NCCPA PANCE Exam Questions

Correct answer: Electromyography (EMG)

This patient has an occupational risk factor for, symptoms of, and findings consistent with carpal tunnel syndrome. In addition to the pain, numbness, and paresthesias, patients may also complain of clumsiness and weakness. It is the most common mononeuropathy, and it is caused by compression of the median nerve under the transverse carpal ligament. Other associated risk factors are premenstrual fluid retention, early RA with thickening of the synovial tendon sheath, acromegaly, pregnancy, repetitive flexion or extension of the wrist, and alcohol abuse. In cases where the diagnosis is unclear or the presentation atypical, electromyography (EMG) and nerve conduction velocity (NVC) studies may be useful.

CT scans, MRIs, and ultrasounds are not useful in the diagnosis of carpal tunnel syndrome.

Correct answer: Cystoscopy with biopsy

Painless hematuria is the most common presenting symptom of bladder cancer. 98% are transitional cell carcinomas (TCCs) and as a whole, uroepithelial tumors account for 3% of cancer deaths in the U.S. Bladder cancer is three times more common in men than in women, and it usually occurs in patients ages 40 to 70. Causal factors include exposure to tobacco, occupational carcinogens from rubber, dye, printing and chemical industries, schistosomiasis, exposure to cyclophosphamide, and chronic infections. Cystoscopy, which has an accuracy rate of nearly 100%, is the definitive diagnostic procedure and biopsy confirms the pathologic diagnosis.

Transrectal ultrasonography is useful in the evaluation and workup of prostate lesions.

An abdominal CT scan with or without contrast can be useful in the workup of abdominal masses or suspected renal tumors or carcinomas.

CBC and urine culture are definitively diagnostic for acute pyelonephritis. Hematuria may occur, but patients will usually be febrile, have flank pain or CVA tenderness, and complain of irritative voiding symptoms.

Correct answer: Biopsy

This patient has symptoms and findings consistent with a fibroadenoma of the breast. Fibroadenomas are the second most common benign breast disorder and typically occur in young women. In a woman younger than 25 years old, a fibroadenomatous mass should be biopsied.

Following with serial exams may be acceptable for fibroadenomas in women older than 25.

Ultrasonography may be used to differentiate a solid and cystic breast mass, but it is not used to follow fibroadenomas.

Vitamin B6 may be used in the management of mastodynia. It is not used in the management of fibroadenomas.

Correct answer: Pseudomonas aeruginosa

Pneumonia is the second most common cause of hospital-acquired (nosocomial) infection after urinary tract infection (UTI). It is caused by organisms that colonize ill patients, staff, and equipment, typically producing infection more than 48 hours after admission to the hospital. The mortality rate is high, between 20% and 50%. Those at greatest risk are intensive care unit (ICU) patients on mechanical ventilation. Pseudomonas aeruginosa is the most likely pathogen in the ICU, and it carries the worst prognosis.

Staphylococcus aureus, along with Gram-negative bacilli such as Escherichia coli, Klebsiella sp., and Enterobacter sp. are common pathogens in nosocomial pneumonias that develop in the ICU.

Mycoplasma pneumoniae is not typically involved in nosocomial pneumonia in the ICU. It is the most common cause of atypical community-acquired pneumonia (CAP).

Correct answer: there must be at least three symptoms of inattention, hyperactivity/impulsivity, or both, which are developmentally inappropriate and present for at least six months

This answer is incorrect because the diagnostic criteria specify that at least six symptoms must be present for at least six months for the diagnosis.

Between 2% and 20% of school-age children may be affected by ADD/ADHD. It is two to five times more frequent in boys than in girls and is most common in the firstborn son. It typically manifests as hyperactivity and impulsivity or as inattentiveness. Most diagnoses are based on symptoms of hyperactivity and attention deficits. Secondary symptoms include emotional immaturity and lability, poor social skills, and sometimes, motor incoordination. Disruptive behavior, peer rejection, and poor self-image are common. At home, children with ADD/ADHD do not comply with parents' requests and can become explosive and irritable.

