answer)
Reduced cardiac output from decreased preload during apneas
Nocturnal hypoventilation causing CO2 retention

Correct answer: Repetitive hypoxemia and sympathetic surges causing systemic hypertension

Repetitive hypoxic episodes and arousal-associated sympathetic activation cause sustained systemic hypertension, which is the primary cardiovascular complication of OSA.

Question 132: A 68-year-old man with a history of smoking and alcohol use presents with chronic epigastric pain radiating to the back, steatorrhea, and new-onset diabetes. CT shows pancreatic calcifications. What is the most likely diagnosis?

Pancreatic adenocarcinoma
Autoimmune pancreatitis
Chronic pancreatitis (Correct answer)
Acute pancreatitis

Correct answer: Chronic pancreatitis

Pancreatic calcifications on CT with steatorrhea (exocrine insufficiency) and diabetes (endocrine insufficiency) in a patient with chronic alcohol use is classic chronic pancreatitis.

Question 133: A PA uses Bayesian reasoning when formulating a diagnosis. Which factor most directly influences the post-test probability of a disease?

Insurance coverage of the diagnostic test
Pre-test probability combined with test sensitivity and specificity (Correct answer)
The number of symptoms reported
The patient's age alone

Correct answer: Pre-test probability combined with test sensitivity and specificity

Bayesian reasoning integrates pre-test probability with the likelihood ratios derived from test sensitivity and specificity to determine post-test probability.

Question 134: A patient taking lisinopril develops a dry, nonproductive cough. What is the most appropriate alternative antihypertensive?

Losartan (Correct answer)
Amlodipine
Enalapril
Hydrochlorothiazide

Correct answer: Losartan

ARBs (e.g., losartan) do not cause bradykinin accumulation and are the preferred substitute for ACE inhibitor-induced cough.

Question 135: Which feature distinguishes cardiac syncope from vasovagal syncope during diagnostic formulation?

Syncope occurring without prodrome during exertion or at rest (Correct answer)
Syncope with slow recovery over several minutes
Syncope preceded by nausea and diaphoresis in a warm environment
Syncope triggered by prolonged standing

Correct answer: Syncope occurring without prodrome during exertion or at rest

Syncope without prodrome during exertion or at rest suggests an arrhythmic or structural cardiac cause and requires urgent cardiac evaluation.

Question 136: DNA gyrase, the bacterial enzyme targeted by fluoroquinolone antibiotics, belongs to which class of enzymes?

Type II topoisomerase (Correct answer)
DNA helicase
DNA primase
Type I topoisomerase

Correct answer: Type II topoisomerase

DNA gyrase is a bacterial type II topoisomerase that introduces negative supercoils to relieve tension ahead of the replication fork; fluoroquinolones inhibit it by stabilizing the cleavage complex.

Question 137: A 35-year-old woman with no prior history presents with sudden onset severe headache she describes as 'the worst headache of my life.' Neck stiffness and photophobia are present. CT head is negative. What is the next best step?

Start empiric antibiotics and discharge
Administer sumatriptan and observe
Obtain MRI brain with contrast
Perform lumbar puncture (Correct answer)

Correct answer: Perform lumbar puncture

A negative CT with classic subarachnoid hemorrhage (SAH) presentation requires lumbar puncture to detect xanthochromia or blood that CT may miss.

Question 138: A patient with sarcoidosis has bilateral hilar lymphadenopathy on CXR and an ACE level of 85 U/L. Serum calcium is 11.4 mg/dL. What is the mechanism of hypercalcemia in this condition?

Bone destruction from osteolytic granulomatous lesions
1-alpha hydroxylation of vitamin D by activated macrophages in granulomas (Correct answer)
Increased PTH secretion from parathyroid gland hyperplasia
Decreased renal calcium excretion from tubular dysfunction

Correct answer: 1-alpha hydroxylation of vitamin D by activated macrophages in granulomas

Activated macrophages within sarcoid granulomas express 1-alpha-hydroxylase, converting 25-OH vitamin D to calcitriol, which increases intestinal calcium absorption.

Question 139: Which vaccine is contraindicated in a 26-year-old pregnant woman at 20 weeks gestation?

COVID-19 mRNA vaccine
Inactivated influenza vaccine
Tdap
MMR vaccine (Correct answer)

Correct answer: MMR vaccine

MMR is a live attenuated vaccine and is contraindicated during pregnancy due to theoretical risk of fetal infection; it should be given postpartum.

Question 140: Which of the following DOES NOT characterize a typical pulmonary embolism clinical finding?

Dyspnea
Slow breathing (Correct answer)
Chest pain
Anxiety and nervousness

Correct answer: Slow breathing

Pulmonary embolism (PE) typically presents with acute onset dyspnea, chest pain, and anxiety. The body's physiological response to hypoxemia and increased respiratory drive is usually tachypnea (rapid breathing), not slow breathing (bradypnea). Slow breathing would be an atypical finding and could indicate severe respiratory compromise or other underlying issues.

Question 141: A mechanically ventilated ARDS patient has plateau pressure of 32 cmH2O and PEEP of 10 cmH2O. Driving pressure is 22 cmH2O. Which ventilator adjustment best reduces ventilator-induced lung injury?

Switch to pressure-controlled ventilation mode
Increase respiratory rate to normalize PaCO2
Increase FiO2 to reduce PEEP requirement
Reduce tidal volume to achieve driving pressure ≤15 cmH2O (Correct answer)

Correct answer: Reduce tidal volume to achieve driving pressure ≤15 cmH2O

Driving pressure (plateau - PEEP) >15 cmH2O is associated with increased ARDS mortality; reducing tidal volume to lower driving pressure reduces stress on remaining functional lung units.

Question 142: Which of the following cardiovascular diseases has aberrant pupillary reflexes (Argyll Robertson pupil) as a potential cause?

Thoracic aortic aneurysm (Correct answer)
Aortic regurgitation
Coarctation of the aorta
Myocarditis

Correct answer: Thoracic aortic aneurysm

Syphilis of the central nervous system is characterized by the Argyll Robertson pupil, which constricts with accommodation but not in response to light. This condition frequently leads to thoracic aortic aneurysm.

Question 143: A 55-year-old woman presents with bilateral knee pain worse with activity and relieved by rest. X-ray shows joint space narrowing and osteophytes. What is the most likely diagnosis?

Gout
Psoriatic arthritis
Rheumatoid arthritis
Osteoarthritis (Correct answer)

Correct answer: Osteoarthritis

Osteoarthritis is characterized by joint space narrowing, osteophytes, and pain worsened by activity, most commonly affecting weight-bearing joints.

Question 144: A 60-year-old male smoker presents with ptosis, diplopia, and proximal muscle weakness that improves with exercise. Which paraneoplastic syndrome is most likely?

Polymyositis
Myasthenia gravis
Dermatomyositis
Lambert-Eaton myasthenic syndrome (Correct answer)

Correct answer: Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome is a paraneoplastic syndrome most commonly associated with small cell lung cancer, causing proximal weakness that paradoxically improves with repeated movement.

Question 145: A pie chart shows that 25% of clinic visits are for hypertension, 40% for diabetes, and 35% for other conditions. If there were 200 total visits, how many were for diabetes?

80 (Correct answer)
85
90
70

Correct answer: 80

40% of 200 = 0.40 × 200 = 80 visits.

Question 146: Which of the following types of tumors originates in the mediastinum the most frequently?

Squamous cell carcinoma
Thymoma (Correct answer)
Adenoma
Fibroadenoma

Correct answer: Thymoma

The mediastinum is divided into compartments, and the anterior mediastinum is the most common site for tumors. Among these, thymomas are the most frequently occurring primary tumors, originating from the thymus gland. Other common anterior mediastinal masses include lymphomas, teratomas, and thyroid goiters.

Question 147: Which medication class is first-line for long-term rate control in atrial fibrillation in a patient with heart failure with reduced ejection fraction?

Beta-blockers (Correct answer)
Class IC antiarrhythmics
Non-dihydropyridine calcium channel blockers
Digoxin alone

Correct answer: Beta-blockers

Beta-blockers (e.g., carvedilol, metoprolol succinate) are first-line for rate control in AF with HFrEF and provide mortality benefit.

Question 148: Which blood group system determines the Rh factor, and what antigen is most clinically significant?

Rh system; D antigen (Correct answer)
Duffy system; Fya antigen
ABO system; A antigen
Kell system; K antigen

Correct answer: Rh system; D antigen

The Rh blood group system's D antigen is the most immunogenic and clinically important, particularly in hemolytic disease of the newborn.

Question 149: A PA student on clinical rotation witnesses a potential HIPAA violation. What is the most appropriate first action?

Report it to the clinical supervisor or preceptor immediately (Correct answer)
Report directly to the U.S. Department of Health and Human Services
Ignore it as a student to avoid conflict
Post about it anonymously on social media

Correct answer: Report it to the clinical supervisor or preceptor immediately

The appropriate first step is to report the concern to the supervising preceptor or clinical site supervisor through internal channels.

Question 150: Which nutritional deficiency most commonly causes night blindness?

Vitamin D
Zinc
Vitamin A (Correct answer)
Vitamin C

Correct answer: Vitamin A

Vitamin A (retinol) is required for rhodopsin synthesis in rod photoreceptors; deficiency impairs dark adaptation and causes night blindness.

Question 151: What materials are collected by the Physician Assistant History Society?

videos, movies, songs
papers, manuscripts, magazine and newspaper clippings, newsletters, reports, dissertations, oral histories (Correct answer)
recipes, cooking tips, meal plans
books, novels, poems, plays

Correct answer: papers, manuscripts, magazine and newspaper clippings, newsletters, reports, dissertations, oral histories

The PA History Society collects written and recorded historical materials—papers, manuscripts, magazine and newspaper clippings, newsletters, reports, dissertations, and oral histories. The other options (videos/songs, novels/poems, recipes) are not the documentary records used to preserve the profession's history.

Question 152: A 7-year-old boy has been struggling in school, is frequently out of his seat, and interrupts others. Symptoms are present at home and school. What is the first-line pharmacotherapy?

Fluoxetine
Atomoxetine
Methylphenidate (Correct answer)
Clonidine

Correct answer: Methylphenidate

Stimulant medications such as methylphenidate are first-line pharmacotherapy for ADHD in school-age children.

Question 153: Which dietary modification is the first-line treatment for non-alcoholic fatty liver disease (NAFLD)?

