Physician Assistant Exam Articles

Article / Updated 06-20-2023

A lot of pathology and Physician Assistant Exam questions concern the small and large intestines. Here you see conditions such as irritable bowel syndrome (IBS), ischemic bowel, inflammatory bowel disease (IBD), celiac disease, and diverticulitis. Irritable bowel syndrome (IBS) Irritable bowel syndrome (IBS) is a diagnosis of exclusion after other conditions have been ruled out. It’s a clinical diagnosis — you can’t diagnose this condition with endoscopy and biopsy or barium swallow as you can with many other GI conditions, because the findings are often normal. Common symptoms include constipation, diarrhea, or a combination of both. A stereotypical candidate for IBS is someone under a great deal of stress who has problems with either diarrhea or constipation during the day. In a typical PANCE question, you get hints such as “it has been going on for a while,” “both endoscopy and colonoscopy are negative,” “and stool studies, including those for ova and parasites, are negative.” A very common syndrome associated with IBS is fibromyalgia syndrome. The treatment for IBS includes recognizing the triggers, including food, physical stressors, and psychological stressors. Many of the anticholinergic medications, such as dicyclomine (Bentyl), have been tried in treating IBS. Ischemic bowel Ischemic bowel, also known as ischemic colitis, commonly occurs in older individuals. Risk factors and medical conditions associated with ischemic bowel include atherosclerosis of the intestinal vessels, atrial fibrillation or the presence of a left ventricular mural thrombus, and a hypercoagulable state. Low blood pressure can precipitate mesenteric ischemia due to hypoperfusion of these vessels. Here are key points about ischemic bowel: The classic presentation is pain out of proportion to clinical findings. The person (usually with one of the preceding risk factors) can have diffuse midepigastric pain but also have a benign physical examination. The pain worsens after eating a meal. Blood flow to the mesenteric area increases after a meal to aid with digestion, and the timing of the abdominal discomfort in relation to eating can point to ischemic bowel. A person can have mesenteric angina or mesenteric ischemia, which is an acute problem. If a large amount of the bowel is affected, expect to see a lactic acidosis and an anion gap on the CHEM-7. If the affected person’s abdominal pain is just an episode of angina, you may not see a lactic acidosis. If findings suggest an acute mesenteric event, the best way to look at the intestine is an exploratory laparotomy. A CT scan of the abdomen and pelvis with oral contrast may suggest bowel wall thickening, but this is a nonspecific pattern that you also see with other types of colitis. That being said, the CT scan is the best test for looking at the integrity of the bowel wall. Inflammatory bowel disease (IBD) Inflammatory bowel disease (IBD) is a comprehensive term covering two different but overlapping conditions: Crohn’s disease and ulcerative colitis. Both of these conditions confer an increased risk of colon cancer. Crohn’s disease is an inflammatory condition that can involve any area of the GI tract from the mouth to the anus, although it’s usually predominant in the ileum and ileocecal region of the small intestine. When confined to this area, it’s called regional enteritis. Histologically, Crohn’s disease is characterized by noncaseating granulomas on tissue biopsy. The etiology behind the inflammation is unknown. Note that this condition affects all layers of the intestine. When it affects the small intestine, especially the ileum, Crohn’s can cause malabsorption of key nutrients, especially the fat-soluble vitamins A, D, E and K. Here are the key points about Crohn’s disease: It usually occurs in younger people, with an initial onset in the teenage years up to the mid-30s. It’s characterized by the presence of skip lesions as well as what looks like a cobblestoning mucosa on colonoscopy. Crohn’s can affect the anus. If on you’re asked about the presence of anal fissures on the PANCE, think Crohn’s disease. Treatment can involve steroids and salicylate derivatives such as mesalamine. Antibiotics such as metronidazole can be used. In advanced cases that have been refractory to treatment, you can use intravenous infliximab. Surgery is not curative in Crohn’s diseas. Ulcerative colitis (UC) overlaps with Crohn’s disease to some extent, but here are some key differences: Unlike Crohn’s, ulcerative colitis involves only the superficial mucosa, not all layers of the intestine. Ulcerative colitis doesn’t have these skip lesions; the area of inflammation is continuous. Ulcerative colitis is predominantly in the sigmoid-rectal region. In fact, a common presenting symptom of ulcerative colitis is hematochezia and a colonoscopy that demonstrates ulcerative proctitis. Crohn’s, on the other hand, is predominantly in the small intestine, is sometimes in the large intestine, and can affect the anus. Crohn’s disease has a higher rate of strictures than ulcerative colitis. Both are associated with the possible development of obstruction, abscess formation, perforation, and fistula formation. Ulcerative colitis increases the risk of developing sclerosing cholangitis. Remember Charcot’s triad of right upper-quadrant pain, fevers, and jaundice for the diagnosis of cholangitis. Ulcerative colitis treatment can consist of steroids, although it primarily consists of 5-ASA derivatives. They can be given either orally or rectally. Both ulcerative colitis and Crohn’s disease can be associated with extraintestinal manifestations, which makes sense because both conditions are inflammatory. They can be associated with eye disease and certain skin lesions, including pyoderma gangrenosum and erythema nodosum. IBD is also associated with inflammatory arthritis. IBD, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis are examples of the seronegative spondyloarthropathies. All are associated with HLA-B27 expression. The arthritis associated with IBD is thought to affect more of the peripheral joints, especially during an active flare of IBD. Which of the following conditions can be associated with caseating granulomas? (A) Crohn’s disease (B) Sarcoidosis (C) Ulcerative colitis (D) Tuberculosis (E) Silicosis The correct answer is Choice (D). Tuberculosis is associated with caseating granulomas.

