NCCPA PANCE Exam Questions

Correct answer: Right lower quadrant abdominal pain, nausea/anorexia, fever

The initial symptom in acute appendicitis is intermittent periumbilical or epigastric pain. In about 12 hours, the pain will localize to the RLQ (McBurney point), become constant, and is worsened by any type of movement. Nausea and anorexia are common. If there is vomiting, it may be isolated and will begin after the onset of pain. Low-grade fever will begin as the inflammation of the appendix grows and worsens.

Perforation and frank peritonitis occur in up to 20% of acute appendicitis cases. This will lead to generalized abdominal pain, high fever, and increased leukocytosis all following the initial signs and symptoms of acute appendicitis.

Correct answer: Most patients do not have an identifiable neurologic lesion responsible for the pain

Complex regional pain syndrome (CRPS) is also known as reflex sympathetic dystrophy. It is characterized by regional pain in the affected limb, restricted mobility, edema, color changes in the skin, and spotty bone thinning. Its cause is poorly understood, but it is believed to be partially secondary to abnormal sensitivity to inflammatory mediators of pain. Most patients do not have an identifiable neurologic lesion responsible for their pain.

The hallmark feature of CRPS is a severe burning or throbbing pain with associated allodynia in the affected region/extremity. Cyanosis, atrophy, and abnormal skin temperature and sensitivity to warm and cold exposure, however, may also be present.

The diagnosis of CRPS is primarily clinical. A regional nerve block may be used diagnostically; complete relief of pain is consistent with CRPS.

CRPS usually begins after surgery, an injury, or a vascular event (stroke or MI). Most cases occur after a soft-tissue injury; however, no inciting event is identified in about one-third of all cases.

Correct answer: Barium swallow

This patient presents with classic symptoms of Zenker diverticulum, which is an outpouching of the posterior hypopharynx. Because it is a structural abnormality of the esophagus, a barium swallow would be the best choice to better visualize and diagnose it.

Endoscopy would allow for direct observation of the structural defect, but biopsy is not necessary in this case.

Esophageal manometry is useful in assessing the strength and coordination of esophageal peristalsis; however, in this case, that is not the direct cause of this patient's symptoms.

Ambulatory 24-hour pH monitoring is a test that may be helpful in patients with severe or refractory gastroesophageal reflux disease (GERD).

Correct answer: Purulent cervicitis

Absolute contraindications to IUD use include pregnancy, undiagnosed vaginal bleeding, past salpingitis, suspected gynecologic malignancy, and acute infection such as purulent cervicitis.

Menorrhagia is not a contraindication for IUD use. 

Relative contraindications for IUD use include nulliparity, previous ectopic pregnancy or sexually transmitted disease, multiple sex partners, severe dysmenorrhea, uterine abnormalities (such as retroverted uterus), anemia, valvular heart disease, and young age.

Correct answer: Coronary angiography 

This patient has a history of stable angina that has previously been controlled with nitroglycerin (NTG). This episode constitutes an immediate diagnosis of unstable angina (UA) as his pain is unresponsive to NTG. According to the American Heart Association, UA is indistinguishable from non-ST segment myocardial infarction (NSTEMI) and should be treated as a single entity for initial treatment and intervention algorithms. It is considered an acute coronary syndrome (ACS) and, along with his symptoms and the finding of Levine's sign (clenched fist over the chest and clenched teeth), is highly suggestive of ischemia. The 12-lead EKG is central to the decision pathway in patients with ACS. Based on initial findings, patients can be triaged to acute reperfusion therapy if indicated (by STEMI). Therefore, it is essential for the evaluation, but not definitively diagnostic. The evolution of cardiac biomarkers is diagnostic of myocardial infarction in that those biomarkers provide evidence of damaged myocardium. However, coronary angiography is the most definitive diagnostic procedure as it allows for direct visualization of the occluded coronary vessel. Despite this, it should be used selectively because of cost and invasiveness. It is helpful if surgical intervention (stents) is indicated. 

Exercise stress tests are the most useful, cost-effective non-invasive testing method to make the diagnosis of angina. For stable patients with ACS who have no acute EKG changes and no cardiac biomarker elevations during evaluation, it can be used as a diagnostic test for MI.