Mediterranean diet without caloric restriction
High-protein diet with resistance training only
Elimination of red meat and dairy
Low-fat, low-calorie diet with weight loss of 7–10% (Correct answer)

Correct answer: Low-fat, low-calorie diet with weight loss of 7–10%

A sustained weight loss of 7–10% through caloric restriction improves hepatic steatosis, inflammation, and fibrosis in NAFLD.

Question 154: A 35-year-old man with a headache walks into your office and is being evaluated. His blood pressure reading during a physical examination was 240/120 mmHg. You discover papilledema during the fundoscopic examination. What is the underlying diagnosis of this person?

Prehypertension
Hypertensive emergency (Correct answer)
Stage I hypertension
Hypertensive urgency
Stage III hypertension

Correct answer: Hypertensive emergency

The patient's blood pressure reading of 240/120 mmHg is significantly elevated and falls within the range of a hypertensive emergency. Hypertensive emergency is a severe and acute elevation in blood pressure that requires immediate medical attention to prevent potential organ damage or life-threatening complications. The presence of papilledema during the fundoscopic examination indicates that the elevated blood pressure is causing increased intracranial pressure, which can be dangerous.

Question 155: A PA student reads: 'Patients with condition X who received treatment Y showed a 30% reduction in symptoms compared to controls.' What type of study design MOST likely produced this result?

Cross-sectional survey
Randomized controlled trial (Correct answer)
Case report
Ecological study

Correct answer: Randomized controlled trial

Comparing a treatment group to controls with measured outcomes is the hallmark of a randomized controlled trial.

Question 156: A 68-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden-onset 'tearing' chest pain that radiates to his back. On examination, his blood pressure is 190/110 mmHg in the right arm and 155/90 mmHg in the left arm. A new diastolic murmur is auscultated at the right sternal border. Which of the following is the most likely diagnosis?

Aortic dissection (Correct answer)
Acute myocardial infarction
Pericarditis
Pulmonary embolism

Correct answer: Aortic dissection

The classic presentation of a sudden-onset 'tearing' or 'ripping' chest pain radiating to the interscapular area of the back, accompanied by a significant blood pressure differential between the upper extremities (>20 mmHg systolic), and a new diastolic murmur of aortic regurgitation strongly suggests an acute aortic dissection.

Question 157: A 72-year-old female presents with a six-week history of severe, symmetrical aching and morning stiffness in her shoulders, neck, and hips. The stiffness lasts for over an hour and makes it difficult for her to get out of bed or comb her hair. She reports fatigue but denies new headaches or vision changes. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 85 mm/hr. Which of the following is the most likely diagnosis?

Osteoarthritis
Polymyalgia rheumatica (Correct answer)
Rheumatoid arthritis
Fibromyalgia

Correct answer: Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disorder that characteristically affects adults over 50, causing pain and stiffness in the proximal joints (shoulders, neck, and hips). [9, 26, 28] The presence of prolonged morning stiffness and a markedly elevated ESR are classic findings. [26, 27] Rheumatoid arthritis typically involves smaller, peripheral joints symmetrically. Osteoarthritis does not have a significant inflammatory component (normal ESR) and stiffness is usually brief. Fibromyalgia presents with widespread pain but lacks the objective inflammatory markers seen in this patient.

Question 158: A 62-year-old man with a history of MI presents with palpitations. ECG shows a wide complex tachycardia at 160 bpm. What is the most important initial step?

Adenosine 6 mg IV push
Synchronized cardioversion only if unstable
Verapamil IV
Assume VT and treat accordingly until proven otherwise (Correct answer)

Correct answer: Assume VT and treat accordingly until proven otherwise

Wide complex tachycardia in a patient with structural heart disease should be presumed ventricular tachycardia until proven otherwise.

Question 159: Which issue with the left bundle branch block (LBBB) is most likely related to it?

Severe aortic valve disease (Correct answer)
VSD
Congenital heart disease
Atrial septal defect (ASD)

Correct answer: Severe aortic valve disease

Left bundle branch block (LBBB) often indicates significant underlying structural heart disease. Severe aortic valve disease, such as aortic stenosis or regurgitation, places a substantial workload and strain on the left ventricle, leading to hypertrophy and fibrosis. These changes can disrupt the normal conduction pathways, making LBBB a common association with severe aortic valve pathology.

Question 160: A 45-year-old industrial painter presents with complaints of fatigue, irritability, and diffuse abdominal pain. A complete blood count reveals a microcytic, hypochromic anemia. Which of the following findings on a peripheral blood smear would be most suggestive of lead poisoning as the underlying cause?

Schistocytes
Hypersegmented neutrophils
Basophilic stippling (Correct answer)
Howell-Jolly bodies

Correct answer: Basophilic stippling

Coarse basophilic stippling on a peripheral blood smear is a classic, though not pathognomonic, finding in lead poisoning. [12, 24, 30] It represents aggregates of ribosomes and is a result of lead inhibiting an enzyme involved in red blood cell degradation. Howell-Jolly bodies suggest asplenia. Schistocytes indicate microangiopathic hemolytic anemia. Hypersegmented neutrophils are characteristic of megaloblastic anemia (B12 or folate deficiency).

Question 161: Which developmental milestone is expected by 12 months of age?

Speaks in 2-word phrases
Points to named body parts
Walks independently (Correct answer)
Copies a circle

Correct answer: Walks independently

Walking independently is a gross motor milestone typically achieved between 9–15 months, with 12 months as the average.

Question 162: When formulating a diagnosis, which approach best reduces diagnostic error from the framing effect?

Focus only on the most recent test results
Deliberately reframe the case from multiple perspectives to challenge the initial impression (Correct answer)
Accept the referring clinician's working diagnosis without further analysis
Treat the patient based on the most likely diagnosis without further history

Correct answer: Deliberately reframe the case from multiple perspectives to challenge the initial impression

Reframing the case from different angles counteracts the framing effect by preventing the initial presentation of information from anchoring the diagnostic conclusion.

Question 163: A patient with peripheral artery disease has an ABI of 0.55. What does this indicate?

Moderate-to-severe PAD (Correct answer)
Normal arterial perfusion
Non-compressible vessels (calcification)
Mild PAD

Correct answer: Moderate-to-severe PAD

An ABI of 0.41–0.70 indicates moderate-to-severe peripheral arterial disease with significant hemodynamic compromise.

Question 164: Which history-taking mnemonic is used to characterize the quality of a patient's pain comprehensively?

OLDCARTS (Correct answer)
HEADSSS
CAGE
SOAP

Correct answer: OLDCARTS

OLDCARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) is used to fully characterize pain in the HPI.

Question 165: The BEST way to strengthen an argument in an academic paper is to:

Present only one perspective without acknowledging counterarguments
Use emotional language to persuade the reader
Cite peer-reviewed evidence that directly supports the claim (Correct answer)
Repeat the thesis multiple times throughout the paper

Correct answer: Cite peer-reviewed evidence that directly supports the claim

Peer-reviewed evidence provides credible, verifiable support that directly strengthens academic arguments.

Question 166: A 30-year-old male presents with acute monoarticular arthritis of the first metatarsophalangeal joint, erythema, and severe pain. Synovial fluid analysis shows negatively birefringent needle-shaped crystals. What is the treatment of choice for an acute attack?

Methotrexate
Allopurinol
Colchicine or NSAIDs (Correct answer)
Prednisone taper over 6 weeks

Correct answer: Colchicine or NSAIDs

Colchicine and NSAIDs are first-line treatments for acute gout attacks; allopurinol is used for long-term urate-lowering therapy, not acute episodes.

Question 167: A 60-year-old with COPD and FEV1 of 35% predicted has multiple hospitalizations yearly. Which long-acting bronchodilator combination has the strongest evidence for reducing exacerbations?

Short-acting beta-agonist plus short-acting muscarinic antagonist
Inhaled corticosteroid alone
Long-acting beta-agonist alone
Long-acting beta-agonist plus inhaled corticosteroid plus long-acting muscarinic antagonist (triple therapy) (Correct answer)

Correct answer: Long-acting beta-agonist plus inhaled corticosteroid plus long-acting muscarinic antagonist (triple therapy)

Triple therapy (LABA + LAMA + ICS) reduces exacerbation rates more than dual therapy in severe COPD patients with frequent exacerbations, per the IMPACT trial.

Question 168: A 4-year-old child is brought to the clinic with a 5-day history of pronounced facial puffiness, especially around the eyes in the morning, and swelling in the legs. The parents also report recent weight gain. Urinalysis reveals 4+ proteinuria, but is negative for blood and white blood cells. Which of the following is the most likely diagnosis?

Urinary tract infection
Minimal change disease (Correct answer)
Post-streptococcal glomerulonephritis
IgA nephropathy

Correct answer: Minimal change disease

The clinical presentation of a young child with significant edema and massive, selective proteinuria (proteinuria without hematuria) is classic for nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children. [1, 4, 8] Post-streptococcal glomerulonephritis typically presents with hematuria, hypertension, and a history of a recent streptococcal infection. IgA nephropathy is the most common cause of glomerulonephritis worldwide but typically presents with gross hematuria following a mucosal infection. A urinary tract infection would present with pyuria and bacteriuria, not massive proteinuria.

Question 169: A newborn presents with bilious vomiting, abdominal distension, and failure to pass meconium within 48 hours. Rectal suction biopsy shows absence of ganglion cells. What is the diagnosis?

Meconium ileus
Intussusception
Hirschsprung's disease (Correct answer)
Pyloric stenosis

Correct answer: Hirschsprung's disease

Hirschsprung's disease results from failed neural crest cell migration, causing an aganglionic segment of colon that cannot relax, leading to functional obstruction.

Question 170: During a cardiovascular exam, you note that a patient's JVP is elevated at 45° with hepatojugular reflux present. These findings suggest:

Tamponade as the only diagnosis
Normal variant in obese patients
Dehydration
Right heart failure or elevated central venous pressure (Correct answer)

Correct answer: Right heart failure or elevated central venous pressure

Elevated JVP with a positive hepatojugular reflux (sustained rise with abdominal compression) indicates elevated right-sided filling pressures consistent with right heart failure.

Question 171: A 30-year-old athlete collapses during a basketball game. ECG shows asymmetric septal hypertrophy. What is the most likely diagnosis?

Myocarditis
Dilated cardiomyopathy
Hypertrophic obstructive cardiomyopathy (Correct answer)
Arrhythmogenic right ventricular cardiomyopathy

Correct answer: Hypertrophic obstructive cardiomyopathy

HOCM is the most common cause of sudden cardiac death in young athletes and presents with asymmetric septal hypertrophy.