Cheat Sheet / Updated 04-13-2022

When you're preparing to take the PANCE or PANRE, you may feel like you have to know an endless amount of information. How will you ever remember all the details of so many diseases and conditions? Here, you can review some useful mnemonics that will not only help your recall as you prepare for your physician assistant exam but also improve your clinical acumen.

Article / Updated 05-13-2016

A common scenario you deal with clinically and for the Physician Assistant Exam (PANCE) is inadvertently finding a lung lesion on a chest radiograph. You’re looking for something, and bam! There it is. What do you do about it? You assess the lesion on the radiograph: Check the other lung findings to make sure that you’re just dealing with a pulmonary nodule. Other lung findings should be normal. Examples of abnormal findings include the presence of atelectasis or a recurrent pneumonia that won’t go away despite repeated treatment with antibiotics. The presence of adenopathy, especially hilar adenopathy, should be inspected on the chest radiograph. Know the size of the lung lesion. The number 3 is the key. If the lung lesion is < 3 cm, you likely have a lung nodule. If it’s > 3 cm, you’re likely dealing with a lung mass. The larger the lung lesion, the more likely that you’re dealing with a malignancy. Look at the edges of the lesion. A lung malignancy has irregular or spiculated borders. Benign lesions tend to have smooth edges. See whether the lesion contains calcium. More often than not, calcification suggests a benign lesion. In fact, calcification has many benign causes, including old, healed infections or reaction to a foreign body. Granulomas are a perfect example of a nonmalignant calcified lung lesion. However, if the calcification is irregular or eccentric, there’s a higher chance that you’re dealing with a malignancy. If all else fails and you need a better assessment of the solitary nodule, obtain a CT scan. This step may or may not be necessary. After you’ve looked at the characteristics of the lesion, look at the characteristics of the person. Is he or she old or young? A smoker? An older person who smokes has a higher chance of malignancy. You can watch people who are at lower risk with serial imaging, but for those who are at higher risk, you may need to get a biopsy to find out what you’re dealing with. You’re evaluating a 55-year-old man who presents to the ER with hemoptysis. He hasn’t been feeling well for a while. He says he has intermittent episodes of dizziness and diarrhea that comes on for no reason. He feels flushed. This has been occurring for a few weeks. You obtain a chest radiograph, and it shows a tumor located on the right mainstem bronchus. What does this lung mass likely represent? (A) Small-cell lung cancer (B) Legionellosis (C) Tuberculosis (D) Carcinoid tumor (E) Pulmonary embolus The correct answer is Choice (D). Carcinoid tumor is a neuroendocrine tumor that, although not aggressive, is treated like a lung mass. Some patients can have the symptoms mentioned in the question, including dizziness, diarrhea, and flushing, because the tumor secretes serotonin. A CT scan is used for staging, because the most common place of spread is to the liver. The treatment is surgery.

