NCCPA PANCE Exam Questions

Correct answer: Pericardial effusion

Pericardial effusion may be secondary to pericarditis, uremia, or cardiac trauma. It produces restrictive pressure on the heart. It may produce chest pain that is accompanied by cough and dyspnea, but it may also be asymptomatic. A massive enlargement of the cardiac silhouette on the frontal view of a chest radiograph, also known as a water bottle heart, is a typical finding.

Congestive heart failure will typically demonstrate cardiomegaly and bilateral or right-sided pulmonary effusions, perivascular or interstitial edema known as Kerley B lines, venous dilation and cephalization, and alveolar fluid on the frontal view of a chest radiograph.

Chest radiography may demonstrate underlying cardiac abnormality or reveal pulmonary infiltrates if the right side of the heart is involved, but there are no key diagnostic findings. Echocardiography is essential to this diagnosis as it will identify vegetations and affected valves.

A chest radiograph is not considered necessary in the evaluation of uncomplicated hypertension; however, in more complicated disease, it may demonstrate the findings of left ventricular hypertrophy or prominence and a slight increase in the tortuosity of the aorta at its arch. Calcifications of the aorta may also be visible as well.

Correct answer: Painless abdominal mass

Wilms tumor, also known as nephroblastoma, is the most common solid renal tumor of childhood. Most occur in healthy children, but 10% occur in children with recognized malformations. The most common sign is an asymptomatic abdominal mass found by a caretaker or during a physical exam. Symptoms can also include anorexia, nausea and vomiting, fever, abdominal pain, or hematuria. Hypertension can occur if the tumor triggers elevated renin levels.

Correct answer: Fever, flushed face, injected conjunctiva, and a maculopapular/petechial rash that demonstrates centripetal spread

Fever, flushed face, injected conjunctiva, and a maculopapular/petechial rash that demonstrates centripetal spread are the classic physical exam findings in RMSF. These findings, along with complaints of chills, headaches, nausea, vomiting, myalgias, restlessness, and insomnia, generally develop two to 14 days after exposure.

An acute, flu-like illness with one or more flat to raised "bulls-eye" shaped lesions are findings in early, localized Lyme disease infection, which develops seven to 10 days after exposure. Flu-like illness occurs in up to 50% of patients. The "bulls-eye" lesions of erythema migrans do not occur in up to 25% of patients.

Fever, exudative pharyngitis, gingivitis, soft palate petechiae, tender posterior cervical lymphadenopathy, splenomegaly, and a diffuse, maculopapular/petechial rash are findings consistent with infectious mononucleosis due to Epstein-Barr virus. The rash occurs in up to 15% of infected patients. The incidence of rash increases to 90% when ampicillin is administered to these patients.

Fever, flushed face with circumoral pallor and a strawberry tongue, and a diffuse, blanching erythematous/fine papular rash (sandpaper rash) are characteristic of scarlet fever, which is due to pharyngitis caused by group A B-hemolytic streptococci (GABHS).

Correct answer: Ridges of the retina (rugae) flapping in the vitreous humor

This patient has a history that is suspicious for a retinal detachment. Tears in the retina can happen either spontaneously or as the result of trauma; other inflammatory changes in the eye or refractive errors (extreme myopia) can be causative as well. A detachment causes the retina to separate from the pigmented epithelial layer and usually begins near the superior temporal retinal area. Exam findings usually include a normal IOP and a relative afferent pupillary defect in the affected eye. A funduscopic exam may show the ridges of the retina (rugae) flapping in the vitreous humor. Emergent consult with an ophthalmologist is required if the diagnosis is made.

Drusen deposits with hemorrhage and fibrosis are common funduscopic findings seen in macular degeneration.

Optic disc swelling with a "blood and thunder" retina are funduscopic findings seen with central retinal vein occlusion.

Retinal edema and pallor with arteriolar narrowing, box-carring, and a cherry-red spot at the macula are funduscopic findings seen with central retinal artery occlusion.

Correct answer: Radiography is not required

Radiography of the spine in non-traumatic low back pain often is not required when pertinent directed history and physical exam findings reveal no sign of a serious condition. Red flags that indicate the urgent need for radiography include fever, weight loss, morning stiffness, history of IVDU or steroid use, trauma, history of cancer, saddle anesthesia, loss of anal sphincter tone, or major motor weakness.