Question 172: Which of the following does NOT contribute to left-sided heart failure?

Mitral regurgitation
Pulmonary hypertension (Correct answer)
Aortic valve disease
Endocarditis

Correct answer: Pulmonary hypertension

Left-sided heart failure occurs when the left ventricle cannot effectively pump blood to the systemic circulation, often due to conditions affecting the left heart like mitral regurgitation or aortic valve disease. While severe left-sided heart failure can *lead to* pulmonary hypertension as blood backs up into the lungs, primary pulmonary hypertension itself is a condition of high pressure in the pulmonary arteries that primarily causes *right-sided* heart failure, as the right ventricle struggles to pump against this increased resistance.

Question 173: Which one of the following best describes the likely cause of paronychia?

A bacterial infection (Correct answer)
A prescribed medication
An autoimmune reaction
A fungal infection
A viral infection

Correct answer: A bacterial infection

Paronychia is a skin infection affecting the nail bed and surrounding tissues. Bacteria most commonly cause it, typically Staphylococcus aureus, which can invade the area through a small cut or injury to the skin around the nail. A fungal infection or other bacteria can also cause paronychia.

Question 174: A PA working in a federally qualified health center (FQHC) is typically covered under which federal liability protection?

Private malpractice insurance only
Federal Tort Claims Act (FTCA) (Correct answer)
State Medical Malpractice Fund
ERISA preemption

Correct answer: Federal Tort Claims Act (FTCA)

PAs employed by FQHCs are deemed federal employees and covered under the FTCA for malpractice liability.

Question 175: Which of the following is the most appropriate initial biochemical test to screen for pheochromocytoma?

Clonidine suppression test
CT scan of the abdomen
Plasma free metanephrines or 24-hour urine fractionated metanephrines (Correct answer)
Serum cortisol level

Correct answer: Plasma free metanephrines or 24-hour urine fractionated metanephrines

Plasma free metanephrines or 24-hour urine fractionated metanephrines are the preferred biochemical tests for screening pheochromocytoma due to high sensitivity.

Question 176: A 58-year-old man with diabetes presents with a painless foot ulcer. His history of peripheral neuropathy is known. Which complication should be highest on the differential?

Diabetic neuropathic ulcer with possible underlying osteomyelitis (Correct answer)
Pressure ulcer
Venous stasis ulcer
Arterial insufficiency ulcer

Correct answer: Diabetic neuropathic ulcer with possible underlying osteomyelitis

Painless foot ulcers in diabetics with neuropathy are hallmarks of diabetic neuropathic ulcers, and osteomyelitis must be excluded given its high prevalence in this context.

Question 177: A 70-year-old woman with dyspnea has an S3 gallop, bilateral crackles, and JVD. Which BNP level best supports acute decompensated heart failure?

BNP 850 pg/mL (Correct answer)
BNP 50 pg/mL
BNP 30 pg/mL
BNP 120 pg/mL

Correct answer: BNP 850 pg/mL

BNP >100 pg/mL strongly supports heart failure; levels above 400-500 pg/mL are highly specific for decompensated HF.

Question 178: Who should be chosen to oversee a PA?

MD (Correct answer)
DO (Correct answer)
Dentist
Pharmacist

Correct answer: MD

DO, and MD can supervise a PA.

Question 179: Which of the following is the most common type of stroke?

Subdural hematoma
Ischemic stroke (Correct answer)
Hemorrhagic stroke
Subarachnoid hemorrhage

Correct answer: Ischemic stroke

Ischemic stroke accounts for approximately 87% of all strokes, caused by thrombotic or embolic occlusion of cerebral vessels.

Question 180: A 25-year-old lady who complains of palpitations is being evaluated by you. You hear a midsystolic click during inspection. Which of the following would you advise in regards to her heart condition assessment?

Her murmur would decrease with a Valsalva maneuver.
She should be screened for a bleeding diathesis.
She may need a beta blocker if the palpitations continue.
She should be screened for rheumatic fever. (Correct answer)
She should be screened for major depressive disorder.

Correct answer: She should be screened for rheumatic fever.

The presence of a midsystolic click during inspection can be indicative of mitral valve prolapse (MVP). Mitral valve prolapse is a condition where the valve between the left atrium and the left ventricle doesn't close properly during systole and bulges back into the atrium. It can sometimes produce a clicking sound. <br> <br> Mitral valve prolapse is often benign and may not require treatment in many cases. However, it can be associated with other complications, and one of them is the increased risk of infective endocarditis, especially in patients with a history of rheumatic fever. Rheumatic fever is a condition caused by an untreated or inadequately treated streptococcal infection, and it can damage the heart valves, leading to mitral valve prolapse.

Question 181: A patient on SSRIs is started on tramadol. Which serious drug interaction could result?

Anticholinergic crisis
Serotonin syndrome (Correct answer)
Neuroleptic malignant syndrome
QT prolongation

Correct answer: Serotonin syndrome

Tramadol inhibits serotonin reuptake; combined with SSRIs this can precipitate serotonin syndrome presenting with hyperthermia, agitation, and clonus.

Question 182: A 65-year-old smoker presents with hemoptysis, weight loss, and a central lung mass. Serum sodium is 120 mEq/L. Which paraneoplastic syndrome is most likely?

Hypercalcemia from PTHrP secretion
Eaton-Lambert syndrome
Cushing's syndrome from ACTH secretion
SIADH from ADH secretion (Correct answer)

Correct answer: SIADH from ADH secretion

Small cell lung cancer most commonly produces SIADH via ectopic ADH secretion, causing hyponatremia.

Question 183: A 22-year-old collegiate soccer player presents with acute right knee pain after an opponent tackled her during a game, causing a valgus force and external rotation of her tibia. She reports hearing a 'pop' and feeling immediate instability. On physical examination, the Lachman test reveals significant anterior translation of the tibia with a soft endpoint compared to the contralateral knee. Which ligament is most likely injured?

Lateral collateral ligament (LCL)
Anterior cruciate ligament (ACL) (Correct answer)
Medial collateral ligament (MCL)
Posterior cruciate ligament (PCL)

Correct answer: Anterior cruciate ligament (ACL)

The Lachman test is the most sensitive and specific physical examination maneuver for an anterior cruciate ligament (ACL) tear. The history of a 'pop' with a rotational or valgus force injury mechanism, coupled with a feeling of instability and a positive Lachman test (anterior tibial translation with a soft endpoint), is classic for an ACL rupture.

Question 184: On auscultation, a mid-systolic click followed by a late systolic murmur is characteristic of:

Aortic regurgitation
Aortic stenosis
Ventricular septal defect
Mitral valve prolapse (Correct answer)

Correct answer: Mitral valve prolapse

A mid-systolic click followed by a late systolic murmur is the hallmark auscultatory finding of mitral valve prolapse.

Question 185: A 29-year-old pregnant woman at 32 weeks gestation presents with acute onset pleuritic chest pain and hemoptysis. D-dimer is elevated. CT pulmonary angiography confirms PE. Which anticoagulant is preferred?

Low molecular weight heparin (LMWH) (Correct answer)
Warfarin (vitamin K antagonist)
Rivaroxaban (direct oral anticoagulant)
Unfractionated heparin infusion

Correct answer: Low molecular weight heparin (LMWH)

LMWH is the preferred anticoagulant for PE in pregnancy; warfarin is teratogenic, DOACs lack safety data in pregnancy, and LMWH does not cross the placenta.

Question 186: The renin-angiotensin-aldosterone system (RAAS) is activated primarily by which stimulus?

Decreased renal perfusion pressure (Correct answer)
Elevated serum sodium
Hyperkalemia alone
Increased atrial natriuretic peptide

Correct answer: Decreased renal perfusion pressure

Decreased renal perfusion pressure triggers juxtaglomerular cells to release renin, initiating the RAAS cascade to restore blood pressure and volume.

Question 187: When building a problem representation, which element best distinguishes it from a simple symptom list?

A list of all abnormal lab values
A concise synthesis that highlights key epidemiological, temporal, and clinical features (Correct answer)
A chronological list of every symptom the patient reports
A verbatim transcript of the patient's chief complaint

Correct answer: A concise synthesis that highlights key epidemiological, temporal, and clinical features

A problem representation distills the case into a one-line synthesis emphasizing the most discriminating features to guide differential diagnosis.

Question 188: A 28-year-old woman presents with palpitations, heat intolerance, weight loss, and exophthalmos. TSH is undetectable and free T4 is elevated. What is the most likely diagnosis?

Hashimoto's thyroiditis
Subacute thyroiditis
Graves' disease (Correct answer)
Toxic multinodular goiter

Correct answer: Graves' disease

Graves' disease is an autoimmune hyperthyroid condition, and exophthalmos (Graves' ophthalmopathy) is pathognomonic for this diagnosis.

Question 189: Which type of hepatitis is most commonly transmitted via the fecal-oral route and does NOT cause chronic disease?

Hepatitis C
Hepatitis D
Hepatitis B
Hepatitis A (Correct answer)

Correct answer: Hepatitis A

Hepatitis A is transmitted fecal-orally (contaminated food/water) and never leads to chronic hepatitis or cirrhosis.

Question 190: Which finding on urinalysis is most specific for acute tubular necrosis (ATN)?

Red blood cell casts
Muddy brown granular casts (Correct answer)
Waxy casts
White blood cell casts

Correct answer: Muddy brown granular casts

Muddy brown granular casts are the hallmark finding of acute tubular necrosis, representing sloughed renal tubular epithelial cells.

Question 191: Which statement about the management of STEMI is correct?

Aspirin should be withheld until after revascularization
Anticoagulation is not required if PCI is performed
Fibrinolysis is preferred over PCI when door-to-balloon time is under 90 minutes
Primary PCI is preferred when door-to-balloon time is under 120 minutes (Correct answer)

Correct answer: Primary PCI is preferred when door-to-balloon time is under 120 minutes

Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed within 90-120 minutes of first medical contact.

Question 192: A patient with Clostridium difficile infection (CDI) has a first recurrence after metronidazole treatment. What is the preferred management?

IV metronidazole plus oral vancomycin
Repeat metronidazole course
Oral vancomycin standard course
Fidaxomicin or vancomycin tapered/pulsed regimen (Correct answer)

Correct answer: Fidaxomicin or vancomycin tapered/pulsed regimen

IDSA guidelines recommend fidaxomicin or a vancomycin tapered/pulsed regimen for first recurrence of CDI to reduce further recurrence rates.

