NCCPA PANCE Exam Questions

Correct answer: Chronic cough that is either productive or non-productive

Asthma affects 7% to 10% of the population. Its prevalence, hospitalization, and mortality rates have risen during the past 20 years. Many asthma syndromes have been identified, and the strongest predisposing factor to asthma is atopy. Although asthmatic patients have intermittent occurrence of cough, it is not one of the three characteristics that define the disease state. Chronic productive cough is seen in bronchiectasis as well as chronic bronchitis-predominant COPD (chronic obstructive pulmonary disease). Chronic non-productive cough is a feature of emphysema-predominant COPD.

Obstruction of airflow, bronchial hyperreactivity, and inflammation of the airway are the three main components of asthmatic disease. It is a disease of chronic inflammation that leads to airway narrowing and increased mucus production.

Correct answer: it cannot be diagnosed in a patient with non-convulsive seizures

Status epilepticus can occur in non-convulsive or absence seizures. It is diagnosed when seizures fail to cease spontaneously or recur so frequently that full consciousness is not restored between successive episodes. The length of time seizure activity must persist to diagnose it is generally more than five minutes. It is a medical emergency because it may induce permanent brain damage secondary to hyperthermia, circulatory collapse, or excitotoxic neuronal damage.

Correct answer: chalazion

A chalazion is a relatively painless, indurated lesion located deep to the palpebral margin. It forms secondary to chronic inflammation of an internal hordeolum of a meibomian gland. While it may become pruritic and cause some erythema of the eyelid, it is not an infectious process; therefore, S aureus is not a causative factor.

A hordeolum (stye) is an acute development of a painful, infectious nodule or pustule of either the meibomian gland (internal hordeolum) or the gland of Moll or Zeis (external hordeolum). There is induration and erythema of the affected eyelid. The causative pathogen is typically S aureus.

Blepharitis is a chronic inflammation of the eyelid margins. It causes the rims of the eyelids to appear erythematous with adherent eyelashes and dandruff-like deposits (scurf) or fibrous scales (collarettes). It can be due to non-infectious processes such as seborrhea and meibomian gland dysfunction, but it may also be the result of either staphylococcal or streptococcal infection.

Orbital cellulitis is a medical emergency that presents with fever, edema, and erythema of the eyelids and skin, ptosis, exophthalmos, purulent discharge, and conjunctivitis. Elevated WBCs are noted on a CBC and blood and drainage cultures should be obtained. S aureus is a common pathogen, as well as Streptococcus pneumoniae, Haemophilus influenzae, methicillin-resistant Staphylococcus aureus (MRSA), and gram-negative bacteria.

Correct answer: A normal physical examination of the abdomen

This patient has a history that is suspicious for irritable bowel syndrome (IBS). It is a functional disorder without a known pathology that is thought to be a combination of altered motility, hypersensitivity to intentional distention, and psychological distress. IBS is the most common cause of chronic or recurrent abdominal pain in the U.S. Physical exam is generally normal.

Patients with IBS may have a tender, palpable sigmoid colon.

There is usually hyperresonance on percussion over the abdomen of a patient with IBS.

Abdominal pain may occur anywhere with IBS, but if there is localized pain, it is usually located in the hypogastric area or left lower quadrant. Localized RLQ pain and rebound are characteristic of acute appendicitis. 

Hemoccult positive stool testing will not occur with IBS. Inflammatory bowel disease, some invasive forms of infectious diarrhea, PUD, and colorectal cancers will demonstrate positive hemoccult stool testing.

Correct answer: Supine with the head turned toward the affected side

Supine with the head turn toward the affected side is the correct positioning of a patient with a retinal detachment as most tears of the retina begin at the superior temporal area. It will help prevent further detachment while the patient is waiting for emergent consultation with the ophthalmologist. 

Supine with the head turned away from the affected side is incorrect, as are prone positions.

Correct answer: Functional incontinence is caused by dysfunction of the urethral sphincter, allowing urine to leak with increased intra-abdominal pressure.

Functional incontinence is untimely urination caused by a physical or cognitive disability that prevents a person from getting to the toilet on time. Stress incontinence is caused by dysfunction of the urethral sphincter, allowing urine to leak with increased intra-abdominal pressure such as with sneezing, coughing, and laughing.

Overflow incontinence occurs when urinary retention leads to bladder distention and overflow of urine through the urethra. If untreated, it can lead to hydronephrosis and obstructive nephropathy.

Urinalysis is helpful to rule out glycosuria or urinary tract infections, which are both reversible causes of incontinence.

Urge incontinence results from bladder contractions that cannot be controlled by the brain. Anticholinergics, such as oxybutynin or tolterodine, are effective treatments for this condition.