Correct answer: Asymptomatic

Sick sinus syndrome includes inappropriate sinus bradycardia, sinus pause, sinus arrest, or episodes of alternating sinus tachycardia and bradycardia. Elderly patients are most often at risk, but it may occur in infants who have had heart surgery.

Most patients with sick sinus syndrome are asymptomatic; however, they may have syncope, dizziness, confusion, heart failure, palpitations, or decreased exercise tolerance. Symptomatic patients may require permanent pacing.

Correct answer: Anti-HBs

Antibody against hepatitis B surface antigen (anti-HBs) indicates immunity either by past infection or vaccination. Titers generally rise between 18 and 20 weeks post-exposure.

Hepatitis B surface antigen (HBsAg) indicates ongoing infection of any duration. This is the first titer to rise and will start in the pre-icteric phase of hepatitis B, around six to eight weeks post-exposure.

Hepatitis B envelope antigen (HBeAg) indicates an active infection that is highly contagious. This is the second titer to rise following HBsAg in the pre-icteric stage, generally around eight weeks post-exposure.

Hepatitis B envelope antigen-antibody (anti-HBe) indicates a lower viral titer in active disease. It appears at the end of the icteric phase, between weeks 13 and 14 post-exposure, and continues to rise in the convalescent phase.

Correct answer: Amiodarone, lidocaine, and procainamide

The preferred pharmacologic interventions for acute V-tach include amiodarone, lidocaine, and procainamide, in that order. It should be noted that in V-tach with severe hypotension or loss of consciousness, synchronized cardioversion may be necessary. In pulseless V-tach, immediate defibrillation with CPR is indicated.

Correct answer: Streptococcus pneumoniae

This patient has classic signs and symptoms of acute bacterial sinusitis. The most common etiologic agents involved are Streptococcus pneumoniae and Haemophilus influenzae. Less common etiologies are Staphylococcus aureus and Moraxella catarrhalis.

Pseudomonas aeruginosa is not typically the cause of acute sinusitis. It is commonly involved in chronic otitis media and otitis externa.

Group A B-hemolytic streptococci (GABHS) are commonly the cause of acute pharyngitis.

Candida albicans can be involved in a number of conditions such as diaper dermatitis, oral thrush, and esophagitis, and vulvovaginal infections. Patients who are immunosuppressed, diabetic, chronically ill, or who have recently taken broad-spectrum antibiotics or corticosteroids are at a higher risk for developing candidal infections.

Correct answer: Multiple myeloma

To screen for hypercalcemia, you must always calculate the adjusted total calcium. It is measured by: the measured serum calcium (mg/dL) + [0.8 X (4.0 - serum albumin [g/dL])]. Elevated adjusted serum calcium with an elevated parathyroid hormone (PTH) level indicates a primary disorder. However, elevated adjusted serum calcium with a low PTH level indicates a secondary disorder such as a malignancy. Multiple myeloma, head-neck-lung cancers, and Hodgkin's lymphoma are common malignancies that trigger hypercalcemia.

Benign parathyroid gland adenoma is a primary cause of hypercalcemia and is responsible for 85% of primary hyperparathyroidism cases. PTH levels will be normal.

Parathyroid gland hyperplasia is also a primary cause of hypercalcemia and accounts for 15% of primary hyperparathyroidism. PTH levels will likely be normal.

Parathyroid carcinoma is a rare, primary cause of hypercalcemia accounting for just 3% of all primary hyperparathyroidism. In these patients, PTH levels will be elevated as well.

Correct answer: 50 beats per minute

Sinus bradycardia may be normal in well-conditioned athletes. Sinus node pathology, with increased risk for ectopic rhythms, is another possible cause of bradycardia. Symptoms due to bradycardia do not generally occur at heart rates above 50 beats per minute.

Correct answer: a postmenopausal 63-year-old with no other health history

Screening bone density is recommended for the following groups:

• all postmenopausal women over the age of 65 and men older than 70;
• postmenopausal women under age 65 with one or more additional risk factors;
• postmenopausal women who present with fractures;
• all women who are considering therapy for other conditions in which the bone mineral density will affect that decision;
• women who have been on HRT for prolonged periods;
• patients who experience fractures after minimal trauma;
• patients with evidence of osteopenia on radiography or with a disease known to increase the risk for osteoporosis; and
• patients with rheumatoid arthritis.