Article / Updated 03-26-2016

In anemia, the body has a reduced quantity of red blood cells. One of the best ways to classify anemia is by the MCV, or mean corpuscular volume, which is expressed in femtoliters (fL). The MCV helps you think about the cause of the anemia and how to evaluate for it: Microcytic anemias (low MVC, < 79 fL): Think TAIL: thalassemia, anemia of chronic disease, iron deficiency anemia, lead poisoning. Macrocytic anemias (high MCV, > 100 fL): Think BILL: B12 deficiency, impaired liver function, low folate levels, low thyroid levels. Normocytic anemias (normal MCV, 80–99 fL): Think RAM: renal dysfunction, anemia of chronic disease (also can cause a low MCV), malignancy or myelopthisic anemia.

Article / Updated 03-26-2016

When you're treating a non-ST elevation myocardial infarction (an NSTEMI), keep OH BATMAN in mind. The mnemonic works for treating unstable angina, too. O = oxygen: Ischemia implies oxygen deprivation, which leads to increased myocardial oxygen demand and increased myocardial work. The goal of treatment is to reduce the workload of the heart. Every person admitted to the hospital with acute coronary syndrome (ACS) is given oxygen via nasal cannula. H = heparin: This blood thinner works by potentiating antithrombin III. Its purpose is to prevent clotting and to thin the blood during an ACS. Heparin can be given for unstable angina, but it's almost always given to a person with an NSTEMI. B = beta blocker: This is a standard of care for anyone with ACS, both an NSTEMI and a STEMI. It decreases the workload of the heart and should improve morbidity and mortality. The most common beta blockers used are metoprolol (Lopressor) and atenolol (Tenormin). A = aspirin: Anyone with an MI needs to chew an aspirin right away. It's an antiplatelet agent that has saved countless lives. T = thrombolysis: Use thrombolysis in the setting of a STEMI if and only if cardiac catheterization can't be done within a few hours of the ischemic event. M = morphine: Morphine is for managing the pain associated with an MI. You can also use it in treating CHF/pulmonary edema. A = ACE inhibitors: ACE inhibitors can help preserve myocardium in the setting of an MI. They're usually given in the first 24 hours unless acute kidney failure is present. N = nitroglycerin: This coronary artery vasodilator helps in the management of ACS. In the setting of an NSTEMI, nitroglycerin is usually given as a continuous infusion along with heparin. It can also be given as a pill (isosorbide mononitrate, brand name Imdur) or as a topical nitropaste applied across the chest. The person with ACS is going to be on multiple treatments at one time. For example, the person with an NSTEMI will be on IV heparin and nitroglycerin, on oxygen via nasal cannula, and on oral metoprolol. Just because someone comes into the hospital on warfarin (Coumadin) doesn't mean that he or she can't have an MI. Coumadin isn't an antiplatelet drug. It works on the extrinsic clotting pathway. Coumadin won't inhibit platelet aggregation/clumping, which is why aspirin and clopidrogel (Plavix) are used in treating ACS.

Article / Updated 03-26-2016

An APGAR score measures how well a newborn is doing at 1 and 5 minutes after birth. The five factors you evaluate just happen to line up with the last name of the doctor, Dr. Virginia Apgar, who created the scoring system. Here are the APGAR factors: A = appearance: The skin color should be pinkish. P = pulse: The pulse should be 140–160 beats per minute. G = grimace: After stimulation, the newborn should pull away or maybe give a good cry. A = activity: The arms and legs should be flexed and resist extension. R = respiration: There should be a good, loud cry (from the baby, not you). Each factor gets a score of 0, 1, or 2, and you perform the test twice. A total score of 7 or greater means that the newborn is in good shape. A score of less than 7 means that the newborn's in trouble. Check your textbooks for details on designating a specific score for each factor.

Article / Updated 03-26-2016

You can use the alphabetic classification system to evaluate melanoma, the most aggressive form of skin cancer. This guide helps you determine whether a skin lesion is malignant. The mnemonic is the first five letters of the English alphabet — A, B, C, D, and E. Here are the warning signs: A = asymmetry: If one side of the lesion differs from the other, the lesion is more likely to be malignant. B = borders: Are the borders of the skin lesion regular or irregular? Are they smooth or spiculated? The more irregular the borders, the greater the likelihood that you’re dealing with a malignancy. C = colors: The melanoma may have more than one color. D = diameter: The larger the lesion, the greater the risk that it’s melanoma. A skin lesion of more than 9–10 mm is more suspicious for melanoma. E = evolution: How is the lesion changing over time, in terms of appearance and size? Melanoma is more likely to change. If you suspect melanoma, the next step is a skin biopsy.

