NCCPA PANCE Exam Questions

Correct answer: Sclerodactyly

Sclerodactyly is often seen as part of CREST syndrome associated with limited scleroderma. It is not part of the diagnostic criteria for SLE.

In order for the diagnosis of SLE to be made, a total of four of the following criteria must be met, including a significantly high-titer ANA: malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis (heart, lungs, or peritoneal), renal disease (proteinuria or cellular casts), ANA titer, hematologic disorders (hemolytic anemia, leukopenia, leukocytosis, thrombocytopenia) and/or neurologic disorders (seizures or psychosis in the absence of any other cause).

Correct answer: Visual changes

The pituitary gland lies below the hypothalamus attached by a stalk called the infundibulum. It lies in very close proximity to the optic chiasm, which accounts for the frequent involvement of visual changes when pituitary neoplasms occur.

Correct answer: Lobar pneumonia

In a patient who is otherwise healthy and free of respiratory distress or complications, treatment as an outpatient with appropriate antibiotics and supportive measures is appropriate. However, neutropenia, the involvement of more than one lobe, or poor host resistance indicates a need for hospitalization. Inpatient treatment should also be considered for those over the age of 50 with comorbidities, those with altered mental status, and/or hemodynamic instability.

Correct answer: An inwardly turned right upper eyelid and eyelashes 

Entropion is a condition where the affected eyelid and eyelashes are turned inward, toward the eye itself. It is likely the result of scar tissue or spasm of the orbicularis oculi muscle. If asymptomatic, no treatment is indicated; however, surgical correction of the eyelid is indicated if it is causing trichiasis (trauma), excessive tearing, exposure keratitis, or cosmetic distress.

An everted eyelid is a finding with ectropion. This condition causes the eyelid to turn away from the eye due to advanced age, trauma, infection, or palsy of the facial nerve. As with entropion, no treatment is indicated if the patient is asymptomatic; however, it may cause excessive tearing, exposure keratitis, or cosmetic distress prompting surgical correction.

Entropion does not usually cause erythema of the eyelid margins; this finding is more consistent with chronic blepharitis.

Entropion does not usually cause loss of eyelashes. However, trichiasis or rubbing of the lashes on the surface of the eye is very common with entropion.

Correct answer: Depression

Insomnia complaints include difficulty falling asleep or staying asleep, intermittent wakefulness during the night, early morning awakenings, or some combination of all of these. Psychiatric disorders, including depression and manic disorders, are often associated with persistent insomnia. Depression is associated with fragmented sleep, decreased total sleep time, quicker onset of REM sleep (when dreaming takes place), and a shift to REM earlier in the night.

Hypothyroidism may be a consideration in this patient, but he is a normal weight, and his physical exam is normal.

Sleep apnea is often seen in obese, middle-aged, and older men with hypertension and associated congestive heart failure. It typically presents with the complaint of hypersomnia (excessive daytime sleepiness) rather than sleep disruption.

An anxiety disorder may co-exist with depression, but depression is a psychiatric disorder that is more frequently associated with chronic insomnia.

Correct answer: Late decelerations

Fetal monitoring is used in labor to assess the fetus' response to labor. Fetal monitors can either be external (attached to the mother's abdomen) or internal (electrode placed on the fetus' head). Late decelerations are fetal heart rate drops during the second half of the contractions. They denote uteroplacental insufficiency and are always worrisome.

Early decelerations mirror the images of the contractions and denote fetal head compression. They are often present as a woman approaches the second stage of labor and are considered to be benign.

Variable decelerations are rapid drops in fetal heart rate with a return to baseline with variable shape and no identifiable pattern. They occur with cord compression and, if mild or infrequent, are benign.

Accelerations of an increase of 15 bpm for 15 seconds above the normal baseline heart rate of 120 to 160 bpm are reassuring and denote fetal well-being.

Correct answer: Diabetic retinopathy

Ophthalmic care of diabetic patients is a necessity. All diabetics should have yearly, dilated ophthalmoscopic examinations. Fundoscopic findings include venous dilation, microaneurysms, retinal hemorrhages, retinal edema, and hard exudates for nonproliferative retinopathy, and neovascularization and vitreous hemorrhage for proliferative retinopathy. Severe disease causes permanent loss of vision. 