Correct answer: Mild persistent asthma

Mild persistent asthma is characterized by symptoms on more than two days, but not daily, and with only minor limitation of activity. Nighttime symptoms occur three to four times per month and FEV1 is more than 80% of the predicted value with a normal FEV1/FEV ratio. If rescue medication is used, it is not used daily nor more than once a day, but at least more than two days per week in a patient with this severity of asthma.

Intermittent asthma is characterized by symptoms on two or fewer days per week with no interference with daily activity. Nighttime symptoms occur on no more than two nights per month. FEV1/FVC ratio is normal, and FEV1 is more than 80% of the predicted value. Rescue medication is used less than two days per week.

Moderate persistent disease is classified as daily symptoms with some limitation in daily activity. Nighttime symptoms occur more than once a week, but not nightly, and rescue medication must be used daily. FEV1 is more than 60%, but less than 80%, of the predicted value, and FEV1/FVC is reduced by 5%.

In severe persistent asthma, patients will have continued symptoms and extreme limitations of physical activity. Nighttime symptoms occur often, sometimes nightly, and rescue medication is used several times daily. The FEV1 is less than 60% of the predicted value, and the FEV1/FVC is reduced by more than 5%.

Correct answer: Berylliosis

Berylliosis is a pneumoconiosis that is caused by the inhalation and sensitization to beryllium, a natural metallic chemical element used in the making of metal alloys. It is a chronic fibrotic lung disease that causes restrictive changes and reduced diffusion capacity in the lungs. High-technology fields, aerospace, nuclear power, ceramics and foundry workers, and those in the tool and die manufacturing industries are at risk for this occupational exposure. The findings of diffuse infiltrates along with hilar adenopathy in the setting of progressive, chronic dyspnea, cough, fatigue, and weight loss in a patient with occupational exposure should lead to the diagnosis.

Silicosis (another pneumoconiosis) may trigger similar presenting symptoms, but patients will typically have chest x-rays that demonstrate small, rounded opacities throughout the lung and calcified hilar lymph nodes. A history of occupational exposure in the mining, sandblasting, quarry, or stonework industries should raise suspicion of this diagnosis.

Asbestosis is also a pneumoconiosis that may occur after occupational exposure due to working in the insulation, demolition, and/or construction industries. Again, it causes a restrictive pulmonary disease that may present with similar symptoms. There is an increased risk of mesothelioma in asbestosis patients who continue to smoke after the diagnosis. Chest radiograph shows interstitial fibrosis, thickened pleura, and calcified plaques on the diaphragm or lateral chest walls.

Sarcoidosis is a multiorgan disease of idiopathic cause. Approximately 90% of patients have lung involvement, and the incidence is highest in African American women and Northern European whites. The presenting pulmonary symptoms may be the same, but usually there will also be extrapulmonary findings such as erythema nodosum or enlarged parotid glands, lymph nodes, liver, or spleen. Radiographic findings usually demonstrate symmetric bilateral hilar and right paratracheal adenopathy, as well as bilateral diffuse reticular infiltrates.

Correct answer: A reduced FEV1 and FEV1/FVC ratio with an increased TLC

Because COPD is a form of obstructive lung disease, you would expect the findings of a reduced FEV1 and FEV1/FVC ratio with an increased TLC. The air is able to get into the lungs but is not able to get out.

A reduced FEV1/FVC ratio that increases by more than 12% after administration of a bronchodilator is characteristic of, as well as supportive for, the diagnosis of asthma.

A normal FEV1/FVC ratio may be seen in restrictive lung diseases such as idiopathic fibrosing interstitial pneumonia, but it will always be decreased in obstructive diseases such as COPD.

A normal to increased FEV1/FVC with a decreased TLC are characteristic findings of restrictive lung disease such as idiopathic fibrosing interstitial pneumonia or pneumoconioses.