First-line treatment for uncomplicated low back pain is short-term relative rest (two days maximum) with neck and knee support and administration of NSAIDs and analgesics. Physical therapy is not a first-line treatment.

While low back pain is often related to the mechanical use of the back, it can also be the result of referred pain from the intra-abdominal, pelvic, or retroperitoneal areas.

If, after six weeks of conservative treatment, there is no improvement, further evaluation with a bone scan, MRI, CT, or EMG, and a medical workup to rule out spinal tumor or infection, should be initiated. Surgical intervention is a last resort that is used in about 5% of all patients who present with low back pain.

Correct answer: rats and mice are vectors that can transmit rabies

Rhabdovirus is transmitted to humans via infected saliva from an animal bite or an open wound. Common vectors are dogs, bats, skunks, foxes, raccoons, and coyotes. Rodents and lagomorphs (rabbits and hares) do not transmit rabies.

The incubation period between bite and onset of symptoms may be anywhere from 10 days to years; the typical period is three to seven weeks. There is a correlation between the length of incubation and the distance of the wound from the brain.

A history of an animal bite may not be apparent. Pain and paresthesias, along with temperature and wind sensitivity, are common at the wound site. Restlessness, muscle spasms, and extreme excitability along with bizarre behavior are all common manifestations. Hydrophobia and ascending paralysis may also be seen. Convulsions, paralysis, and thick, tenacious saliva are also common in those infected with rabies.

There is no specific treatment for rabies. Prevention of the disease is key. Household pets should be immunized. Wounds from animal bites should be thoroughly cleaned, debrided, and flushed. They should not be sutured. Postexposure immunization includes rabies immunoglobulin (in the wound and IM at a distant site) and human diploid cell vaccine (HDCV) on days 0, 3, 7, 14, and 28.

Correct answer: She will require induction at 38 weeks gestation, even if her glucose is well-controlled and there are no signs of macrosomia present. 

This patient's three-hour glucose tolerance test results confirm the presence of gestational diabetes, a carbohydrate intolerance of variable severity that is only present during pregnancy. Risk factors for developing gestational diabetes include a history of a previous large-for-gestational-age infant, obesity, age over 25 years, glycosuria, a family history of diabetes, or being a member of the following ethnic groups: African-American, Asian, Hispanic, or Native American. Patients are usually asymptomatic.

Induction of labor at 38 weeks is only required if the patient's glucose is poorly controlled or there are signs of macrosomia. Otherwise, induction of labor should occur at 40 weeks.

Correct answer: Clostridium difficile colitis

HIV infects all cells containing the T4 antigen, primarily the CD4 helper-inducer lymphocytes. As a result, HIV disease results in a disordered function of the immune system that manifests as a syndrome of nonspecific and specific diagnoses. The immunodeficiency causes infections and malignant diseases at any site, and these will typically develop as the CD4 count drops. Clostridium difficile colitis is an HIV-related illness that can occur anytime in HIV infection but may become more likely as the CD4 count falls below 500 cells/uL. It is not an AIDS indicator disease.

AIDS is defined by the CDC as a CD4 count below 200 cells/uL or the development of an AIDS indicator disease. Invasive cervical cancer, progressive multifocal leukoencephalopathy, and histoplasmosis (disseminated or extrapulmonary) are all AIDS indicator diseases. Others include multiple or recurrent bacterial infections, candidiasis, coccidioidomycosis, cryptosporidiosis, cytomegalovirus, HIV-related encephalopathy, chronic/severe herpes simplex, isosporiasis, Kaposi sarcoma, lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia, lymphomas, mycobacterium sp. infections, pneumocystis jiroveci pneumonia, any recurrent pneumonia, recurrent Salmonella septicemia, toxoplasmosis of the brain, and HIV-related wasting syndrome.

