NCCPA PANCE Exam Questions

Correct answer: the skin disease and joint disease frequently present at the same time

Psoriatic arthritis is an inflammatory arthritis with skin involvement that usually precedes joint disease by months to years. It is a symmetric arthritis that resembles RA and may involve the hands and feet. Nail pitting and onycholysis are frequently seen. "Sausage finger" appearance of the hands occurs due to arthritis and tenosynovitis of the flexor tendon. ESR is typically elevated, and there may be a normochromic anemia. RF is normal and "pencil in cup" deformities of the proximal phalanx are demonstrated on radiography. NSAIDs are sufficient treatment for mild cases, but methotrexate, biologic DMARDs, and tumor necrosis factor inhibitors may be used in severe cases. Corticosteroids and antimalarials should be avoided.

Correct answer: Enchondroma

Enchondromas are benign, cartilaginous tumors. They are the most common primary bone neoplasm of the hand and are usually asymptomatic unless complicated by pathologic fracture.

Osteosarcomas are primary, malignant sarcomas that most commonly arise in individuals 10–20 years of age. They commonly occur in the metaphyseal area of the long bones.

Chondrosarcomas are primary, malignant sarcomas commonly affecting those 60 years of age and older. They typically present within the central metaphyseal area.

Ewing sarcoma is a primary, malignant sarcoma found in patients between the ages of five and 25. It usually presents in the diaphyses of long bones, ribs, and flat bones.

Correct answer: 33%

Although asthma typically presents with all the symptoms mentioned above, up to one-third (33%) of children have no wheeze.

Correct answer: Diabetes insipidus

Paraneoplastic syndromes occur in 10% to 20% of all patients with lung cancer. Diabetes insipidus (DI) is a condition of water deficiency that produces hypernatremia. It is due to either a deficiency of or resistance to vasopressin (ADH). Primary disease may be genetic or sporadic and secondary disease may be due to hypothalamic or pituitary pathology. DI is not typically a paraneoplastic syndrome that is associated with lung cancer.

Gynecomastia may be seen in those with large cell carcinoma.

Acanthosis nigricans may be seen in those with any type of lung cancer.

Eaton-Lambert syndrome, or myasthenia, is a neuromuscular disorder that develops in those with small-cell lung cancer.

Correct answer: Thalassemia

Erythropoiesis is defined as the production of red blood cells (RBCs). In all the thalassemia syndromes, there is an underproduction of different parts of the globin chains of hemoglobin due to genetic causes. Therefore, in thalassemia, there is deficient RBC production which causes anemia. However, severe forms may also produce hemolytic anemia.

G6PD deficiency is not characterized by ineffective erythropoiesis. It is a genetic enzyme deficiency that causes episodic hemolysis of RBCs when affected patients are exposed to certain oxidative medications. It is a form of hemolytic anemia.

Sickle cell disease is not characterized by ineffective erythropoiesis. It is a genetic disorder that is a hemoglobinopathy characterized by RBCs that "sickle" and are unable to carry oxygen during certain conditions. It may also cause hemolytic or aplastic crises that are life-threatening.

Hereditary spherocytosis is a genetic disorder characterized by an RBC membrane abnormality in which certain surface receptors are missing. Erythropoiesis is normal. This causes a form of hemolytic anemia due to lysis of RBCs by complement, which manifests as paroxysmal nocturnal hemoglobinuria.

Correct answer: An Austin Flint murmur best heard at the apex

An Austin Flint murmur suggests a large-flow aortic regurgitation. It may be best heard with the patient sitting, leaning forward, and in full exhalation. Lower-grade disease may sound like a mid-systolic, high-pitched, blowing murmur that is best heard at the 2nd to 4th left intercostal space (LICS). An Austin Flint murmur is a mid-diastolic, low-pitched, rumbling murmur that is best appreciated at the apex. Other physical signs include large, bounding arterial pulses due to volume overloading of the left atrium.

A thready carotid pulse is a finding common in severe aortic stenosis.

A harsh, mid-systolic murmur best heard at the 2nd right intercostal space (RICS) is typical of aortic stenosis.

Jugular venous distention, peripheral edema, and hepatosplenomegaly are common physical findings in right-sided heart failure that may be due to disorders of either the tricuspid or pulmonic valves.