Article / Updated 03-26-2016

The National Commission on Certification of Physician Assistants administers the two tests that are required of Physician Assistants: the PANCE, which certifies you to work as a PA, and the PANRE, which you take every 6 years (or 10 years starting in 2014) for recertification. Here is a quick overview of each test. Get your PANCE on The PANCE is the essential exam for certification, and certification is essential for licensure. This exam has 300 questions and takes 5 hours to complete, not including breaks. The PANCE is a testimonial to your knowledge. Doctors and nurses take qualifying exam-inations, so for a PA, certification is expected, too. This tells the world you’re ready to do the work. A few simple — but not easy — steps are involved in preparing for the PANCE. You’ve already accomplished the first few items: Enter a PA program at an accredited school. Take the classes and do the clinical rotations. Buy an excellent test preparation book. Begin a concerted program of test preparation. Review for the PANRE The Physician Assistant National Recertifying Examination (PANRE) is just what it says — a periodic recertifying examination that ensures that your knowledge is up to date. Every 6 years, a PA must successfully complete the PANRE. This test has 240 questions (instead of the PANCE’s 300), and there are four test blocks instead of five. You still average, however, about a minute per question (60 questions in 60 minutes). The PANRE offers you content options. About 60 percent is the same generalist exam as the PANCE, but you choose the emphasis of the other 40 percent. Here are your three options: Adult medicine Surgery Primary care A recertifying PA may want to choose adult medicine or surgery if that’s where he or she works. If you choose primary care, then the PANRE content won’t be at all different from the PANCE. And even if you choose the surgery or the adult medicine option, a large portion of the examination will still contain general medicine questions. Earn a Certificate of Added Qualification (CAQ) A practicing PA can earn a Certificate of Added Qualification, or CAQ. This certificate recognizes the PA for advanced knowledge and a skill set in a particular specialty. Current CAQ specialties include nephrology, orthopedic surgery, cardiothoracic surgery, emergency medicine, and psychiatry. Here are the requirements for the CAQ: Having worked the equivalent of 2 years full time as a PA with at least 50 percent of that time spent in that particular specialty Obtaining continuing medical education (CME) hours that are specific to the specialty Having a supervising physician write a letter of support stating a high level of performance Taking a multiple-choice examination of 120 questions in that specialty area