Hypertensive retinopathy can cause blindness, but it is not the leading cause of it in the U.S. Fundoscopic findings include diffuse arteriolar narrowing, copper or silver wiring, and arteriovenous nicking. Again, severe, long-standing disease can cause permanent vision loss.

Macular degeneration is the leading cause of irreversible central visual loss, but not total blindness. It may either be age-related (increased prevalence in those over age 50) or secondary to cumulative toxic effects of some drugs (chloroquine or phenothiazine). Fundoscopic findings include drusen deposits, mottling, serous leaks, and hemorrhaging on the retina. Scarring/fibrosis of the macula can be seen in the late stages.

Retinal detachment is a reversible cause of partial or complete blindness. Fundoscopic findings may include the edges of the retina (rugae) flapping in the vitreous humor. 80% of patients have a complete recovery with no recurrence; however, 15% will require re-treatment and 5% will never reattach.

Correct answer: ezetimibe (Zetia)

Ezetimibe blocks intestinal absorption of dietary and biliary cholesterol by blocking a cholesterol transporter. By this mechanism, it lowers cholesterol intake but doesn't have a specific, LDL-lowering effect.

Niacin reduces the long-term risk of CAD by reducing production of very-low-density lipoprotein (VLDL) and LDL in addition to increasing HDL levels. It may also reduce triglycerides.

The Mediterranean diet has been found to reduce LDL without reducing HDLs.

Soluble fiber has also been found to reduce LDL levels.

Correct answer: Conization

Incompetent cervix is also known as cervical insufficiency. It is a condition in which weakened cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. Of all the treatments listed for HSIL, conization is more likely to lead to incompetent cervix. There is also a risk of incompetent cervix with LEEP, but it is greater with conization.

Correct answer: Nummular dermatitis (discoid eczema)

The presentation and predilection for the cooler, drier months of the year are consistent with this type of dermatitis. Nummular dermatitis (discoid eczema) appears as coin-shaped plaques with an erythematous base that most commonly occur on the extremities.

Atopic dermatitis may get worse in the fall and winter, but is typically present, waxing and waning, throughout the entire year for those affected. It typically appears as papules and plaques with xerosis, excoriations, and crust on the flexural surfaces, neck, eyelids, forehead, face, and dorsum of the hands and feet.

Seborrheic dermatitis may flare during the fall and winter and improve in the summer. However, it appears as scattered yellowish or gray, scaly macules with a greasy look in areas where the sebaceous glands are most active (face, scalp, genitalia, and body folds).

Stasis dermatitis does not have a seasonal predilection. It occurs as a result of chronic venous insufficiency and manifests in the lower legs with inflammatory papules and plaques, scaling, and crusting. Ulceration occurs in up to 30% of patients.

Correct answer: A short course of benzodiazepines followed by SSRIs

This patient has classic history and symptoms of panic disorder, which is characterized by recurrent, unexpected panic attacks that occur abruptly and are accompanied by a debilitating fear of having additional attacks. The intense fear and physical symptoms may be accompanied by feelings of impending harm or death, fear of a heart attack or stroke, and/or fears of "going crazy." First-line therapy is a short course of benzodiazepines (alprazolam or lorazepam) for acute management of the anxiety followed by SSRIs (paroxetine, fluoxetine, venlafaxine, or sertraline) for maintenance.

Lithium with a benzodiazepine would be a first-line treatment for bipolar I disorder during an acute manic episode or if agitation or psychotic symptoms are present.

Hospitalization while beginning a course of atypical antipsychotics is indicated for schizophrenia with suicidal or homicidal ideation.

Higher-than-normally-prescribed doses of SSRIs and relaxation therapy may be helpful for obsessive-compulsive disorder.