Correct answer: a patient with progressive dysphagia and weight loss

This presentation is common in esophageal neoplasms.

Infectious esophagitis is rare except in immunocompromised persons. Odynophagia and dysphagia are the main presenting symptoms. Physical exam findings may include findings of lymphadenopathy, fever, or rashes. 

Herpes simplex virus (HSV) and Cytomegalovirus (CMV) are common causes of infectious esophagitis. Infections with HSV are characterized by multiple shallow ulcerations on endoscopy. Cytology or culture from endoscopic brushings is needed for the definitive diagnosis. Multinucleated giant cells on Tzank smear are definitive for HSV.

Fungal infection with Candida species should be considered in a patient with oral thrush.

Correct answer: Endoscopy

This patient has had mild, stable, well-controlled gastroesophageal reflux disease (GERD) for the past ten years. Worsening of or more severe disease, such as the symptoms reported here, warrants an endoscopy. Endoscopy is also indicated for any patient over the age of 45 with new onset of symptoms, long-standing or frequently recurring symptoms, failure to respond to therapy, or symptoms that indicate more severe conditions such as anemia, dysphagia, or recurrent vomiting.

PPIs are the most powerful anti-GERD medications. They are the first-line treatment in moderate to severe disease or in those who are unresponsive to H2 blockers or have evidence of erosive gastritis. However, in this case, a more severe disease warrants endoscopy to assess the patient's condition prior to prescribing specific therapy.

A CBC is indicated to assess for anemia if there is suspicion or evidence of an esophageal bleed. Symptoms of hematemesis or recurrent vomiting in addition to generalized symptoms of anemia should prompt this test. 

Evaluation and discussion of lifestyle modifications (cessation of smoking, eating at bedtime, eating large meals, alcohol avoidance, and decreasing caffeine, acidic, and irritating foods) should always be done on a presumptive diagnosis of GERD. This patient requires imaging given the progression of his symptoms.

Correct answer: Ampicillin

This patient has symptoms and exam findings consistent with infectious mononucleosis, most likely due to Epstein-Barr virus (EBV) infection. In addition to the findings listed for this patient, administration of ampicillin can increase the incidence of a maculopapular rash to 90%. A maculopapular and, occasionally, petechial rash develops in about 15% of mononucleosis cases.

Correct answer: Direct inguinal hernia

A hernia is a profusion of an organ or structure through the wall that normally contains it. Hernias can entrap the intestines and cause intestinal blockage. A direct inguinal hernia is the passage of the intestine through the external inguinal ring at Hesselbach's triangle. It rarely enters the scrotum.

Indirect inguinal hernias are the most common type. This hernia involves the passage of the intestine through the internal inguinal ring down the inguinal canal and, sometimes, into the scrotum.

Femoral hernias are the least common. In this type, the intestine passes through the femoral ring.

Ventral hernias occur when there is a weakening in the anterior abdominal wall. They may either be incisional (associated with surgery; increased in obesity or concurrent wound infection) or umbilical (congenital; may resolve on its own).

Correct answer: Anorexia is an egosyntonic disorder while bulimia is egodystonic.

Anorexia nervosa patients have a distorted body image and an intense fear of becoming fat despite being underweight. They often feel that losing weight is a desired achievement of self-control, and gaining weight is an unacceptable lack of discipline. Therefore, it is an egosyntonic disorder, and patients will often deny they have a problem. Bulimia nervosa, however, is egodystonic. Patients will binge-eat and then employ the use of vomiting, laxatives, diuretics, and/or compensatory measures such as excessive exercise to avoid gaining weight. Their binge-eating causes emotional distress and a feeling of loss of control. They often have less denial of their problem and are therefore more likely to seek treatment and have a better prognosis than anorexic patients.

There are two types of anorexia nervosa: restricting (eating very little) and binge-eating and purging. There are also two types of bulimia nervosa: purging (vomiting, laxatives, diuretics, enemas) and non-purging (excessive compensatory exercise or prolonged fasting). The differentiation of diagnosis lies in the patient's body weight. Anorexics are underweight; most often less than 85% of their expected body weight with a BMI of less than 17.5 kg/m2, whereas bulimics tend to be normal weight or overweight.