Correct answer: Abnormal, heightened neuronal sensitivity

The symptoms and findings described here are consistent with a diagnosis of a tension headache. Tension headaches are the most frequent type of headache. Patients may also describe the pain as a generalized head pain that is non-pulsatile. There may be an associated history of significant stress or minor head trauma. They can be episodic or chronic in nature. Precipitants may include stress, sleep deprivation, hunger, and/or eyestrain. Other exam findings include tenderness of the masseter, posterior cervical, trapezius, sternocleidomastoid, and occipital muscles, but the physical exam may be normal. Tension headaches are currently believed to be due to an abnormal, heightened neuronal sensitivity.

Tension headaches were once thought to be related to prolonged muscle contraction, but that is no longer the current theory.

Migraine headaches are believed to be due to dysfunction of the trigeminovascular system that results in the release of substance P and subsequent neurogenic inflammation.

Cluster headaches may have a vascular etiology, and current evidence suggests a disturbance of serotonergic mechanisms.

Correct answer: Epiglottitis

"Thumb sign" may be found on a lateral soft tissue neck x-ray with epiglottitis due to the enlargement and swelling of the epiglottis. It is a potentially serious infection often caused by Haemophilus influenzae and can lead to rapid decompensation and airway compromise. The rapid development of a sore throat, stridor, drooling, and a tripod or sniffing posture (in children) are other common features.

Peritonsillar abscess is a clinical diagnosis. X-rays are typically not helpful. It results from penetration of infection (usually group A B-hemolytic streptococcus) through the tonsillar capsule with involvement of neighboring tissue. A sore throat, pain with swallowing, trismus, deviation of the soft palate and/or uvula, and a muffled, "hot potato" voice are all common features.

Laryngitis is an inflammation of the larynx and/or vocal cords that typically follows a viral upper respiratory infection, but may also be the result of bacterial infection with Moraxella catarrhalis and Haemophilus influenzae. Hoarseness and cough are the main presenting symptoms, and the diagnosis is made clinically, without the use of x-ray or other ancillary tests.

Croup (laryngotracheobronchitis) is an acute, viral infection that usually affects children aged six months to five years. Clinical findings include a harsh, barking, seal-like cough; inspiratory stridor; hoarseness; aphonia; low-grade fever; and rhinorrhea. Although the diagnosis is usually made clinically, a posterior-anterior (PA) neck x-ray may show subglottic narrowing known as "steeple sign." A lateral neck x-ray helps to differentiate croup from epiglottitis.

Correct answer: Diabetes mellitus 

Aseptic necrosis of the hip is also known as osteonecrosis or avascular necrosis in which there is loss of blood supply to the trabecular bone causing a collapse of the femoral head. It can occur at any age but is seen with greater frequency during the third to fifth decades of life and often is bilateral. The cause is generally unknown, but it is often seen in patients with a history of trauma, steroid use, alcohol abuse, rheumatoid arthritis, radiation therapy, and systemic lupus erythematosus (SLE).

Patients with diabetes mellitus do not have an increased risk of aseptic necrosis of the hip.

Correct answer: Eye lavage with normal saline twice a day for seven to 14 days

This child has viral conjunctivitis. Therefore, no specific therapy is indicated, and treatment will be supportive until the infection resolves on its own. Vasoconstrictor-antihistamine drops may also have beneficial effects for viral conjunctivitis.

Ophthalmic sulfonamide drops every four hours may help prevent secondary bacterial conjunctivitis, but will not speed resolution and are not indicated for the treatment of viral conjunctivitis.

Gentamicin ophthalmic drops every four hours would be indicated for the treatment of bacterial conjunctivitis.

Erythromycin ophthalmic ointment applied every four hours is typically not a treatment used for either viral or bacterial conjunctivitis. It may be of use in blepharitis and hordeolum (stye).

Correct answer: barotrauma

Barotrauma is the inability to equalize barometric pressure in the middle ear and is usually associated with eustachian tube dysfunction (congenital or acquired). It typically occurs with flying (descent), rapid altitude changes, or diving underwater. Typical symptoms are ear pain and hearing loss that persist past the inciting event. 

An acoustic neuroma, also known as vestibular schwannoma, is a benign, intracranial tumor affecting the eighth cranial nerve. It usually presents with progressive, unilateral hearing loss, impaired speech discrimination, and continuous vertigo.