Correct answer: Start ceftriaxone (Rocephin) plus vancomycin (Vancocin)

The symptoms of bacterial meningitis develop acutely, usually within hours to one to two days of infection. They are based on the combination of three processes: inflammation, increased intracranial pressure, and/or tissue necrosis. The primary causes today are Streptococcus pneumoniae, Neisseria meningitidis, and group B streptococcus (especially in infants). The incidence of Hib meningitis has decreased dramatically since the widespread use of the vaccine. Altered mental status, fever, headache, vomiting, and a stiff neck are all typical symptoms. A petechial rash may also occur with N. meningitidis. Meningeal signs may be absent or subtle at the age extremes or difficult to assess with altered consciousness. Prompt lumbar puncture (LP) and CSF analysis are essential. Antibiotic treatment is started empirically if the CSF is not clear and colorless. Because this child is an immunocompetent six-month-old, starting ceftriaxone or cefotaxime plus vancomycin is the correct next step in managing this patient.

Antibiotic therapy should not be delayed in suspected cases of bacterial meningitis if the LP cannot be accomplished or imaging is necessary.

Ampicillin with cefotaxime and, in some cases, gentamicin are appropriate choices for neonates and infants up to three months of age (increase dose in older infants).

Dexamethasone is an appropriate adjunctive treatment to antibiotics with Hib meningitis in infants older than one month of age as it greatly reduces morbidity and mortality when given promptly, but not the most important next step in this scenario.

Correct answer: The patient must have a symptom-free time period during the follicular phase.

Premenstrual syndrome (PMS) lacks agreed-upon diagnostic criteria, pathophysiologic mechanisms, and optimal treatment. Its reported incidence is 10% to 90%. It is debilitating in 10% of women who are affected by it. An association exists among postpartum depression, perimenopausal depression, other affective disorders, and PMS. Symptoms generally begin one to two weeks prior to the onset of menses (during the luteal phase) and end one to two days after its onset. During each cycle, the patient must have a symptom-free time period during the follicular phase. 

Symptoms are consistent month to month within the same patient and vary widely from woman to woman. They commonly include mood alteration, irritability, anxiety, depression, sleep and appetite changes, poor concentration, fatigue, insomnia, fluid retention (edema, weight gain, breast pain), bloating, constipation, and backache.

The prevalence of PMS is the greatest between 20 and 40 years of age.

Pyridoxine (vitamin B6) and evening primrose oil show no benefit over placebo in clinical trials for the treatment of PMS, but they have been reported to relieve breast tenderness and depression in some women.

Correct answer: Tram-track lung markings, honeycombing, and basal cystic spaces

This patient presents with a history and findings of bronchiectasis. It is a condition that involves permanent dilation of the bronchi and destruction of the bronchial walls. It may be congenital (due to cystic fibrosis) or acquired (due to infections such as TB or fungal or due to obstruction from a tumor). The chest radiograph of a patient with clinically significant bronchiectasis will be abnormal. The degree of abnormality will depend on the extent and severity of the underlying disease process. Crowded bronchial markings, basal cystic spaces, tram-track lung markings, honeycombing, and atelectasis may all be seen.

Parenchymal bullae and/or subpleural blebs are radiographic findings in a patient with emphysema-predominant COPD. Hyperinflation and flattened diaphragms may also be seen. Presenting symptoms in these patients will include dyspnea, and the exam will show decreased breath sounds and inspiratory crackles.

Blunting of the costophrenic angle, loss of demarcation of the diaphragm, and a mediastinal shift will be seen on a chest ray of a patient with a large pleural effusion. These patients will have dyspnea, dullness on percussion of the thorax in the area of the effusion, in addition to decreased or absent breath sounds over the affected area.

Mild hyperinflation on a chest x-ray may be seen in asthma. These patients will likely present with the complaint of intermittent episodes of wheezing, dyspnea, cough, and chest tightness.

Correct answer: Meniere's disease (endolymphatic hydrops)

These exam findings are all suggestive of Meniere's disease, also known as endolymphatic hydrops. The symptoms appear to be related to the distention of the inner ear's endolymphatic compartment, but the etiology of the disorder is unknown.

Otitis media with effusion is the retention of non-infected fluid within the middle ear. It can present with a sensation of aural pressure and conductive hearing loss on the affected side. Your physical exam findings will show a dull, retracted TM with fluid behind it. 

Labyrinthitis is another disorder of unknown etiology that usually presents with an acute, severe, continuous vertigo that slowly improves over time. Patients will also typically complain of hearing loss; this may or may not improve.

