Practice Physician Assistant Exam Questions on Surgical Topics
To do well on the Physician Assistant Exams (PANCE or PANRE), you need a good sense of broad-based surgical concepts, not encyclopedic knowledge about a specific topic. One vital area is the surgical signs and symptoms that you’d focus on when performing a history and physical (H&P). You need to know the essentials of a thorough pre-operative assessment (including pre-operative risk) and how to care for the post-operative patient.
These practice questions are similar to the PANCE/PANRE surgical questions.
Example PANCE Questions
You’re preparing a patient to go into surgery for emergent cholecystectomy. The patient presented with a fever of 38.9°C (102°F) and acute right upper-quadrant pain. Ultrasound demonstrates ductal dilatation, thickening of the gallbladder wall, and pericholecystic fluid. The patient is made NPO and started on intravenous fluids. Which antibiotic would be appropriate to administer?
(A) Vancomycin (Vancocin)
(B) Gentamicin (Garamycin)
(C) Metronidazole (Flagyl)
(D) Ampicillin-sulbactam (Unasyn)
(E) Azithromycin (Zithromax)
Which one of the following statements concerning deep venous thrombosis prophylaxis is true?
(A) Intravenous heparin administered every 8 hours is acceptable for deep venous thrombosis prophylaxis.
(B) Hip surgery for repair of a fracture would be considered a moderate risk for the development of deep venous thrombosis.
(C) The dose of fondaparinux (Arixtra) must be reduced if kidney disease is present.
(D) A full-strength aspirin can be used solely for deep venous thrombosis prophylaxis.
(E) The efficacy of fondaparinux (Arixtra) can be followed by measuring partial thromboplastin time (PTT) levels.
You’re evaluating a 65-year-old woman who presents with fever and acute lower left-quadrant pain. She states that it began last night and won’t let up. She says that it began in the back and radiates to the lower left-quadrant area. She denies nausea, vomiting, or diarrhea. She has no history of diverticulosis. Her temperature is 38.9°C (102°F). There is lower left-quadrant tenderness and left costovertebral tenderness. She admits to dysuria and urinary frequency. The urinalysis is pending. What is the most likely diagnosis?
(C) Ovarian torsion
(E) Ulcerative proctitis
Which medical condition is associated with Grey-Turner’s sign?
(A) Acute appendicitis
(B) Ulcerative colitis
(C) Emphysematous pyelonephritis
(D) Hemorrhagic pancreatitis
(E) Acute cholecystitis
An older gentleman with a history of alcoholism and chronic pancreatitis presents with pain radiating to the back. He states the pain is much worse than before. He has a mild fever. His white blood cell count is normal, but you note that his hemoglobin level is 8.5 mg/dL. You look at the lab values in his medical record and note that it was 10.5 on a prior hospitalization. Lab values, including liver function tests, amylase, and lipase, are normal. What is your next step?
(A) Send the gentleman home because the lipase is normal.
(B) Obtain a CT scan with intravenous contrast if able.
(C) Obtain an outpatient gastrointestinal consultation.
(D) Obtain an abdominal ultrasound.
(E) Repeat the labs because there may be a mistake.
Which of the following conditions causes left lower-quadrant pain?
(A) Acute appendicitis
(B) Meckel’s diverticulum
(E) Regional enteritis
Example PANCE Answers and Explanations
Use this answer key to score the practice surgical questions. The answer explanations provide insight into why the correct answer is better than the other choices.
1. D. Ampicillin-sulbactam (Unasyn) is a good choice for intra-abdominal surgeries because it has good Gram-positive, Gram-negative, and anaerobic coverage. The flora of the biliary tract are predominantly Gram-negative and anaerobic. Vancomycin (Vancocin) covers Gram-positive organisms, and gentamicin (Garamycin) is predominantly Gram-negative. Metronidazole (Flagyl) is anaerobic in its coverage. Azithromycin (Zithromax) is not indicated to treat biliary infections. It’s used in treating community-acquired pneumonia (CAP).
2. C. Fondaparinux (Arixtra) is administered in a standard dose of 2.5 mg per day. The dose needs to be adjusted for kidney disease, usually requiring a decrease in dosing. A heparin infusion, Choice (A), is usually given for the treatment of a documented pulmonary embolism or deep venous thrombosis. It wouldn’t be used for DVT prophylaxis; subcutaneous dosing of 5,000 units every 8 hours is the recommended regimen for DVT prophylaxis. Hip surgery, Choice (B), or any orthopedic surgery below the waist is considered to be high-risk, not moderate-risk, for deep venous thrombosis. Note that full-strength aspirin, Choice (D), can’t be used for DVT prophylaxis; it’s prescribed for the prevention and treatment of coronary artery disease (CAD). Concerning Choice (E), factor Xa levels, not a partial thromboplastin time (PTT), are measured in patients taking fondaparinux (Atrixa). This lab value is measured in anyone receiving intravenous heparin.
3. D. Part of being on a surgical rotation is the evaluation and identification of abdominal pain. The pattern of the pain is important here. Pyelonephritis, Choice (D), usually presents with back pain. The patient may have had a kidney stone that passed, but she has positive costovertebral tenderness on examination and urinary symptoms, too. And in the question, you’re told that she has no history of diverticulosis. In the end, this isn’t a surgical case at all, but her presentation may look surgical, and you should know the differential.
4. D. Grey-Turner’s sign, which is ecchymoses and bruising located in the flank areas, is a sign of hemorrhagic pancreatitis. Cholecystitis, Choice (E), is associated with Murphy’s sign. Appendicitis, Choice (A), is associated with Rovsing’s sign, psoas sign, obturator sign, and Blumberg’s sign.
5. B. Even if you weren’t sure of the answer, this question includes enough red flags to signal you to order the CT scan: the patient’s report that the pain has worsened and the decrease in hemoglobin. The reasons to obtain a CT scan in this case are several: The gentleman may have hemorrhagic pancreatitis, he may have some abdominal trauma (he may be too drunk to remember), or he may have a pseudocyst.
You may be asking yourself, “Isn’t his lipase level normal?” In chronic pancreatitis, the lipase levels may not rise like they do in acute pancreatitis. An ultrasound isn’t likely to show you much. This gentleman needs a CT scan.
6. D. Diverticulitis commonly presents as left-sided abdominal pain. All the other choices — acute appendicitis, Meckel’s diverticulum, volvulus, and regional enteritis — present as right-sided pain. Meckel’s diverticulum is a cause of right lower-quadrant pain in a young child.