Meniere's disease, also known as endolymphatic hydrops, is a condition that seems to be related to the distention of the inner ear's endolymphatic compartment, but its etiology is unknown. Typical symptoms include episodic vertigo (lasting minutes to hours), lower-range hearing loss, tinnitus, and a sensation of unilateral aural pressure.

Labyrinthitis presents with acute, severe vertigo and hearing loss. The vertigo may last for several days to weeks and generally improves over time, but the hearing loss may persist. The etiology is unknown.

Correct answer: Sjogren's syndrome

Sjogren's syndrome is an autoimmune disorder that destroys the salivary and lacrimal glands (exocrine glands). It may also be a secondary complication to a pre-existing connective tissue disorder such as RA, SLE, polymyositis, or scleroderma. It is most often diagnosed in middle-aged females and presents with dry mouth (xerostomia) and dry eyes (xerophthalmia or keratoconjunctivitis sicca) and parotid gland enlargement. A Schirmer's test may be useful to evaluate lacrimal gland function as it measures tear secretions. It is performed by placing a filter paper in the lower eyelid for five minutes. If less than 5 mm of the paper is wet after that time, the test is positive for decreased tear secretions.

Correct answer: Conversion disorder

Conversion disorder presents as one or more neurologic complaints that cannot be explained clinically. Symptoms are not intentionally produced and may be motor, sensory, or seizure activity, or mixed. The most common symptoms are shifting paralysis, blindness, and mutism. Episodes are sporadic, lasting days to months, and tend to recur during times of stress. Patients demonstrate an unexpected lack of concern (la belle indifference) and are typically diagnosed in adolescence or young adulthood. It is two to five times more common in females than males, and there is a 20% to 25% incidence in general medical practice.

Somatization disorder presents with vague physical complaints involving many organ systems that cannot be explained by a general medical condition or substance use. Symptoms are generally related to the gastrointestinal (GI) tract, reproductive, or neurological systems. Pain is usually a complaint. The somatic symptoms may be associated with periods of increased stress. It occurs more frequently in females and more often in low socioeconomic groups. Onset is typically before age 30, usually in adolescence, and up to 50% of patients have a comorbid mental disorder.

Factitious disorder occurs when patients intentionally fake signs and symptoms of a medical or psychiatric condition. The primary motivation is to assume the sick role. It usually begins in young adulthood. Patients will commonly seek hospital admission under various names and by feigning different illnesses. When (or if) they are confronted with their ruse, they typically become very angry and abruptly sign out.

Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in physical appearance or an exaggerated distortion of a minor flaw. The most common are facial flaws. Age of onset is typically 15 to 30 years of age, and females are more commonly affected than males. Patients feel very self-conscious and fear humiliation. They frequently go to great lengths to hide or correct their perceived anomaly. Despite multiple visits to the dermatologist or plastic surgeon, patients still are not satisfied with their appearance.

Correct answer: Hepatitis C

This patient has symptoms and a history consistent with perimenopause. Perimenopause may last from three to five years around the time of menopause. Symptoms may include vasomotor reactions (hot flashes), triggering tiredness, insomnia, and irritability; urogenital atrophy, triggering poor vaginal lubrication; dyspareunia, urge incontinence, pelvic relaxation, atrophic cystitis, and easy bleeding; as well as thinning skin, increased facial hair, thinning scalp and body hair, and brittle nails. Women are at increased risk of osteoporosis and cardiovascular disease due to declining levels of estrogen. An FSH level greater than 30 mIU/mL is diagnostic for menopause. Combined hormone replacement therapy (HRT) may be helpful at reducing some symptoms, but each woman should be treated on the basis of individual risk factors and symptoms. Contraindications include undiagnosed vaginal bleeding, acute vascular thrombosis, liver disease, and a history of either endometrial or breast cancer.

Angina is not a contraindication. However, combined HRT appears to increase the risk of cardiovascular disease, so it should only be used with great caution in a patient with this history.

Combined HRT may increase the risk of migraines, so the risks and benefits of using it in a patient with this history should be weighed carefully.

Combined HRT is not contraindicated in those with known osteoporosis.