Question 193: A 38-year-old male presents to his primary care provider after being bitten by a tick while hiking in New England two weeks ago. He now complains of fever, fatigue, and myalgias. On examination, a large, annular, erythematous rash approximately 15 cm in diameter with central clearing is noted on his thigh. Which of the following is the most appropriate term for this rash?

Erythema migrans (Correct answer)
Urticaria
Nummular eczema
Tinea corporis

Correct answer: Erythema migrans

Erythema migrans is the pathognomonic skin lesion of early localized Lyme disease, which occurs after a bite from an infected Ixodes tick. It classically appears as an expanding erythematous rash, often with central clearing, resembling a 'bull's-eye'. [7, 13, 14] Urticaria (hives) consists of pruritic wheals. Nummular eczema presents as coin-shaped, scaly plaques. Tinea corporis (ringworm) is a fungal infection with a scaly, advancing border and is typically pruritic.

Question 194: A patient is found to have hemoglobin of 9.2 g/dL, MCV of 72 fL, low serum ferritin, and low serum iron with elevated TIBC. What is the most likely diagnosis?

Thalassemia trait
Anemia of chronic disease
Sideroblastic anemia
Iron deficiency anemia (Correct answer)

Correct answer: Iron deficiency anemia

Iron deficiency anemia presents with microcytic anemia, low ferritin (depleted stores), low serum iron, and high TIBC (transferrin upregulation).

Question 195: A 55-year-old man with Type 2 DM presents with a foot ulcer and no sensation on 10-gram monofilament testing. Which diabetic complication does this represent?

Diabetic peripheral neuropathy (Correct answer)
Peripheral arterial disease
Diabetic nephropathy
Charcot arthropathy

Correct answer: Diabetic peripheral neuropathy

Loss of protective sensation on monofilament testing is the hallmark of diabetic peripheral neuropathy, a microvascular complication of diabetes.

Question 196: A 60-year-old male smoker presents with hemoptysis, weight loss, and a central lung mass on CT. Biopsy shows small blue cells. Which lung cancer type is this?

Large cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Small cell lung carcinoma (Correct answer)

Correct answer: Small cell lung carcinoma

Small cell lung carcinoma presents as a central mass with small blue cells on biopsy and is strongly associated with smoking; it often presents with paraneoplastic syndromes.

Question 197: A patient with known HFrEF reports dizziness after starting a new medication. Potassium is 5.9 mEq/L and creatinine has risen. Which drug is most likely responsible?

Digoxin
Metoprolol succinate
Hydralazine
Spironolactone (Correct answer)

Correct answer: Spironolactone

Spironolactone, a potassium-sparing aldosterone antagonist, commonly causes hyperkalemia and can worsen renal function.

Question 198: A 35-year-old female presents with a 3-month history of weight loss despite an increased appetite, heat intolerance, anxiety, and palpitations. On examination, she is tachycardic, her skin is warm and moist, and a fine tremor is noted in her outstretched hands. Based on this history and physical examination, which of the following is the most likely diagnosis?

Cushing's syndrome
Addison's disease
Hyperthyroidism (Correct answer)
Hypothyroidism

Correct answer: Hyperthyroidism

This patient's constellation of symptoms—including weight loss with increased appetite, heat intolerance, tachycardia, anxiety, and tremors—is classic for a hypermetabolic state caused by an overactive thyroid gland, or hyperthyroidism. Hypothyroidism would present with opposite symptoms (weight gain, cold intolerance), while Cushing's and Addison's disease involve the adrenal glands and have different clinical presentations.

Question 199: A 65-year-old male presents with sudden onset right-sided facial droop, arm weakness, and aphasia that resolved completely within 45 minutes. What is the most likely diagnosis?

Transient ischemic attack (TIA) (Correct answer)
Todd's paralysis
Ischemic stroke
Complex migraine

Correct answer: Transient ischemic attack (TIA)

A transient ischemic attack (TIA) presents with stroke-like symptoms that resolve completely within 24 hours (typically minutes), with no infarction on imaging.

Question 200: Which pattern of joint involvement is most consistent with a diagnosis of rheumatoid arthritis?

Monoarthritis of the first MTP joint
Symmetric small joint polyarthritis affecting MCPs and PIPs with morning stiffness (Correct answer)
Migratory arthritis following a gastrointestinal infection
Asymmetric large joint arthritis affecting weight-bearing joints

Correct answer: Symmetric small joint polyarthritis affecting MCPs and PIPs with morning stiffness

Rheumatoid arthritis classically presents with symmetric polyarthritis of the MCPs and PIPs accompanied by prolonged morning stiffness.

Question 201: A 50-year-old woman presents with fatigue, weight gain, cold intolerance, constipation, and dry skin. TSH is 9.2 mIU/L and free T4 is low. What is the first-line treatment?

Radioactive iodine ablation
Propylthiouracil
Levothyroxine (Correct answer)
Methimazole

Correct answer: Levothyroxine

Primary hypothyroidism is treated with levothyroxine (synthetic T4) to replace the deficient thyroid hormone.

Question 202: A patient with mitral stenosis is most at risk for which complication?

Ventricular tachycardia
Atrial fibrillation and systemic embolism (Correct answer)
Complete heart block
Ventricular fibrillation

Correct answer: Atrial fibrillation and systemic embolism

Mitral stenosis causes left atrial enlargement, predisposing to atrial fibrillation and thrombus formation with embolic risk.

Question 203: A 58-year-old with rheumatoid arthritis develops bilateral lower lobe subpleural honeycombing and traction bronchiectasis on HRCT. Pulmonary biopsy shows usual interstitial pneumonia (UIP) pattern. What is the best pharmacologic treatment?

Rituximab infusion
High-dose prednisone and azathioprine
Nintedanib (antifibrotic agent) (Correct answer)
Hydroxychloroquine

Correct answer: Nintedanib (antifibrotic agent)

RA-ILD with UIP pattern can be treated with nintedanib, which has demonstrated slowed FVC decline in progressive pulmonary fibrosis regardless of underlying cause.

Question 204: A 35-year-old non-smoker presents with lower lobe-predominant emphysema and recurrent liver disease. Which deficiency should be suspected?

Primary ciliary dyskinesia
IgA deficiency
Cystic fibrosis transmembrane conductance regulator mutation
Alpha-1 antitrypsin deficiency (Correct answer)

Correct answer: Alpha-1 antitrypsin deficiency

Alpha-1 antitrypsin deficiency causes panacinar emphysema predominantly in the lower lobes and can cause liver disease from misfolded protein accumulation in hepatocytes.

Question 205: After making lifestyle changes, which drug class is advised as the first-line treatment for hypercholesterolemia?

Beta channel antagonists
HMG CoA reductase inhibitors (statins) (Correct answer)
Calcium channel blockers
Antithrombolytics

Correct answer: HMG CoA reductase inhibitors (statins)

After lifestyle modifications, HMG CoA reductase inhibitors, commonly known as statins, are the first-line pharmacologic treatment for hypercholesterolemia. Statins work by inhibiting a key enzyme in cholesterol synthesis in the liver, effectively lowering LDL (bad) cholesterol levels and reducing the risk of cardiovascular events. They are highly effective and well-tolerated medications.

Question 206: Which of the following is the most significant risk factor for stroke that can be modified?

Hypotension
Congestive heart failure
Hypertension (Correct answer)
Diabetes

Correct answer: Hypertension

Hypertension is recognized as the single most significant and modifiable risk factor for stroke. Chronically elevated blood pressure damages blood vessels, promoting atherosclerosis, increasing the risk of clot formation, and weakening vessel walls, which can lead to both ischemic and hemorrhagic strokes. Effective management of hypertension is crucial for stroke prevention.

Question 207: A patient with myasthenia gravis will show which characteristic pattern on repetitive nerve stimulation?

No change
Incremental response
Fibrillation potentials
Decremental response (Correct answer)

Correct answer: Decremental response

Myasthenia gravis is characterized by a decremental response on repetitive nerve stimulation due to depletion of acetylcholine at the neuromuscular junction.

Question 208: A 42-year-old woman presents with massive hemoptysis (>300 mL in 24 hours). She has a history of bronchiectasis from childhood tuberculosis. What is the MOST important immediate intervention?

Emergent surgical resection
Airway protection and positioning the bleeding lung in the dependent position (Correct answer)
IV tranexamic acid administration
Bronchoscopy with cold saline lavage

Correct answer: Airway protection and positioning the bleeding lung in the dependent position

The bleeding lung should be placed dependent (affected side down) to prevent aspiration of blood into the healthy lung, which is the most immediate life-threatening risk.

Question 209: A 28-year-old female presents with malar rash, arthritis, and proteinuria. ANA is positive at 1:640. Which antibody is most specific for systemic lupus erythematosus (SLE)?

Anti-Scl-70
Anti-Smith (Sm) (Correct answer)
Anti-histone
Anti-SSA (Ro)

Correct answer: Anti-Smith (Sm)

Anti-Smith (anti-Sm) antibodies are highly specific for SLE, though not sensitive, making them useful when positive.

Question 210: Which accrediting body oversees PA educational programs in the United States?

AAPA
ARC-PA (Correct answer)
LCME
NCCPA

Correct answer: ARC-PA

The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) accredits PA programs.

Question 211: Which of the following statements regarding the various forms of sleep apnea is FALSE?

Obstructive apnea: Restricts inspiratory airflow
Central apnea: There is a lack of signal from respiratory center, no drive to breathe
Mixed apnea: It is a combination of the above factors
Central apnea is the most common type of sleep apnea (Correct answer)

Correct answer: Central apnea is the most common type of sleep apnea

Obstructive sleep apnea (OSA) is by far the most common type of sleep apnea, characterized by recurrent episodes of upper airway obstruction despite ongoing respiratory effort. Central sleep apnea (CSA), which involves a lack of respiratory drive from the brain, is much less common. Therefore, the statement that central apnea is the most common type is false.

Question 212: A 28-year-old woman presents with pleuritic chest pain, hemoptysis, and recent long-haul flight. Which diagnosis should be immediately considered?

Spontaneous pneumothorax
Pulmonary embolism (Correct answer)
Community-acquired pneumonia
Pericarditis

Correct answer: Pulmonary embolism

Pleuritic chest pain, hemoptysis, and recent immobilization from a long-haul flight constitute classic risk factors and symptoms for pulmonary embolism.

Question 213: A 68-year-old female with diabetes presents with a 3-day history of fever, productive cough, and new-onset confusion. On examination, her respiratory rate is 32 breaths/min, blood pressure is 88/58 mmHg, and her BUN is 25 mg/dL. Which of the following is the most appropriate action based on the CURB-65 score?