Correct answer: Barotrauma

Barotrauma is the inability to equalize barometric pressure in the middle ear. It is due to ETD from either congenital narrowing or acquired mucosal edema. It commonly occurs with flying (especially during descent), rapid altitude changes, or diving underwater.

Meniere's disease is not associated with ETD. It is a condition related to the distention of the inner ear's endolymphatic compartment, and its etiology is unknown. It causes episodic vertigo, tinnitus, hearing loss, and unilateral aural pressure.

Labyrinthitis is not associated with ETD. It causes acute, severe vertigo and hearing loss. Its etiology is unknown, but there may be an infectious cause. 

Presbycusis is not associated with ETD. It is the most common form of sensorineural hearing loss characterized by a gradual impairment of higher sound frequencies that occurs with increasing age.

Correct answer: Digital cervical exam

PROM is the rupture of the amniotic membranes before the onset of labor at or beyond 37 weeks of gestation. It occurs in approximately 8% of all pregnancies. Most women (90%) will go into spontaneous labor within 24 hours after PROM. PPROM occurs before 37 weeks of gestation and precedes 30% to 40% of all preterm deliveries. The major risk associated with both PROM and PPROM is infection (chorioamnionitis and endometritis). Cord prolapse can also occur with ruptured membranes. The digital cervical exam should be avoided in a patient with either PPROM or PROM unless delivery is imminent, as these exams have been associated with greater morbidity and mortality.

Ultrasonography can be used to diagnose PROM or PPROM as it is a reliable tool to check the amniotic fluid index.

Direct visualization of pooling of the amniotic fluid can also be used to confirm the diagnosis. This is also the preferred way to examine a patient for cervical dilation.

Due to the alkaline nature of amniotic fluid, nitrazine paper is a simple test that can be used to confirm the diagnosis. The fern test (dried amniotic fluid on low-power microscopy) can also be used if a false positive is suspected with the nitrazine paper test.

Correct answer: A non-contrast head CT is the initial investigational test that should be used.

This patient has classic symptoms consistent with a subarachnoid hemorrhage (SAH). It presents with a sudden onset of an unusually severe, generalized headache that patients usually describe as "the worst that I've had in my life." It may be accompanied by nausea, vomiting, seizure activity, or an altered state of consciousness. It is frequently precipitated by vigorous physical activity or cocaine use. It most frequently occurs in the fifth and sixth decades of life and has an equal gender distribution. A non-contrast head CT is the initial investigational study of choice for suspected SAH.

Risk factors for cerebral aneurysms (the most common cause of SAH) include hypertension (HTN), hypercholesterolemia, smoking, and heavy alcohol use. They are also associated with polycystic kidney disease and coarctation of the aorta. Diabetes, oral contraceptive use, AIDS, and elevated homocysteine levels are major risk factors for stroke.

75% of all nontraumatic cases of SAH are due to a ruptured saccular (berry) aneurysm. Intracranial AVMs account for less than 10% of SAHs. Most are congenital, occur twice as often in men, and are typically diagnosed during the second to fourth decades of life.

A ruptured cerebral arterial aneurysm (saccular or berry) has a mortality rate of 50%. Management of hypertension is important along with supportive measures to prevent elevated arterial or intracranial pressures that might lead to re-rupture of the affected vessel.

Correct answer: a further workup is indicated when a patient's constipation has not improved after one week of modifications in diet, exercise, and fluid intake

A patient with constipation lasting for more than two weeks or with constipation refractory to modifications in diet, exercise, and fluid intake should undergo further investigation to detect the underlying cause. Any patient over the age of 50 with new-onset constipation should have an evaluation for colon cancer.

Correct answer: 14 to 16 weeks

Uterine fundal height correlates with the age and size of the fetus. When the fundus is palpable midway between the pubic symphysis and the umbilicus, the fetus is at 14 to 16 weeks gestation.

At 12 weeks, the fundus should be palpable above the pubic symphysis.

At 20 weeks, the fundus should be palpable at the level of the umbilicus. From 21 weeks on, the fundal height should roughly correlate with the number of weeks of gestation. 

At 6 to 8 weeks, you cannot yet palpate the fundus, as it is below the level of the pubic symphysis.