Correct answer: A sputum culture

Definitive diagnosis of TB requires identification of Mycobacterium tuberculosis from either sputum cultures (six to eight weeks to grow) or by RNA or DNA amplification techniques (one to two days for results). 

This patient has a known history of LTBI, so his TST/PPD is already positive. These tests are used to identify individuals who have been infected, but it does not differentiate between active and latent infection. Positive testing is reported in terms of the size of induration, not the presence of erythema. There is a lower threshold for those with immunosuppression, radiographic evidence of TB, or contacts of those with active TB infection.

A chest radiograph in the setting of reactivation TB illness will demonstrate fibrocavitary apical disease with nodules and infiltrates in the posterior and apical segments of the right upper lobe, apical-posterior segments of the left upper lobe, and superior segments of the lower lobes. While this is highly suggestive of reactivation TB, it does not definitively diagnose it.

A sputum smear showing acid-fast bacilli is, again, highly suggestive of reactivation TB but does not definitively diagnose it.

Correct answer: Diabetes

Dilated cardiomyopathy is the most common cardiomyopathy, accounting for approximately 95% of all cases. The most common cause of dilated cardiomyopathy is a genetic abnormality (25% to 30% of cases); other causes include excessive alcohol consumption, postpartum state, chemotherapy toxicity, endocrinopathies, and myocarditis. Men, particularly African-American men, have a higher rate of incidence.

Diabetes can be a cause of restrictive cardiomyopathy. Other causes include amyloidosis, radiation, postoperative changes, and endomyocardial fibrosis.

Correct answer: Steroid injections

This patient likely has Achilles tendinitis. It is a condition attributed to inflammation and degeneration of the Achilles tendon and its attachment to the calcaneus. It is common in runners and in those who suddenly increase their activity level. If left untreated, it may result in rupture of the tendon. In addition to this patient's exam findings, radiographs may show a soft-tissue shadow and calcifications along the tendon and its insertion. MRI is the imaging test of choice to help rule out a rupture and may show hypertrophy of the tendon. Steroid injections are contraindicated due to the increased risk of tendon rupture.

Appropriate therapeutic interventions for Achilles tendonitis include NSAIDs and physical therapy for calf stretching and strengthening exercises.

Correct answer: Check and record the visual acuity

Based on this patient's history and presentation, you should suspect a corneal abrasion. Intense pain, photophobia, foreign body sensation, tearing, injection, and blepharospasm are hallmarks of this problem. The first and most important step to take is to check and record the visual acuity prior to further examination or treatment.  

Flushing the eye with water and/or normal saline is the proper treatment to loosen or remove the debris, but should be done after the examination and is not the first step in the evaluation of a corneal abrasion.

A search for foreign bodies should be undertaken. If found, they should be carefully removed or treated with water or saline flush. However, this is not the first step to take in this situation.

Staining the eye with fluorescein and performing a slit lamp exam is an essential part of the evaluation. If a corneal abrasion is present, you will be able to visualize the epidermal defect with this method. However, you should check and record the visual acuity prior to proceeding with this part of your examination.

Correct answer: Biopsy will demonstrate transmural inflammation.

This patient has a history and exam findings consistent with Crohn's disease, also known as regional enteritis. It is an inflammatory bowel disease for which there is some genetic predisposition, but no identified underlying cause. Males and females are equally affected, and onset is typically between ages 15 to 35. Crohn's disease must be differentiated from ulcerative colitis (UC). A biopsy of the affected bowel will show involvement of the entire wall. UC lesions only extend into the mucosal surface of the bowel.

Surgery is not curative in Crohn's disease and is reserved for treatment of complications such as bleeding, abscess, or obstruction. Surgery can be curative in UC.

Smoking cessation is critical for reducing the frequency and severity of attacks in Crohn's disease. Alternatively, smoking appears to have a protective effect in UC. Smokers who have recently quit will often have a flare-up of their disease.

The onset of Crohn's disease is gradual, and the disease usually waxes and wanes throughout life. UC may have either a sudden or gradual onset.