Correct answer: Subacute

Subacute thyroiditis, also known as subacute painful, De Quervain's, granulomatous, or giant cell thyroiditis, is believed to be the result of a preceding viral illness such as coxsackievirus infection, Epstein-Barr virus infection, mumps, measles, adenovirus infection, echovirus infection, or influenza. It peaks in the summer months and commonly affects young to middle-aged women. It causes a tender thyroid gland, fever, fatigue, dysphagia, and otalgia. Thyrotoxicosis is the presenting clinical scenario, followed by hypothyroidism and then a return to euthyroid within 12 months.

Suppurative thyroiditis is a rare, non-viral condition caused by Gram-positive bacteria (most commonly Staph aureus). Findings include a tender thyroid gland, fever, pharyngitis, and overlying erythema.

Hashimoto's thyroiditis, also known as chronic lymphocytic thyroiditis, is the most common thyroid disease in the U.S. It is six times more common in females and is often familial. It causes a diffusely enlarged thyroid gland with firm, small nodules and often progresses to hypothyroidism.

Fibrous thyroiditis, or Riedel thyroiditis, is the rarest form of thyroiditis. 80% of cases arise in females. It causes the development of dense, fibrous tissue in the thyroid gland (an asymmetric, "woody" thyroid). There may also be extra-glandular involvement such as sclerosing cholangitis, retroperitoneal fibrosis, and orbital pseudotumor.

Correct answer: Ostium secundum atrial septal defect

This infant presents with failure to thrive (based on his weight loss crossing more than two major percentiles downward on the standardized growth scale) in addition to an audible murmur and fixed split S2 that is consistent with an atrial septal defect (ASD). This is a non-cyanotic congenital heart anomaly, and it most commonly presents as failure to thrive and easy fatigability in addition to the physical findings noted here. There may also be a right ventricular heave that is palpable as well.  ASD accounts for seven percent of congenital heart disease and is the second most common type after ventricular septal defect. Ostium secundum is the most common type of ASD.  

A ventricular septal defect is associated with a systolic murmur heard best at the left lower sternal border. Symptoms of heart failure may also be present.

Coarctation of the aorta presents with a systolic murmur heard best at the left upper sternal border and left interscapular area, which may be continuous. Infants may present with symptoms of heart failure, and older children may have systolic hypertension or murmur. Pathognomonic is a finding of differences between arterial pulses and blood pressure in the upper extremity and lower extremity.

Pulmonary atresia is a cyanotic congenital heart defect. The associated murmur depends on the presence of tricuspid regurgitation. Physical exam findings include cyanosis with tachypnea at birth, tachypnea without dyspnea, hyperdynamic apical impulse, and single S1 and S2.

Correct answer: Local spread to the mediastinum is common

Local spread of esophageal cancer to the mediastinum is common because the esophagus has no serosa. All esophageal cancers are frequently related to cigarette smoking and chronic alcohol use. Contributing factors include exposure to other caustic agents, spicy foods, mucosal abnormalities, poor oral hygiene, and human papillomavirus (HPV). The main presentation is rapidly progressing dysphagia with marked weight loss.

Barrett's esophagitis is associated with adenocarcinomas. These tend to arise in the distal third of the esophagus.

Squamous cell lesions tend to occur in the proximal two-thirds of the esophagus.

Biphasic barium esophagram is the best initial test to visualize the lesion. Endoscopic sonography and CT may be used for staging. Endoscopy with brushings is used to make the diagnosis.

Correct answer: Perform a throat culture

This patient has met all four of the Centor criteria for group A B-hemolytic streptococcal pharyngitis (GABHS). The presence of pharyngotonsillar exudate, fever, tender cervical adenopathy, and lack of a cough strongly indicate GABHS infection. Although rapid streptococcal screening in this scenario has a greater than 90% sensitivity, if it is negative, a throat culture should be done to confirm the diagnosis. The presence of all four Centor criteria for GABHS strongly suggests bacterial pharyngitis. Therefore, viral pharyngitis is incorrect.

Although you strongly suspect a diagnosis of GABHS pharyngitis, a positive throat culture should be obtained prior to initiating antibiotic therapy. If positive, a macrolide would be appropriate given this patient's known penicillin allergy. There is cross-reactivity with a second-generation cephalosporin such as cefuroxime.

Laryngoscopy in a controlled environment should be done in suspected cases of epiglottitis due to its tendency to induce airway spasm in affected patients. It is not indicated in this patient as his history and exam suggest the diagnosis of GABHS pharyngitis.