Admit to the intensive care unit for management of severe pneumonia (Correct answer)
Discharge home with oral antibiotics
Admit to a general medical ward for inpatient treatment
Observe in the emergency department for 4-6 hours before making a disposition decision

Correct answer: Admit to the intensive care unit for management of severe pneumonia

The patient scores 4 points on the CURB-65 scale: Confusion (1), Urea >20 mg/dL (1), Respiratory rate ≥30 (1), and Blood pressure <90 systolic (1). A score of 3 or more indicates severe pneumonia with a high risk of mortality, warranting urgent admission to the hospital, typically to an intensive care unit (ICU), for aggressive management.

Question 214: Which imaging modality is the preferred initial study for a patient presenting with acute stroke symptoms?

Carotid ultrasound
MRI brain with contrast
CT angiography
Non-contrast CT head (Correct answer)

Correct answer: Non-contrast CT head

Non-contrast CT head is the first-line imaging study in acute stroke to rapidly exclude hemorrhage before considering thrombolytic therapy.

Question 215: A patient's apical pulse is palpated at the 6th intercostal space, anterior axillary line. This displacement suggests:

Left ventricular hypertrophy or dilation (Correct answer)
Right ventricular enlargement
Normal variant in a thin patient
Pericardial effusion

Correct answer: Left ventricular hypertrophy or dilation

The point of maximal impulse (PMI) displaced laterally and inferiorly from the 5th ICS, MCL suggests left ventricular enlargement.

Question 216: A 35-year-old woman presents with weakness, fatigue, hyperpigmentation, hyponatremia, and hyperkalemia. Cortisol is low and ACTH is markedly elevated. What is the most likely diagnosis?

Addison's disease (Correct answer)
Secondary adrenal insufficiency
Cushing's disease
Primary hyperaldosteronism

Correct answer: Addison's disease

Addison's disease (primary adrenal insufficiency) features elevated ACTH causing hyperpigmentation, with low cortisol, hyponatremia, and hyperkalemia.

Question 217: Which medication is contraindicated in a patient with decompensated heart failure and an ejection fraction of 20%?

IV furosemide
Nitrates for preload reduction
Carvedilol initiated at low dose (Correct answer)
Dobutamine infusion

Correct answer: Carvedilol initiated at low dose

Beta-blockers should not be started during decompensated HF; they should only be initiated once the patient is stabilized.

Question 218: A 55-year-old man reports chest pain that worsens with inspiration and is relieved by leaning forward. Which component of the history is MOST critical to document next?

Smoking history
Onset and duration of pain (Correct answer)
Current medications
Family history of cardiac disease

Correct answer: Onset and duration of pain

Pleuritic chest pain relieved by leaning forward suggests pericarditis; documenting onset and duration is essential to characterize the presentation.

Question 219: Which finding on colonoscopy is most characteristic of ulcerative colitis compared to Crohn's disease?

Skip lesions
Cobblestoning mucosa
Transmural inflammation
Continuous involvement starting at the rectum (Correct answer)

Correct answer: Continuous involvement starting at the rectum

Ulcerative colitis causes continuous, contiguous mucosal inflammation that always involves the rectum and extends proximally.

Question 220: Which laboratory finding is most characteristic of rheumatoid arthritis?

Positive rheumatoid factor and anti-CCP antibodies (Correct answer)
Elevated uric acid
Positive ANA with anti-dsDNA
Elevated alkaline phosphatase

Correct answer: Positive rheumatoid factor and anti-CCP antibodies

Rheumatoid factor and anti-CCP (anti-cyclic citrullinated peptide) antibodies are the hallmark serologic markers of rheumatoid arthritis.

Question 221: A 48-year-old bird handler presents with fever, dry cough, and diffuse interstitial infiltrates 6 hours after cleaning the bird cage. Pulmonary function tests show a restrictive pattern. What is the most likely diagnosis?

Acute eosinophilic pneumonia
Pulmonary alveolar proteinosis
Hypersensitivity pneumonitis (bird fancier's lung) (Correct answer)
Psittacosis (Chlamydophila psittaci infection)

Correct answer: Hypersensitivity pneumonitis (bird fancier's lung)

Bird fancier's lung is a classic hypersensitivity pneumonitis triggered by avian antigens, presenting hours after exposure with fever, dyspnea, and restrictive physiology.

Question 222: A patient presents with thunderclap headache described as 'the worst headache of my life.' CT head is negative. What is the next most appropriate step?

Discharge with analgesics
EEG
Lumbar puncture to check for xanthochromia (Correct answer)
MRI brain without contrast

Correct answer: Lumbar puncture to check for xanthochromia

When CT is negative in a patient with thunderclap headache, lumbar puncture to detect xanthochromia is essential to rule out subarachnoid hemorrhage, which may not appear on CT after several hours.

Question 223: A 30-year-old woman is diagnosed with irritable bowel syndrome (IBS) with predominant constipation. Which dietary intervention has the strongest evidence for improving her symptoms?

High-fiber diet with insoluble fiber
Gluten-free diet
Low FODMAP diet (Correct answer)
Lactose-free diet alone

Correct answer: Low FODMAP diet

The low FODMAP diet reduces fermentable carbohydrates that cause osmotic diarrhea and gas production, and has the strongest evidence for symptom relief in IBS.

Question 224: A patient on amiodarone develops thyroid dysfunction. Which pattern is MOST common?

Euthyroid sick syndrome
Hyperthyroidism due to iodine excess only
Thyroid storm
Hypothyroidism (Correct answer)

Correct answer: Hypothyroidism

Amiodarone-induced hypothyroidism is the most common thyroid side effect, especially in iodine-sufficient populations.

Question 225: Which of the following ECG changes is MOST specific for hyperkalemia?

Left bundle branch block
Q waves in inferior leads
Peaked T waves (Correct answer)
ST depression in lateral leads

Correct answer: Peaked T waves

Peaked, narrow, symmetrical T waves are the earliest and most characteristic ECG finding in hyperkalemia.

Question 226: A malnourished patient who is started on aggressive refeeding develops hypophosphatemia, hypokalemia, and hypomagnesemia. What syndrome does this represent?

Refeeding syndrome (Correct answer)
Dumping syndrome
Short bowel syndrome
Wernicke's encephalopathy

Correct answer: Refeeding syndrome

Refeeding syndrome occurs when rapid introduction of carbohydrates drives intracellular shifts of electrolytes in malnourished patients, causing dangerous deficiencies.

Question 227: Which of the following best describes the collaborative practice model for PAs?

PAs work under the supervision of a licensed physician (Correct answer)
PAs practice independently without physician oversight
PAs practice under hospital administrative oversight only
PAs must refer all cases to a physician before treatment

Correct answer: PAs work under the supervision of a licensed physician

PAs practice medicine with physician supervision or collaboration, though the degree varies by state law.

Question 228: Which heart valves are shutting when the first heart sound is made?

Aortic and tricuspid valves
Mitral and tricuspid valves (Correct answer)
Aortic and pulmonic valves
Aortic and mitral valves

Correct answer: Mitral and tricuspid valves

The first heart sound, S1, commonly referred to as the 'lub' sound, marks the beginning of ventricular systole (contraction). It is produced by the simultaneous closure of the atrioventricular (AV) valves: the mitral valve, located between the left atrium and left ventricle, and the tricuspid valve, located between the right atrium and right ventricle. This closure prevents the backflow of blood into the atria as the ventricles begin to contract.

Question 229: Which valve disorder characteristically produces a mid-systolic click followed by a late systolic murmur?

Tricuspid regurgitation
Aortic stenosis
Mitral valve prolapse (Correct answer)
Mitral stenosis

Correct answer: Mitral valve prolapse

Mitral valve prolapse produces a mid-systolic click with a late systolic murmur heard best at the apex.

Question 230: Which of the following is the most important initial intervention in the management of Diabetic Ketoacidosis (DKA)?

Sodium bicarbonate infusion
Oral potassium replacement
IV fluid resuscitation with normal saline (Correct answer)
IV insulin bolus

Correct answer: IV fluid resuscitation with normal saline

IV fluid resuscitation is the most critical initial step in DKA to correct severe dehydration before initiating insulin therapy.

Question 231: Which of the following is most helpful in determining whether a newborn has congenital hip dysplasia in addition to a physical examination?

Bone scan
MRI
CT scan
Ultrasound (Correct answer)
Radiograph

Correct answer: Ultrasound

The Barlow and Ortolani maneuvers are frequently brought up in PANCE concerns about congenital hip dysplasia in newborns. The ultrasound is the most effective imaging test for newborns. Much of the joint may not be clearly seen on routine radiologic imaging during the first few months of life.

Question 232: A patient with low back pain radiating down the posterior leg to the foot has a positive straight leg raise at 45 degrees. Which nerve root is most likely involved?

L5 or S1 (Correct answer)
L3
L4
L2

Correct answer: L5 or S1

A positive straight leg raise combined with posterior leg pain radiating to the foot is classic for L5 or S1 nerve root compression, typically from a herniated disc.

Question 233: A 5-year-old boy is brought in with inspiratory stridor, fever, and a 'steeple sign' on anteroposterior neck X-ray. What is the most likely causative organism?

Staphylococcus aureus
Parainfluenza virus (Correct answer)
Haemophilus influenzae type b
Streptococcus pyogenes

Correct answer: Parainfluenza virus

Croup (laryngotracheobronchitis) is most commonly caused by parainfluenza virus and produces the classic steeple sign on AP neck X-ray.

Question 234: Which sign is used to diagnose De Quervain tenosynovitis?

Phalen sign
McMurray test
Finkelstein test (Correct answer)
Tinel sign

Correct answer: Finkelstein test

The Finkelstein test, where ulnar deviation of the wrist with the thumb enclosed in the fist reproduces pain over the radial styloid, is used to diagnose De Quervain tenosynovitis.

Question 235: What position does PA have among US News and World Report's "top 100 jobs"?

2
1
3 (Correct answer)
4

Correct answer: 3

Physician Assistant has consistently ranked near the very top of U.S. News & World Report's Best Jobs list, placing 3rd in the cited ranking. The other positions don't match the report's listed standing for the PA profession.

Question 236: Which antifungal requires monitoring of hepatic function and is associated with QT prolongation due to CYP3A4 inhibition?

Nystatin
Terbinafine
Voriconazole (Correct answer)
Fluconazole

Correct answer: Voriconazole

Voriconazole is a potent CYP inhibitor that prolongs QT interval and is hepatotoxic; LFTs and ECG monitoring are recommended during therapy.