An acoustic neuroma, also known as a vestibule schwannoma, is a benign, intracranial tumor affecting the eighth cranial nerve. Patients with this lesion generally complain of continuous vertigo and a unilateral, progressive hearing loss.

Correct answer: G6P3123

A patient's obstetric history can be expressed as gravida (G: the number of total pregnancies) and parity (P: the number of deliveries). The parity is denoted as a sequence of four digits (P_ _ _ _) signifying the number of term infants (3), premature deliveries (1), therapeutic/elective/spontaneous abortions (2), and living children (3).

Correct answer: Marked hyponatremia

The symptoms and findings are due to an absence or lack of cortisol. Adrenal crises can be precipitated by infection, trauma, surgery, stress, lymphoma, metastatic cancer, amyloidosis, scleroderma, hemochromatosis, or cessation of corticosteroid medication. The presentation will feature hypotension, acute pain (abdomen or low back), vomiting, diarrhea, dehydration, and altered mental status. Laboratory findings include marked hyperkalemia, hyponatremia, hypoglycemia, hypercalcemia, and low BUN. It can be fatal if left untreated.

Correct answer: S₃ gallop

Dilated cardiomyopathy is the most common type of cardiomyopathy, accounting for approximately 95% of cases. Dilation of the left ventricle occurs secondary to a reduction in the strength of contraction. The most common cause of dilated cardiomyopathy is 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. Signs and symptoms are that of left or biventricular congestive heart failure: dyspnea, S₃ gallop, pulmonary crackles, and increased jugular venous pressure. Long-standing disease may show cardiomegaly and pulmonary congestion on radiography. ECG may show nonspecific ST- and T-wave changes, conduction abnormalities, and ventricular ectopy. Left ventricular dilation and dysfunction, with high diastolic pressure and low cardiac output, will be seen on echocardiography. Treatment should be targeted at the underlying disease, abstinence of alcohol, if causal, and supportive therapies for congestive heart failure.

An S₄ gallop may be heard in hypertrophic cardiomyopathy. Signs and symptoms, as well as ECG changes, are similar to that of dilated cardiomyopathy. A prominent “a” wave may be seen on examination of the jugular venous pulse. Chest radiography is often unremarkable.

Patients with mitral valve prolapse commonly present with mid-systolic clicks or a late systolic murmur. A thin female is the most common patient type. Patients are commonly asymptomatic.

A mid-diastolic “opening snap” after S₂ can be heard on the apex of patients with mitral stenosis, which impedes the blood flow between the left atrium and left ventricle.

Correct answer: Decreased BP, decreased cardiac output, increased heart rate

Shock is defined as severe cardiovascular failure caused by poor blood flow or inadequate distribution of flow. The inadequate delivery of oxygen to body tissues may lead to organ failure and death unless the underlying cause is identified and treated. There are multiple causes of shock; hypovolemic, cardiogenic, obstructive, distributive (septic, anaphylactic, neurogenic) shock can all produce the clinical syndrome known as shock. The primary clinical features include hypotension (decreased BP), orthostatic changes, tachycardia (increased heart rate), peripheral hypoperfusion, altered mental status, oliguria or anuria, insulin resistance, and metabolic acidosis. In the case of hypovolemic and cariogenic shock, there will also be decreased cardiac output.

Correct answer: fluoroquinolones

Neisseria gonorrhoeae infection typically includes a history of sexual contacts, clinical signs and symptoms of dysuria, and serous or milky penile discharge in men or dysuria, frequency, and urgency, and purulent urethral discharge in women. Vaginitis, cervicitis, pelvic inflammatory disease, and infertility in women can be possible as well. Gram stains and cultures are essential to confirm the diagnosis. There is widespread resistance to penicillin, tetracyclines, and fluoroquinolones; therefore, they are not recommended treatments. 

IM ceftriaxone is currently a treatment of choice for Neisseria gonorrhoeae infection as well as for oral cefixime. Azithromycin or doxycycline should be given at the time of treatment for a confirmed case of Neisseria gonorrhoeae infection to cover for co-infection with chlamydia.