Correct answer: Coarctation of the aorta

This child is presenting with symptoms of congestive heart failure. Coarctation of the aorta, a non-cyanotic congenital heart defect, may present with symptoms of congestive heart failure in infants. Older children may have systolic hypertension, a murmur, or underdeveloped lower extremities. A difference between arterial pulses and blood pressure in the upper and lower extremities is pathognomonic.

Patent ductus arteriosus is also a non-cyanotic congenital defect, but will typically have a machinery murmur and wide pulse pressure.

Pulmonary atresia and transposition of the great vessels are cyanotic congenital defects.

Correct answer: Pulsus paradoxus

Acute arterial occlusion is a sequela of peripheral arterial disease and may be caused by either thrombosis or embolism. The symptoms of occlusion depend on the artery, the area it supplies, and the collateral circulation. Acute arterial occlusion threatens limb viability and results in pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis. Pulsus paradoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. It may be present in various disorders, but especially those that put restrictive pressure on the heart (pericardial effusion, cardiac tamponade, pericarditis).

Correct answer: Acute herpetic gingivostomatitis

This patient's age, prodrome, symptoms, and clinical findings are indicative of acute herpetic gingivostomatitis, which is caused by the initial or primary infection of HSV-1. The acute symptoms of this disorder last five to seven days and usually resolve within two weeks. Patients affected will usually have abrupt onset of fever, anorexia, listlessness, and gingivitis. The oral mucosa is red, edematous, and friable. Vesicles form and rupture creating ulcerations and plaques on the oral mucosa, tongue, gingiva, and lips. Regional lymphadenopathy is common.

Herpangina is another common cause of stomatitis in children. It is due to coxsackievirus and is contagious. There is an acute onset of fever, dysphagia, vomiting, and anorexia. Exam findings show grayish-white vesicles and ulcerations with erythematous halos on the posterior palate, uvula, and tonsillar pillars. The lesions may be linearly arranged. The infection is self-limited and usually resolves within a week.

Aphthous ulcers can affect children and adults and generally do not have any prodrome or constitutional symptoms. The etiology is unclear, but they may be associated with human herpesvirus 6. The presentation shows one or more painful, round ulcers with yellow-grey centers and erythematous halos. They only occur on non-keratinized mucosa (labial or buccal). Recurrence is common.

Oral candidiasis is due to Candida albicans and occurs spontaneously in some infants and children, but it can also occur in anyone with diabetes or who is immunocompromised, undergoing chemotherapy or radiation, or recently been treated with corticosteroids or broad-spectrum antibiotics. It presents as creamy white patches that can be removed revealing erythematous underlying mucosa. Lesions may or may not be painful. There are usually no prodrome or associated constitutional symptoms.

Correct answer: Prerenal

AKI refers to a syndrome of rapidly deteriorating glomerular filtration rate (GFR) with the accumulation of nitrogenous wastes (urea, creatinine) known as azotemia. Serum creatinine acutely increases by more than 0.5 mg/dL or more than 50% over baseline levels. 60% to 70% of AKI is due to prerenal causes. These include hypovolemia; hypotension; ineffective circulating volume due to CHF, cirrhosis, nephrotic syndrome, or early sepsis; aortic aneurysm; and renal artery stenosis, or embolic disease.

Intrinsic renal causes account for 25% to 40% of all AKI cases. These include acute tubular necrosis; nephrotoxins such as NSAIDs, aminoglycosides, radiologic contrast; interstitial diseases such as acute interstitial nephritis, SLE, infection; glomerulonephritis; and vascular diseases such as polyarteritis nodosa and vasculitis.

Postrenal causes account for 5% to 10% of AKI cases. Tubular obstruction and obstructive uropathy (urolithiasis, BPH, bladder outlet obstruction) are postrenal causes.

There are no idiopathic causes for AKI.

Correct answer: Cough

GABHS-suggestive manifestations include fever greater than 100.4 F (38 C), tender cervical lymphadenopathy, lack of cough, and pharyngotonsillar exudate. Together, these four are known as the Centor criteria and strongly suggest GABHS infection. Rapid strep testing sensitivity is greater than 90% when three out of the four criteria are present. Cough, coryza, and hoarseness are not suggestive of GABHS pharyngitis.