Question 237: Which of the following electrocardiogram (ECG) findings is most characteristic of acute pericarditis?

ST-segment elevation in a localized coronary distribution
Development of pathologic Q waves
Deep, symmetric T-wave inversions
Diffuse ST-segment elevation and PR-segment depression (Correct answer)

Correct answer: Diffuse ST-segment elevation and PR-segment depression

The classic ECG finding in acute pericarditis is diffuse, concave-up ST-segment elevation across multiple limb and precordial leads, which does not conform to a specific coronary artery territory. This is often accompanied by PR-segment depression, particularly in lead II. Localized ST elevation and Q waves are more indicative of a myocardial infarction.

Question 238: Which test is the gold standard for diagnosing H. pylori infection in a patient who has not recently taken PPIs or antibiotics?

Stool antigen test
Upper endoscopy with biopsy (Correct answer)
Urea breath test
Serology (IgG antibody)

Correct answer: Upper endoscopy with biopsy

Upper endoscopy with biopsy allows direct visualization and multiple testing methods (urease test, culture, histology), making it the gold standard for H. pylori diagnosis.

Question 239: A patient with gout and hyperuricemia is started on allopurinol. When should urate-lowering therapy ideally begin relative to an acute gout flare?

Immediately during the acute attack
Only after two confirmed flares
Six months after the last flare
Only after the acute flare has resolved, typically 2-4 weeks later (Correct answer)

Correct answer: Only after the acute flare has resolved, typically 2-4 weeks later

Initiating urate-lowering therapy during an acute flare can prolong or worsen symptoms; it is generally started 2-4 weeks after resolution.

Question 240: A 45-year-old with idiopathic pulmonary fibrosis develops acute worsening of dyspnea over 2 weeks with new bilateral ground-glass opacities on CT superimposed on honeycombing. What is this complication called?

Acute respiratory distress syndrome
Acute exacerbation of IPF (Correct answer)
Hypersensitivity pneumonitis flare
Organizing pneumonia

Correct answer: Acute exacerbation of IPF

Acute exacerbation of IPF is defined as rapid respiratory deterioration with new bilateral ground-glass opacities without an identifiable cause in a patient with established IPF.

Question 241: A 50-year-old woman presents with chronic watery diarrhea, episodic flushing, and wheezing. Urine 5-HIAA levels are elevated. Where is this tumor most likely located?

Appendix or terminal ileum (Correct answer)
Rectum
Stomach
Duodenum

Correct answer: Appendix or terminal ileum

Carcinoid syndrome (flushing, diarrhea, wheezing) with elevated 5-HIAA is most commonly caused by carcinoid tumors of the appendix or terminal ileum with hepatic metastases.

Question 242: Carpal tunnel syndrome results from compression of which nerve?

Radial nerve
Musculocutaneous nerve
Ulnar nerve
Median nerve (Correct answer)

Correct answer: Median nerve

Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel, causing numbness and tingling in the thumb, index, middle, and radial half of the ring finger.

Question 243: Which feature on history is most helpful in distinguishing inflammatory from mechanical back pain?

Onset after a specific lifting injury
Morning stiffness lasting more than 1 hour that improves with activity (Correct answer)
Pain relieved by rest
Pain that worsens with prolonged standing

Correct answer: Morning stiffness lasting more than 1 hour that improves with activity

Morning stiffness lasting over 60 minutes that improves with activity is a hallmark of inflammatory back pain, as seen in ankylosing spondylitis.

Question 244: A 28-year-old woman with known Crohn's disease presents with perianal fistulas and abscesses that have not responded to antibiotics. Which biologic agent is most appropriate?

Vedolizumab
Certolizumab pegol
Ustekinumab
Infliximab (Correct answer)

Correct answer: Infliximab

Infliximab (anti-TNF-α) is FDA-approved specifically for fistulizing Crohn's disease and has demonstrated efficacy in closing perianal fistulas.

Question 245: The Lachman test is used to assess integrity of which structure?

Posterior cruciate ligament
Anterior cruciate ligament (Correct answer)
Lateral meniscus
Medial collateral ligament

Correct answer: Anterior cruciate ligament

The Lachman test, performed with the knee at 20-30° flexion with anterior tibial translation, evaluates ACL integrity and has high sensitivity for ACL tears.

Question 246: Which of the following findings is most consistent with cardiac tamponade?

Beck's triad: hypotension, distended neck veins, muffled heart sounds (Correct answer)
Wide pulse pressure, bradycardia, hypertension
Loud S3 gallop, pulmonary edema, peripheral edema
Fever, friction rub, pleuritic chest pain

Correct answer: Beck's triad: hypotension, distended neck veins, muffled heart sounds

Beck's triad (hypotension, jugular venous distension, and muffled heart sounds) is the classic presentation of cardiac tamponade caused by pericardial fluid compressing the heart.

Question 247: A 28-year-old presents with sudden right-sided pleuritic chest pain and dyspnea after a long flight. CXR shows a 25% right-sided pneumothorax. He is hemodynamically stable with SpO2 of 96%. What is the best initial management?

Chest tube thoracostomy at 5th ICS anterior axillary line
Immediate needle decompression at 2nd ICS midclavicular line
Aspiration with 14-gauge angiocatheter and discharge if successful
Observation with supplemental oxygen and repeat CXR in 6 hours (Correct answer)

Correct answer: Observation with supplemental oxygen and repeat CXR in 6 hours

A small-to-moderate primary spontaneous pneumothorax in a stable patient can be managed with observation and supplemental O2, which accelerates pleural air reabsorption.

Question 248: A 15-year-old presents with fever, migratory polyarthritis, and a new heart murmur 3 weeks after untreated strep pharyngitis. What is the most likely diagnosis?

Acute rheumatic fever (Correct answer)
Reactive arthritis (Reiter syndrome)
Juvenile idiopathic arthritis
Systemic lupus erythematosus

Correct answer: Acute rheumatic fever

Acute rheumatic fever follows Group A strep infection and presents with carditis, migratory polyarthritis, chorea, erythema marginatum, and subcutaneous nodules (Jones criteria).

Question 249: A 45-year-old woman presents with fatigue, cold intolerance, weight gain, and constipation. TSH is 18 mIU/L and free T4 is low. Which is the most appropriate treatment?

Levothyroxine (T4) replacement (Correct answer)
Combined T3/T4 therapy
Methimazole
Liothyronine (T3) replacement

Correct answer: Levothyroxine (T4) replacement

Levothyroxine (synthetic T4) is the standard treatment for hypothyroidism; the body converts T4 to T3 as needed.

Question 250: A 55-year-old male complains of a chronic, gnawing epigastric pain that improves with meals but worsens 2-3 hours later. He has no alarm symptoms. Which of the following is considered the most accurate diagnostic test for an active Helicobacter pylori infection in this patient?

Stool antigen assay
Urea breath test
Serology testing
Upper endoscopy with biopsy (Correct answer)

Correct answer: Upper endoscopy with biopsy

While the urea breath test and stool antigen assay are excellent non-invasive tests, upper endoscopy with biopsy is considered the most accurate or 'gold standard' for the diagnosis of an active H. pylori infection. [30, 39] It allows for direct histological examination, rapid urease testing, and culture. In a patient over 50 with new-onset dyspepsia, endoscopy is also indicated to rule out other pathology like malignancy.

Question 251: Which neurotransmitter is deficient in Parkinson's disease?

Acetylcholine
GABA
Serotonin
Dopamine (Correct answer)

Correct answer: Dopamine

Parkinson's disease results from degeneration of dopaminergic neurons in the substantia nigra, leading to dopamine deficiency in the nigrostriatal pathway.

Question 252: A 29-year-old is diagnosed with Major Depressive Disorder (MDD) of moderate severity and has no other medical conditions. Which of the following is considered a first-line pharmacologic treatment for this patient?

Lithium
Alprazolam
Amitriptyline
Sertraline (Correct answer)

Correct answer: Sertraline

Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, are considered the first-line pharmacologic choice for Major Depressive Disorder due to their favorable balance of efficacy and tolerability. Amitriptyline is a tricyclic antidepressant (TCA) with a less favorable side-effect profile and is not a first-line agent. Alprazolam is a benzodiazepine used for anxiety and is not a primary treatment for MDD. Lithium is a mood stabilizer primarily used for bipolar disorder.

Question 253: Which of the following is the most appropriate initial imaging study for a patient with suspected osteoporosis?

CT scan of the lumbar spine
Plain X-ray of the spine
MRI of the hip
DEXA scan (Correct answer)

Correct answer: DEXA scan

DEXA (dual-energy X-ray absorptiometry) scan is the gold standard for measuring bone mineral density and diagnosing osteoporosis.

Question 254: Which electrolyte abnormality is most commonly associated with prolonged nasogastric suctioning?

Hypernatremia
Hypokalemic hypochloremic metabolic alkalosis (Correct answer)
Hyperkalemia
Hyperchloremic metabolic acidosis

Correct answer: Hypokalemic hypochloremic metabolic alkalosis

Prolonged NG suctioning removes HCl and K+, leading to hypokalemic hypochloremic metabolic alkalosis.

Question 255: A patient presents with pain and swelling over the lateral epicondyle of the elbow, worsened by wrist extension and gripping. What is the most likely diagnosis?

Medial epicondylitis
Olecranon bursitis
Lateral epicondylitis (tennis elbow) (Correct answer)
Radial tunnel syndrome

Correct answer: Lateral epicondylitis (tennis elbow)

Lateral epicondylitis (tennis elbow) involves overuse of the forearm extensor muscles, causing pain at the lateral epicondyle worsened by wrist extension and gripping.

Question 256: A PA is asked to perform a procedure they have not been trained to do. The most appropriate response is to:

Decline and refer the patient to a qualified provider (Correct answer)
Ask a nurse to assist and proceed
Perform the procedure with the patient's verbal consent only
Attempt the procedure to avoid inconveniencing the patient

Correct answer: Decline and refer the patient to a qualified provider

PAs are ethically and legally obligated to practice within their competency and should decline procedures they are not trained to perform, ensuring patient safety.

Question 257: A 58-year-old man presents with exertional chest pain relieved by rest. ECG at rest is normal. What is the most appropriate next diagnostic step?

Holter monitor
Coronary angiography
Exercise stress test (Correct answer)
Echocardiogram

Correct answer: Exercise stress test

Exercise stress testing is the standard initial evaluation for stable angina when the resting ECG is normal.