Correct answer: Respiratory syncytial virus (RSV)

This child has acute bronchiolitis, an inflammation of the bronchioles (the airways smaller than 2 mm in diameter). It is primarily an illness of young children and infants. In addition to the symptoms and findings listed here, the CBC will usually be normal and the chest radiograph may demonstrate air trapping and peribronchial thickening. Nasal washings for RSV culture and antigen assay are often done in infants. Although each of the choices listed is a possible cause of acute bronchiolitis, RSV is the most common cause of the illness.

Correct answer: Post-void dribbling

With BPH, the proliferation of the fibrostromal tissue of the prostate leads to compression of the prostatic urethra, creating an obstruction of the urinary outlet. This leads to LUTS (lower urinary tract symptoms). The mean age of onset of BPH is 60 to 65 years, but LUTS may develop as early as age 45.

BPH involves a combination of obstructive and irritative symptoms. Obstructive symptoms include decreased force of the urinary stream, hesitancy and straining, post-void dribbling, and a sensation of incomplete emptying. Irritative symptoms include frequency, nocturia, and urgency.

Correct answer: Asbestosis

Pneumoconioses are chronic fibrotic lung diseases caused by the inhalation of coal dust or various other inert, inorganic, or silicate dusts. There is no specific treatment for them other than supportive measures, including oxygen, vaccinations (influenza and pneumococcal), and rehabilitation. Smoking cessation is especially important for patients with asbestosis because smoking interferes with short asbestos fiber clearance from the lung. Smoking and asbestos are synergistically linked to lung cancer, especially mesothelioma.

Correct answer: Borrelia burgdorferi

This patient has classic symptoms of early disseminated Lyme disease which is caused by the organism Borrelia burgdorferi. It is transmitted by the small tick Ixodides, and it is the most common vector-borne illness in the U.S. Up to 75% of those affected do not recall having been bitten by a tick. She describes the classic, early localized infection known as erythema migrans, which typically occurs seven to 10 days after the bite. A flu-like illness can also occur during this stage in up to 50% of patients. Her current symptoms are typical of the second stage of the illness, occurring days to weeks later. Patients may also have cardiac or neurologic symptoms in 20% of cases as well. Stage 3 or late persistent infection can occur months to years later and typically demonstrates musculoskeletal symptoms of frank arthritis and chronic synovitis. Subacute encephalopathy (memory loss, mood changes), axonal polyneuropathy (paresthesias, encephalopathy), and leukoencephalitis (cognitive change, paraparesis, ataxia, bladder dysfunction) are common findings.

Rickettsia rickettsii is the organism responsible for Rocky Mountain spotted fever. It is transmitted by the wood tick. Two to 14 days after exposure, patients will present with a flushed face, injected conjunctiva and faint modules to maculopapules, and petechiae that develop on the wrists and ankles and then spread to the extremities and the trunk. Fever, chills, headache, nausea, vomiting, myalgias, restlessness, insomnia, and irritability are all common symptoms. Up to 10% of patients do not develop a rash. 

Hookworms are endemic to the tropic and subtropic regions. Humans are the only host. The larvae are present in the sand and the soil and penetrate the skin of the feet causing pruritic, erythematous dermatitis with a maculopapular or vesicular eruption. They then migrate via the bloodstream to the pulmonary alveoli where they are carried to the mouth by cilia and swallowed. The larvae attach to the large intestine, mature, and release eggs to continue the life cycle. The pulmonary stage may present with a cough, wheeze, low-grade fever, and blood-tinged sputum. The intestinal stage may be asymptomatic in a light infection or present with anorexia, diarrhea, pain, and ulcer-like epigastric symptoms with heavy infection.

Entamoeba histolytica are the organisms responsible for amebiasis. Humans are the only host. The cysts are viable in the soil and water for weeks to months and are transmitted via fecally contaminated food, water, fly droppings, or by human-to-human contact. Once ingested, the cysts hatch into trophozoites in the intestines where they invade the mucosa and induce necrosis. The disease may be asymptomatic or cause symptoms of colitis (semiformal stools without blood) or severe dysentery (greater number of liquid stools streaked with blood or bits of necrotic tissue). Cramping, fatigue, weight loss, and increased flatulence are typical complaints. Severe disease can cause fever, colic, tenesmus, and vomiting; patients are prostrate and toxic. Perforation of the bowel is possible. Extraintestinal disease can cause hepatic abscesses.