Correct answer: It is presenting in young patients with increasing incidence.

Type 2 DM represents greater than 90% of all diabetes cases. It typically has a later onset and is associated with overweight or obesity, positive family history, and associated hyperinsulinemia; however, it is presenting in youth with increasing incidence. Untreated type 2 DM can lead to hyperosmolar nonketotic states.

Type 1 DM accounts for <10% of all diabetes cases. It is characterized by early-onset, autoimmune phenomenon, insulinopenia, or absence of insulin, and risk of DKA. It has an association with HLA DR3-DQ2 and DR4 genes.

Correct answer: Tetany and paresthesias

Hyperparathyroidism may be primary (the most common cause in ambulatory patients) or secondary to hyperthyroidism or chronic kidney disease. Increased levels of parathyroid hormone (PTH) will cause hypercalcemia. The mnemonic "stones, bones, moans, and abdominal groans" can be used to help remember the signs and symptoms of hypercalcemia. Renal loss of calcium and phosphate triggers kidney stones. Calcium loss from bones can cause pathologic fractures or cystic bone lesions (the jaw is the most common site). Increased calcium absorption from the GI tract triggers abdominal cramping (groans), and hypercalcemia may also trigger irritability, psychosis, and/or depression (moans). Fatigue, anemia, weight loss, peptic ulcer disease, gastric ulcers, pancreatitis, hypertension, and depressed tendon reflexes are all also likely signs and symptoms. Patients may also develop polydipsia and polyuria due to hypercalcemia-induced nephrogenic diabetes insipidus.

Tetany and paresthesias typically develop in the setting of hypocalcemia.

Correct answer: Atrial fibrillation

Atrial fibrillation is the most common arrhythmia that can lead to a significant decrease in cardiac output and the most common cause of embolic cerebrovascular accidents. Patients will typically present with palpitations, angina, fatigue, and other symptoms of heart failure. Electrocardiogram will reveal an irregularly irregular rhythm with no discernable p waves.

Paroxysmal supraventricular tachycardia is the most common paroxysmal tachycardia in patients without structural pathology. It is more common in younger patients, women, those who consume alcohol or caffeine, smokers, and those with anxiety. Its symptoms will be similar to that of atrial fibrillation. Electrocardiogram will reveal tachycardia.

Atrial flutter may also present the above symptoms, but it will present with a “saw-tooth” pattern on electrocardiogram.

Atrial premature beats will be seen on electrocardiogram and are typically benign, not requiring treatment if asymptomatic.

Correct answer: Fibromyalgia

Fibromyalgia is a central pain disorder whose cause and pathogenesis are poorly understood. It may occur spontaneously or concurrently with RA, SLE, and Sjogren's syndrome. Pregabalin (Lyrica) can be effective in reducing pain and improving sleep. Side effects of fatigue, trouble concentrating, sleepiness, and edema may occur.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that is characterized by inflammation, a positive ANA, and multiple organ involvement. It commonly affects women of childbearing age and certain familial and ethnic groups, particularly African-American women. Antimalarials are used for musculoskeletal complaints and cutaneous manifestations; methotrexate may also be used for those as well as constitutional symptoms, and topical and systemic corticosteroids are useful as well.

Polymyalgia rheumatica is pain and stiffness in the neck, shoulder, and pelvic girdle that is accompanied by constitutional symptoms of fever, fatigue, weight loss, and depression. The underlying cause is unknown. Temporal arteritis is present in up to 30% of cases and must be ruled out. Systemic corticosteroids are the mainstay of treatment.

Systemic sclerosis (scleroderma) is due to an unknown cause. It is characterized by the deposition of collagen in the skin, and, less commonly, the kidney, heart, lungs, and stomach. Treatment of the condition is aimed at organ-specific disease processes (i.e. PPIs for reflux, ACE inhibitors for hypertension/renal involvement, etc.).