Question 258: Which of the following cardiovascular conditions is characterized by a bounding radial pulse, flushing, and paling of the nail beds (Quincke pulse)?

Thoracic aortic aneurysm
Tricuspid regurgitation
Coarctation of the aorta
Aortic regurgitation (Correct answer)

Correct answer: Aortic regurgitation

Aortic regurgitation is linked to a Quincke pulse, which alternately causes the skin or nail beds to flush and turn pale. The waterhammer pulse and pulsus bisferiens are additional distinguishing characteristics of the peripheral pulse in aortic regurgitation.

Question 259: According to the most recent United States Preventive Services Task Force (USPSTF) recommendations, at what age should average-risk adults begin screening for colorectal cancer?

45 (Correct answer)
50
40
55

Correct answer: 45

In May 2021, the United States Preventive Services Task Force (USPSTF) updated its guidelines, lowering the recommended age for average-risk adults to begin screening for colorectal cancer from 50 to 45. [9, 12, 16] This change was based on data showing an increasing incidence of colorectal cancer in younger adults. [12]

Question 260: A patient with Alzheimer's disease has deficiency of which neurotransmitter?

Norepinephrine
Serotonin
Dopamine
Acetylcholine (Correct answer)

Correct answer: Acetylcholine

Alzheimer's disease is associated with loss of cholinergic neurons in the nucleus basalis of Meynert, leading to acetylcholine deficiency, which is the basis of cholinesterase inhibitor therapy.

Question 261: Which statistical test is most appropriate for comparing means between three or more independent groups?

Pearson correlation
Student's t-test
Chi-square test
One-way ANOVA (Correct answer)

Correct answer: One-way ANOVA

One-way ANOVA compares means across three or more independent groups while controlling the type I error rate that would inflate with multiple t-tests.

Question 262: Which of the following is NOT a tetralogy of fallot feature?

Right ventricular hypertrophy
Right ventricular outflow obstruction
Large ventricular septal defect
A left to right cardiac shunt (Correct answer)

Correct answer: A left to right cardiac shunt

Tetralogy of Fallot is a complex congenital heart defect defined by four key features: a large ventricular septal defect (VSD), pulmonary stenosis (right ventricular outflow obstruction), an overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis and right ventricular hypertrophy, pressure in the right ventricle is typically higher than in the left, causing a *right-to-left* shunt of deoxygenated blood through the VSD. A left-to-right cardiac shunt is therefore not a characteristic feature of Tetralogy of Fallot.

Question 263: Which medication from the list below blocks histamine and lowers stomach acid levels?

Omeprazole (Prilosec)
Cimetidine (Tagamet) (Correct answer)
Magnesium Hydroxide (Maalox)
Metoclopramide (Reglan)

Correct answer: Cimetidine (Tagamet)

Cimetidine (Tagamet) is an H2-receptor antagonist. It works by blocking histamine H2 receptors on the parietal cells in the stomach, which are responsible for stimulating gastric acid secretion. By blocking these receptors, cimetidine effectively reduces the production of stomach acid, making it useful for conditions like ulcers and GERD.

Question 264: Which medication is classified as a disease-modifying antirheumatic drug (DMARD) and is first-line for rheumatoid arthritis?

Methotrexate (Correct answer)
Celecoxib
Ibuprofen
Prednisone

Correct answer: Methotrexate

Methotrexate is the anchor DMARD and first-line agent for rheumatoid arthritis, slowing disease progression and joint damage.

Question 265: A child presents with failure to thrive, foul-smelling greasy stools, and recurrent respiratory infections. Sweat chloride testing confirms the diagnosis. Which nutritional supplement is most critical for this patient?

Fat-soluble vitamins (A, D, E, K) (Correct answer)
Iron supplementation
Water-soluble vitamins
Calcium only

Correct answer: Fat-soluble vitamins (A, D, E, K)

Cystic fibrosis causes pancreatic exocrine insufficiency with fat malabsorption, making fat-soluble vitamin supplementation essential.

Question 266: Which of the following is a contraindication to IV tPA in acute ischemic stroke?

Age over 65
Blood pressure of 150/90 mmHg
Ischemic stroke or head trauma within the past 3 months (Correct answer)
Atrial fibrillation

Correct answer: Ischemic stroke or head trauma within the past 3 months

Recent ischemic stroke or serious head trauma within the prior 3 months is an absolute contraindication to IV tPA due to the risk of hemorrhagic transformation.

Question 267: A 45-year-old male presents with low back pain and morning stiffness lasting more than 1 hour that improves with exercise. HLA-B27 is positive. What is the most likely diagnosis?

Osteoarthritis
Reactive arthritis
Lumbar disc herniation
Ankylosing spondylitis (Correct answer)

Correct answer: Ankylosing spondylitis

Ankylosing spondylitis is a seronegative spondyloarthropathy strongly associated with HLA-B27, presenting with inflammatory back pain, prolonged morning stiffness relieved by activity.

Question 268: A patient presents with pain in the heel that is worst with the first steps in the morning and improves after walking. What is the most likely diagnosis?

Plantar fasciitis (Correct answer)
Calcaneal stress fracture
Tarsal tunnel syndrome
Achilles tendinopathy

Correct answer: Plantar fasciitis

Plantar fasciitis classically presents with heel pain that is worst with the first steps after rest (post-static dyskinesia) and improves with continued ambulation.

Question 269: Which medication class is contraindicated in patients with gout who are taking allopurinol and develop a skin rash?

NSAIDs
Colchicine
Corticosteroids
Ampicillin-class antibiotics (Correct answer)

Correct answer: Ampicillin-class antibiotics

Aminopenicillins (ampicillin, amoxicillin) increase the risk of severe drug reactions including Stevens-Johnson syndrome when used with allopurinol.

Question 270: A PA's differential diagnosis is overly influenced by a recently diagnosed patient with the same condition. Which cognitive bias is most likely operating?

Framing effect
Availability heuristic (Correct answer)
Anchoring bias
Overconfidence bias

Correct answer: Availability heuristic

The availability heuristic causes clinicians to overestimate the likelihood of diagnoses that come easily to mind, often due to recent or vivid experiences.

Question 271: A 50-year-old presents with symmetric ascending weakness and areflexia following a GI infection 3 weeks prior. CSF shows albuminocytologic dissociation. What is the most likely diagnosis?

Multiple sclerosis
Amyotrophic lateral sclerosis
Guillain-Barré syndrome (Correct answer)
Myasthenia gravis

Correct answer: Guillain-Barré syndrome

Guillain-Barré syndrome presents with ascending flaccid paralysis, areflexia, and CSF albuminocytologic dissociation (elevated protein with normal cell count), often following infection.

Question 272: A 16-year-old male presents with knee pain after a twisting injury during basketball. Exam shows a positive Lachman test and anterior drawer sign. What structure is most likely injured?

Lateral meniscus
Anterior cruciate ligament (Correct answer)
Posterior cruciate ligament
Medial collateral ligament

Correct answer: Anterior cruciate ligament

The Lachman test and anterior drawer sign both assess anterior tibial translation and are positive with anterior cruciate ligament (ACL) tears.

Question 273: A 35-year-old woman with chronic diarrhea, bloating, and a positive anti-tissue transglutaminase (anti-tTG) IgA antibody most likely has which condition?

Celiac disease (Correct answer)
Lactose intolerance
Whipple's disease
Microscopic colitis

Correct answer: Celiac disease

Elevated anti-tTG IgA is the most sensitive and specific serologic test for celiac disease.

Question 274: Which of the following increases the risk of testicular cancer?

Paraphimosis
Hypospadias
Cryptorchidism (Correct answer)
Hydrocele
Varicocele

Correct answer: Cryptorchidism

Testicular undegression, or cryptorchidism, raises the risk of testicular cancer. Varicocele, hydrocele, paraphimosis, and hypospadias are the remaining options; none of these are known risk factors.

Question 275: A 40-year-old woman presents with exertional dyspnea and a mean pulmonary artery pressure of 30 mmHg on right heart catheterization. She has no left heart disease or lung disease. Which treatment is first-line for Group 1 pulmonary arterial hypertension?

Supplemental oxygen therapy alone
High-dose calcium channel blockers for all patients
Phosphodiesterase-5 inhibitors or endothelin receptor antagonists (Correct answer)
Long-term anticoagulation with warfarin

Correct answer: Phosphodiesterase-5 inhibitors or endothelin receptor antagonists

PDE-5 inhibitors (sildenafil) or endothelin receptor antagonists (bosentan, ambrisentan) are first-line for Group 1 PAH in patients without vasoreactivity on testing.

Question 276: A 68-year-old with a 6 cm solitary pulmonary nodule has a PET scan showing high SUV uptake. CT-guided biopsy reveals adenocarcinoma. Which staging workup is MOST critical before surgical planning?

Echocardiography and stress test
Bronchoscopy with BAL
Brain MRI and mediastinoscopy (Correct answer)
Bone scan and liver biopsy

Correct answer: Brain MRI and mediastinoscopy

Brain MRI detects occult CNS metastases and mediastinoscopy evaluates mediastinal lymph node involvement, both critical for determining resectability in NSCLC.

Question 277: A 62-year-old man with alcoholic cirrhosis develops sudden onset, large-volume hematemesis. Endoscopy reveals actively bleeding esophageal varices. Which pharmacologic agent should be initiated immediately?

Octreotide (Correct answer)
Vasopressin IV bolus only
Propranolol
Nitroglycerin

Correct answer: Octreotide

Octreotide (somatostatin analogue) reduces splanchnic blood flow and portal pressure and is the preferred pharmacologic agent for acute variceal bleeding.

Question 278: A 70-year-old woman presents with confusion, constipation, bone pain, and a serum calcium of 13.2 mg/dL. Intact PTH is elevated. What is the most likely diagnosis?

Vitamin D toxicity
Primary hyperparathyroidism (Correct answer)
Milk-alkali syndrome
Malignancy-associated hypercalcemia

Correct answer: Primary hyperparathyroidism

Elevated PTH with hypercalcemia is diagnostic of primary hyperparathyroidism, most commonly due to a single parathyroid adenoma.

Question 279: A patient on clopidogrel for ACS is found to be a CYP2C19 poor metabolizer. What is the clinical implication?

Reduced antiplatelet effect and higher thrombotic risk (Correct answer)
No clinical significance
Enhanced drug efficacy
Increased bleeding risk

Correct answer: Reduced antiplatelet effect and higher thrombotic risk

Clopidogrel requires CYP2C19 activation to its active metabolite; poor metabolizers have diminished platelet inhibition and higher risk of recurrent events.