Article / Updated 03-26-2016

These practice questions give you a sense of what to expect of hematology and oncology questions on the Physician Assistant Exam (PANCE). They also address important subject areas you need to be familiar with, without regard to the test. Example PANCE Questions You’re evaluating a 43-year-old man who presents to the ER with an abnormal complete blood count (CBC). The white blood cell count is 6.3 mg/dL, the hemoglobin is 7.4 mg/dL, and the platelet count is 40 mg/dL. You order a peripheral smear, and there are schistocytes. The LDH level is 2,500. Plasmapheresis isn’t available at your hospital facility. What would be your next immediate step? (A) Platelet transfusion (B) Intravenous steroids (C) Intravenous immunoglobulin (IVIG) (D) Fresh frozen plasma (FFP) transfusion (E) Splenectomy Which of the following is an example of a macrocytic anemia? (A) Anemia of kidney disease (B) Chronic liver disease (C) Myelophthisic anemia (D) Multiple myeloma (E) Pure red cell aplasia You’re evaluating a patient with anemia. During the course of your examination, you note that the patient has a positive monoclonal spike on a serum protein electrophoresis. You’re not sure of the significance of this. Which one of the following tests would you order next? (A) CT scan of thorax, abdomen, and pelvis (B) Nuclear medicine bone scan (C) A radiographic skeletal survey (D) MRI spine survey with gadolinium (E) CT scan of the spine with intravenous contrast What is the most common cause of a hypercoagulable state? (A) Prothrombin gene mutation (B) Factor V Leiden mutation (C) Nephrotic syndrome (D) Antiphospholipid antibody syndrome (E) Antithrombin III deficiency You are evaluating a 23-year-old woman who presents with recurrent epistaxis. She also experiences some bleeding from her gums when she brushes her teeth. Other past medical history is unremarkable, and the patient denies taking any medications, including NSAIDs. On examination, there is no splenomegaly. The CBC shows a WBC of 7.4 mg/dL, hemoglobin of 11.3 mg/dL, and a platelet count of 220,000. What would be your next step? (A) Obtain an abdominal ultrasound to be sure splenomegaly is not present. (B) Order a bone marrow biopsy. (C) Test for von Willebrand disease. (D) Obtain stat creatinine to evaluate kidney function. (E) Send peripheral blood for flow stat creatinine. Which one of the following tumor markers and its association is correct? (A) CA125 — breast cancer (B) CA19-9 — ovarian cancer (C) Alpha-fetoprotein — hepatocellular carcinoma (HCC) (D) Prostate-specific antigen (PSA) — testicular cancer (E) Carcinoembryonic antigen (CEA) level — prostate cancer Example PANCE Answers and Explanations 1. D. This patient has thrombotic thrombocytopenic purpura (TTP), so you would transfuse fresh frozen plasma. Platelet transfusions are good in the treatment of idiopathic thrombocytopenic purpura (ITP) but not TTP. Steroids and splenectomy are treatments for ITP. Some clinicians also use intravenous immunoglobulin in the treatment of ITP. 2. B. Chronic liver disease is associated with a macrocytic anemia. All the other choices are associated with a normocytic, normochromic anemia. Pure red cell aplasia is an autoimmune process in which antibodies are produced against erythropoietin. This causes a hypoproliferative bone marrow concerning the production of red blood cells, but the patient has normal leukocytes and platelets. 3. C. You suspect that the patient has multiple myeloma based on the initial positive monoclonal spike on the serum protein electrophoresis, but the patient may have a monoclonal gammopathy of unknown significance (MGUS). You’d order a skeletal radiographic survey to look for lytic lesions. Choice (A) isn’t right because a CT scan of the thorax, abdomen, and pelvis is used for staging many solid organ cancers as well as lymphomas. A bone scan is good only when you’re looking for bone metastasis concerning solid organ cancers that have osteoblastic activity. You wouldn’t expect to see multiple myeloma, which is predominantly a lytic process. An MRI, Choice (D), or CT scan, Choice (E), with their respective contrasts, wouldn’t be indicated at this time. 4. B. The most common cause of a hypercoagulable state is a Factor V Leiden mutation. Patients can be homozygous or heterozygous for this mutation. The other choices are causes of a hypercoagulable state but are not as common as Factor V Leiden mutation. Antithrombin III deficiency is a common cause of clotting in younger people, as are Protein C and Protein S deficiencies. 5. C. The patient has recurrent problems with mucosal bleeding, which suggests a problem with platelet function. Her platelet count is normal, which should suggest a qualitative platelet problem. Although kidney disease, Choice (D), could cause qualitative platelet function, there are usually other issues present (anemia, uremic symptoms, and so forth). The other answers are not applicable to this problem. Flow cytometry, Choice (E), is sometimes ordered by a hematologist for evaluation of malignancy. A bone marrow biopsy, Choice (B), is not indicated, and Choice (A), an abdominal ultrasound, doesn’t make sense. You would test for von Willebrand disease. 6. C. Alpha-fetoprotein is associated with hepatocellular carcinoma (HCC). The other choices don’t represent the correct tumor markers with their corresponding cancers. CA19-9 is associated with breast cancer, and CA125 is associated with ovarian cancer. CEA is a tumor marker associated with colon cancer. PSA is associated with prostate cancer, not testicular cancer.