Correct answer: Epigastric tenderness

This patient presents with symptoms commonly found with esophageal varices. These are dilations of the veins of the esophagus, which are generally located at the distal end. Patients will generally present with painless upper GI bleeding that may either be bright red or "coffee ground" in appearance. Esophageal varices are due to portal hypertension, most commonly from cirrhosis due to either chronic alcohol abuse or viral hepatitis. They are generally asymptomatic until they bleed, at which point they may become life-threatening due to the risk of hypovolemia. The diagnosis is usually established clinically when a patient with signs of cirrhosis presents with hematemesis. Epigastric tenderness is usually not present.

Jaundice, ascites, gynecomastia, pleural effusions, peripheral edema, ecchymosis, or signs of hepatic encephalopathy (asterixis, tremor, dysarthria, delirium) are all signs of cirrhosis.

Correct answer: Alpha-glucosidase inhibitors and liver disease

Alpha-glucosidase inhibitors (acarbose, miglitol) delay the absorption of dietary carbohydrates by blocking the intestinal a-glucosidase enzyme, thereby decreasing postprandial glucose levels. Their major side effect is GI symptoms, but they have no contraindications. Liver disease is a contraindication for the use of thiazolidinediones.

Metformin reduces hepatic glucose production and may promote weight loss and decrease triglycerides. It is usually considered the first-line treatment of type 2 DM. It is contraindicated in patients at risk for lactic acidosis, those with serum creatinine >1.5 mg/dL (males) and 1.4 mg/dL (females), or abnormal creatinine clearance.

Thiazolidinediones (pioglitazone, rosiglitazone) sensitize peripheral tissues to insulin and may be used alone or in combination with sulfonylurea, metformin, or insulin. They reduce glucose by increasing the risk of hypoglycemia but are contraindicated in those with congestive heart failure (CHF).

Glucagon-like peptide-1 (GLP-1) receptor agonists (exenatide, liraglutide) lower blood glucose via slowing gastric emptying, stimulating the pancreatic insulin response to glucose, and reducing the glucagon release after meals. They are associated with weight loss, but due to their MOA are contraindicated in those with gastroparesis. Liraglutide has also been associated with C-cell tumors in animals and may not be used in patients with a history of thyroid cancer.

Correct answer: No discernable p waves

In atrial fibrillation, blocking of the AV node results in no identifiable p waves and causes an irregularly irregular rhythm.

A wide-complex tachycardia may be indicative of ventricular tachycardia, a potentially life-threatening rhythm.

A regular, narrow-complex tachycardia typically represents AV nodal reentry tachycardia, such as paroxysmal supraventricular tachycardia.

Torsades de pointes is defined as a QRS complex that twists around the baseline on electrocardiogram.

Correct answer: loss of hair involving the entire scalp

Alopecia totalis is a form of alopecia areata that denotes loss of hair on the entire scalp.

Androgenic alopecia is not a form of alopecia areata. It refers to the loss of hair involving the apex and vertices of the scalp. It is better known as male pattern baldness.

Alopecia universalis is a form of alopecia areata that denotes loss of hair involving the entire body.

Alopecia areata is usually idiopathic. It most commonly presents as loss of hair involving focal areas of the scalp.

Correct answer: Adequate hydration

This patient has nephrogenic diabetes insipidus which can occur in the setting of lithium toxicity. Other causes can be chronic renal failure, hypercalcemia, and hypokalemia. Milder cases can be treated with adequate hydration alone, but because her serum osmolality is moderately elevated, more aggressive treatment is warranted. Nephrogenic diabetes insipidus may respond to indomethacin, either alone or in combination with hydrochlorothiazide, desmopressin, or amiloride.

Correct answer: Echocardiography

Echocardiography is the most useful study for heart failure, as it assesses the size and function of the chambers, valvular abnormalities, pericardial effusion, shunting, and segmental wall abnormalities. Ejection fraction, which is also determined via echocardiography, is a key diagnostic and prognostic indicator in congestive heart failure.

Chest radiography may reveal pulmonary effusions, perivascular or interstitial edema (Kerley B lines), venous dilation and cephalization, and alveolar fluid. However, it is used more in the diagnosis of heart failure, and less in the prognosis.

Patients with heart failure may or may not have anemia, renal insufficiency, hyperkalemia, hyponatremia, and/or elevated liver enzymes.

Electrograms will commonly show nonspecific changes in patients with heart failure, such as low voltage.