Question 280: A patient with CKD stage 3 is started on metformin. Which creatinine clearance threshold requires discontinuation of metformin?

< 30 mL/min (Correct answer)
< 15 mL/min
< 45 mL/min
< 60 mL/min

Correct answer: < 30 mL/min

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to risk of lactic acidosis.

Question 281: An internship or residency.

PA's are educated in the
PA's responsibilities
PA's dont need to do (Correct answer)
# of accredited schools

Correct answer: PA's dont need to do

Unlike physicians, PAs do not need to complete an internship or residency after graduation—they are trained to enter practice directly. While optional postgraduate residencies exist, they are not a required step, which is a key distinction from the physician pathway.

Question 282: Which DOES NOT fall under IPC's purview?

Attitudes
Skills
Lower or stabilized costs (Correct answer)
Knowledge

Correct answer: Lower or stabilized costs

Lower or stabilized costs are not a competency of IPC.

Question 283: Which of the following conditions DOES NOT result from long-term diabetes mellitus?

Glaucoma
Atherosclerosis
Hypotension (Correct answer)
Neuropathy

Correct answer: Hypotension

One of the frequent complications of long-term diabetes mellitus is hypertension, not hypotension.

Question 284: A 45-year-old man presents with dysphagia to solids that has progressed to liquids over 3 months, along with a 20-lb weight loss. Which diagnosis is most likely?

Achalasia
Esophageal spasm
Esophageal adenocarcinoma (Correct answer)
Zenker's diverticulum

Correct answer: Esophageal adenocarcinoma

Progressive dysphagia from solids to liquids with significant weight loss is classic for esophageal carcinoma.

Question 285: A 45-year-old patient is diagnosed with hypertrophic cardiomyopathy (HCM). Which of the following should be strongly advised against for this patient?

Genetic counseling for first-degree relatives
Treatment with beta-blockers for symptomatic relief
Participation in competitive, high-intensity sports (Correct answer)
Annual screening with echocardiography

Correct answer: Participation in competitive, high-intensity sports

Hypertrophic cardiomyopathy is a leading cause of sudden cardiac death in young athletes. The dynamic left ventricular outflow tract obstruction can worsen with intense physical exertion and dehydration. Therefore, patients with HCM are typically restricted from competitive, high-intensity sports to reduce this risk. Beta-blockers are a first-line treatment, and regular screening and genetic counseling are standard parts of management.

Question 286: Which of the following is an example of a primary source in medical research?

An original clinical trial published in a peer-reviewed journal (Correct answer)
A textbook chapter summarizing diabetes management
A news article reporting on a new vaccine
A systematic review of hypertension trials

Correct answer: An original clinical trial published in a peer-reviewed journal

A primary source presents original, firsthand research data, such as an original clinical trial.

Question 287: Which of the following is an example of deductive reasoning?

Observing 100 patients recover and concluding the treatment works
Forming a hypothesis based on repeated clinical observations
Surveying a sample and generalizing to a population
Noting that all mammals breathe air and concluding that whales breathe air (Correct answer)

Correct answer: Noting that all mammals breathe air and concluding that whales breathe air

Deductive reasoning applies a general rule (all mammals breathe air) to a specific case (whales) to reach a certain conclusion.

Question 288: Which opioid analgesic has active metabolites that accumulate in renal failure and can cause CNS toxicity?

Hydromorphone
Fentanyl
Buprenorphine
Morphine (Correct answer)

Correct answer: Morphine

Morphine-6-glucuronide accumulates in renal failure and can cause prolonged sedation, respiratory depression, and seizures.

Question 289: Which sentence contains a dangling modifier?

Running quickly, the bus was missed by the student. (Correct answer)
Because she ran quickly, the student missed the bus.
The student, running quickly, missed the bus.
The student ran quickly but missed the bus.

Correct answer: Running quickly, the bus was missed by the student.

In the first option, the participial phrase 'Running quickly' incorrectly modifies 'the bus' rather than the student.

Question 290: Which organization became a supporting organization of the National Commission on Certification of Physician Assistants in 2011?

Duke University Medical Center
The PA History Society (Correct answer)
American Academy of Physician Assistants
Association of Physician Assistant Programs

Correct answer: The PA History Society

The PA History Society became a supporting organization of the NCCPA in 2011, aligning its historical-preservation mission with the certifying body. The AAPA, Duke, and APAP play different roles and were not the supporting organization referenced here.

Question 291: A 45-year-old with type 2 diabetes and established cardiovascular disease is started on an antidiabetic agent. Which class has demonstrated cardiovascular mortality benefit?

Meglitinides
Alpha-glucosidase inhibitors
SGLT-2 inhibitors (Correct answer)
Sulfonylureas

Correct answer: SGLT-2 inhibitors

SGLT-2 inhibitors (e.g., empagliflozin) have demonstrated significant reduction in major adverse cardiovascular events in large outcome trials.

Question 292: A 30-year-old with epilepsy presents in status epilepticus. After two doses of lorazepam, seizures persist. What is the next pharmacological treatment?

Oral phenytoin
Repeat lorazepam indefinitely
Oral valproate
IV levetiracetam or fosphenytoin (Correct answer)

Correct answer: IV levetiracetam or fosphenytoin

After benzodiazepine failure in status epilepticus, the next step is IV second-line agents such as levetiracetam, fosphenytoin, or valproate per established treatment algorithms.

Question 293: All of the following EKG abnormalities are frequently present while assessing the diagnosis of atrial fibrillation EXCEPT:

Irregular rhythm
No visible P waves
QRX complex of ≤ 0.12 seconds
Abnormal P waves (Correct answer)

Correct answer: Abnormal P waves

Atrial fibrillation (AFib) is characterized by chaotic and disorganized electrical activity in the atria, which prevents the formation of distinct, coordinated P waves. Instead, the EKG typically shows an irregularly irregular rhythm with no visible P waves, or only fine fibrillatory waves. Therefore, the presence of clearly discernible, albeit abnormal, P waves would argue against a diagnosis of atrial fibrillation.

Question 294: A PA prescribes a medication that inhibits HMG-CoA reductase. A patient on this medication begins taking clarithromycin for an infection. What adverse effect is most concerning?

QT prolongation
Serotonin syndrome
Agranulocytosis
Rhabdomyolysis (Correct answer)

Correct answer: Rhabdomyolysis

Clarithromycin inhibits CYP3A4, increasing statin plasma levels and dramatically raising the risk of rhabdomyolysis when co-administered with statins metabolized by CYP3A4.

Question 295: A 45-year-old, otherwise healthy male with no comorbidities or recent antibiotic use is diagnosed with community-acquired pneumonia (CAP) in an outpatient setting. According to the most recent IDSA/ATS guidelines, which of the following is a recommended first-line empiric monotherapy?

Levofloxacin
Vancomycin
Amoxicillin (Correct answer)
Ceftriaxone

Correct answer: Amoxicillin

For healthy outpatient adults with CAP and no significant comorbidities or risk factors for resistant pathogens, the IDSA/ATS guidelines strongly recommend high-dose amoxicillin (1g three times daily) as a first-line agent. Doxycycline is another option. Levofloxacin is a respiratory fluoroquinolone typically reserved for patients with comorbidities or recent antibiotic exposure. Vancomycin is used for suspected MRSA and ceftriaxone is a parenteral antibiotic for inpatient use.

Question 296: A 28-year-old woman with Type 1 DM is found unresponsive with fingerstick glucose of 28 mg/dL. No IV access is available. What is the most appropriate immediate treatment?

Intramuscular glucagon injection (Correct answer)
Orange juice by mouth
Oral glucose gel under the tongue
Dextrose 50% IV push

Correct answer: Intramuscular glucagon injection

IM glucagon is the correct treatment for an unconscious hypoglycemic patient without IV access, as oral agents cannot be safely administered.

Question 297: An intubated patient's capnography waveform shows a gradually rising plateau phase (shark-fin pattern) instead of the normal flat plateau. What does this indicate?

Obstructive airway disease with uneven emptying (Correct answer)
Hypoventilation with CO2 retention
Esophageal intubation
Cardiac output compromise

Correct answer: Obstructive airway disease with uneven emptying

The shark-fin or sloped plateau (phase III) on capnography indicates uneven alveolar emptying due to airflow obstruction, as seen in asthma or COPD.

Question 298: In the cell cycle, at which checkpoint is DNA integrity assessed before the cell commits to DNA replication?

Restriction point
G1/S checkpoint (Correct answer)
Spindle assembly checkpoint
G2/M checkpoint

Correct answer: G1/S checkpoint

The G1/S checkpoint (restriction point) assesses DNA integrity and cell size before the cell commits to S phase DNA replication.

Question 299: A 66-year-old male with a significant smoking history presents with increased dyspnea, wheezing, and a change in sputum color from white to green over the past three days. His baseline oxygen saturation is 91% on 2L nasal cannula, but today it is 87%. According to the GOLD guidelines, which of the following is the most critical initial intervention for his acute COPD exacerbation?

Obtain an urgent CT angiogram of the chest
Start broad-spectrum intravenous antibiotics immediately
Initiate systemic corticosteroids and inhaled short-acting bronchodilators (Correct answer)
Administer high-flow oxygen to achieve an SpO2 of >95%

Correct answer: Initiate systemic corticosteroids and inhaled short-acting bronchodilators

The cornerstones of managing an acute COPD exacerbation are rapid-acting inhaled bronchodilators (beta-agonists and anticholinergics) to relieve bronchospasm and systemic glucocorticoids to reduce airway inflammation. While oxygen is necessary for hypoxemia, the target saturation is typically 88-92% to avoid suppressing the hypoxic respiratory drive. Antibiotics are indicated for increased sputum purulence (as seen here), but bronchodilators and steroids are the priority intervention. A CT angiogram would be considered if pulmonary embolism was highly suspected but is not the first-line step for a typical exacerbation.

Question 300: How many hours of continuing medical education (CME) must a PA complete every two years to maintain NCCPA certification?

100 hours (Correct answer)
50 hours
200 hours
150 hours

Correct answer: 100 hours

PAs must complete 100 hours of CME every two years, with at least 50 hours being Category 1 credits.

Physician Assistant National Certifying Exam (PANCE)

The PANCE is the entry-level certification exam administered by NCCPA that assesses medical and surgical knowledge essential for physician assistants; passing it is required to practice as a PA in the United States.

300

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300 min

Time Limit

65%

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