Article / Updated 03-26-2016

As a student, you’ve likely seen and evaluated patients with toxic ingestions, fatal or near-fatal drug overdoses, or drug-drug interactions that adversely affected their health. These practice questions are similar to the Physician Assistant Exams (PANCE or PANRE) pharmacology and toxicology questions. Example PANCE Questions Which one of the following is true concerning salicylate intoxication? (A) High blood levels cannot be removed by dialysis. (B) If a respiratory alkalosis is present, do not administer intravenous bicarbonate. (C) Salicylate intoxication causes both a metabolic acidosis and a metabolic alkalosis. (D) The recommended treatment is intravenous fluids without dextrose. (E) Oil of wintergreen can cause salicylate poisoning. You are evaluating a 35-year-old woman who presents with an acute lithium overdose. Which one of the following statements concerning lithium is true? (A) Aggressive diuresis is needed to augment lithium excretion. (B) Hypocalcemia can be seen as a side effect of lithium. (C) Lithium cannot be removed by dialysis. (D) It is recommended that you avoid the use of saline in lithium intoxication. (E) You should evaluate thyroid function in anyone taking lithium. Which one of the following is the treatment for a heparin overdose? (A) Vitamin K (B) Fresh frozen plasma (C) Protamine sulfate (D) Desmopressin acetate (DDAVP) (E) Cryoprecipitate Which one of the following antidotes matches the underlying toxicity? (A) Benzodiazepines — naloxone (Narcan) (B) Narcotics — flumazenil (Romazicon) (C) Ethylene glycol — ethanol (booze) (D) Acetaminophen — fomepizole (4-methylpyrazole) (E) High carboxyhemoglobin — methylene blue Which one of the following statements concerning digoxin is true? (A) Digoxin is used in treating diastolic heart failure. (B) Digoxin toxicity is treated with dialysis. (C) Digoxin dosing must be increased when kidney disease is present. (D) Amiodarone and quinidine can decrease digoxin levels. (E) Hypokalemia can exacerbate digoxin toxicity. You are asked to see a 40-year-old man in the emergency room because of fever and altered mental status. He was recently started on fluphenazine (Prolixin). He is agitated and his temperature is 39.4°C (103°F). His blood pressure is 160/100 mmHg. A CPK level is 50,000. What is the most appropriate treatment at this time? (A) Urgent hemodialysis (B) Intravenous saline alone for the rhabdomyolysis (C) Lorazepam (Ativan) for agitation (D) Dantrolene (E) Cyproheptadine Example PANCE Answers and Explanations Use this answer key to score the practice pharmacology/toxicology questions. The answer explanations give you some insight into why the correct answer is better than the other choices. 1. E. Oil of wintergreen is a topical methyl salicylate that can cause salicylate poisoning. Levels greater than 100 mg/dL and a metabolic acidosis can be indications for dialysis. Even if a respiratory alkalosis is present, intravenous bicarbonate is still recommended to enhance the renal elimination of salicylic acid. Choice (C) is incorrect because salicylate intoxication causes a respiratory alkalosis and a metabolic acidosis. And intravenous fluids with dextrose are often recommended because even if the serum glucose level is normal, there can be low blood glucose levels in the central nervous system. 2. E. Thyroid function tests should be obtained in anyone on lithium. The woman needs intravenous saline to facilitate lithium excretion, so Choice (D) is out. Never use diuretics; in fact, volume depletion and dehydration can increase the risk of lithium toxicity. Other metabolic effects of lithium include hypercalcemia (not hypocalcemia), hypothyroidism, hyperthyroidism, and diabetes insipidus. Lithium can be removed by dialysis. 3. C. Use protamine sulfate. Vitamin K and fresh frozen plasma can be used for a warfarin (Coumadin) overdose. Cryoprecipitate is another type of clotting factor, high in vWf and Factor VIII. Desmopressin acetate can be used to treat bleeding in someone with von Willebrand’s disease. 4. C. Before the use of methylpyrazole (fomepizole), ethanol was used to block the breakdown of ethylene glycol and methanol into their more toxic metabolites. Ethanol has a pretty high affinity for alcohol dehydrogenase, the first enzyme in that metabolic pathway. Naloxone (Narcan) is used for an opiate overdose, and flumazenil (Romazicon) is used for a benzodiazepine overdose. N-acetylcysteine is the antidote for acetaminophen overdose, not fomepizole. And there’s no match between high carboxyhemoglobin and methylene blue. Sometimes test-writers try to trick you with terminology. An elevated carboxyhemoglobin level means CO poisoning; the treatment is oxygen. 5. E. Hypokalemia exacerbates digoxin toxicity. Digoxin is used to treat systolic heart failure, not diastolic heart failure. Digoxin is not eliminated by dialysis; its toxicity is treated using Fab antibody fragments. Its dosing is decreased in kidney disease. Both quinidine and amiodarone can increase, not decrease, digoxin levels. 6. D. The patient has neuroleptic malignant syndrome (NMS) and likely has muscle rigidity, so give him dantrolene. Pay attention to key words when answering test questions. Certainly if you were seeing this patient clinically, you’d start IV fluids, especially in the setting of rhabomyolysis. Choice (A), urgent hemodialysis, isn’t the best answer here. You’d need more information for this choice to be the correct answer. The word alone in Choice (B) makes it a wrong answer. Choice (C) isn’t correct because the use of a benzodiazepine isn’t the most complete answer here. Choice (E) isn’t the right answer because cyproheptadine can be used for the treatment of serotonin syndrome, and this is NMS.