Correct answer: A carotid bruit

This patient has symptoms consistent with a transient ischemic attack (TIA). TIAs are noted most frequently in older patients and those at risk for vascular disease. The sudden onset of focal neurologic deficits correlates with a disturbance in either the carotid or vertebral vascular circulation. TIAs associated with the carotid distribution may demonstrate contralateral hand-arm weakness with sensory loss, ipsilateral visual symptoms, or aphasia and/or amaurosis fugax. Those related to the vertebral distribution may demonstrate diplopia, ataxia, vertigo, dysarthria, cranial nerve palsies, lower extremity weakness, dimness or blurring of vision, personal numbness, and/or drop attacks. Therefore, in this presentation, a carotid bruit may be heard on physical exam, but may not be present with a high-grade (>95%) stenosis.

Tachycardia is a non-specific exam finding. Cardiac workup for suspected TIAs should be performed but is more likely to demonstrate murmurs or arrhythmia as a source of cariogenic TIA.

Pulsus paradoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. It is common in cardiac tamponade, constrictive pericarditis, and obstructive lung disease.

Unilateral miosis and ptosis (with/without anhidrosis) are part of Horner's syndrome, which may occur in the setting of an apical lung lesion (Pancoast tumor) or a mass lesion in the brainstem or cerebellar region.

Correct answer: dyshidrotic eczematous dermatitis (dyshidrosis)

Dyshidrotic eczematous dermatitis (dyshidrosis) is an intensely pruritic eruption that causes clusters of small vesicles with a tapioca-like appearance to appear on the fingers, palms, and soles. Prolonged dyshidrosis can cause scaling, lichenification, and fissuring. A KOH prep should be done to rule out dermatophyte infection since there are many similarities in the presentation of dyshidrosis and tinea infections of the hands and feet, but it will be negative.

Tinea versicolor is a skin infection due to the yeast Malassezia furfur. It manifests as multiple, confluent hypo or hyperpigmented macules on the trunk and proximal upper extremities. A KOH prep will demonstrate numerous hyphae and spores in a "spaghetti and meatballs" distribution.

Tinea pedis is a fungal dermatophyte infection of the feet. It causes erythema, scaling, maceration, and peeling between the toes with extension onto the plantar surface and sides of the foot. A KOH prep will demonstrate numerous hyphae.

Onychomycosis is a fungal dermatophyte infection of the nails. It can occur on either the fingernails and/or toenails. It causes thickening, discoloration, and onycholysis (or lifting) of the nail plate. A KOH prep will demonstrate numerous hyphae.

Correct answer: It typically affects runners and obese people

Plantar fasciitis is very common in runners and overweight people. It is caused by microscopic tears in the plantar fascia usually at the calcaneal origin.

Patients with plantar fasciitis will complain of pain with the first few steps in the morning, and they may also complain of heel pain at night. Radiography may demonstrate associated calcaneal fracture or bone spur, and MRI may reveal calcifications of the plantar fascia. Treatment is 6 to 12 months of physical therapy for stretching of the plantar fascia and the Achilles tendon, as well as using heel pads and arch supports and massage of the area with a tennis ball. Steroid injections should be used with caution due to the risk of rupturing the plantar fascia. Surgical correction is recommended only in extreme cases.

Correct answer: the degree of fever correlates with the severity of illness

A fever is produced when monocyte-macrophage cells are stimulated to elaborate pyrogenic cytokines, triggering an elevated set point of the body's temperature. Although elevated temperature and the symptoms caused by the change in body temperature are fairly well correlated with illness, particularly infection, the degree of fever does not correlate with the severity of the illness. 

Irreversible brain damage occurs when the body's temperature is greater than 106.8ºF (41.1ºC).

FUO is defined as a temperature of greater than 101.8ºF (38.8ºC) for three weeks with no discernible cause despite at least one week of diagnostic workup. The most common causes of FUO are infections and multisystem disease (i.e. autoimmune disorders, neoplasms). In 25% of cases, no diagnosis is made.

The elderly and those on chronic medications (i.e. NSAIDs, steroids) have an impaired ability to mount a fever and may not have fever in the presence of infection, etc. Conversely, children typically mount very high fevers.

Correct answer: Hypospadias

Hypospadias refers to the abnormal placement of the urethra where the meatus is proximal and ventral to its normal, anterior location.

Phimosis is a condition in which there is an inability to retract the foreskin over the glans penis. It may be congenital or acquired due to poor hygiene and chronic balanitis.

Epispadias is a dorsal displacement of the urethral meatus. It is less common than hypospadias.

Paraphimosis is defined as the entrapment of the foreskin behind the glans penis. Predisposition to paraphimosis occurs with frequent catheterizations without reducing the foreskin, forcibly retracting a constricted foreskin (phimosis) for cleaning or catheterization, or vigorous sexual activity.

Correct answer: Deep anorectal abscess

Anorectal abscess is the result of infection. Perianal and perirectal abscesses are the most common and produce painful swelling at the anus and painful defecation. Fever is uncommon. A deep anorectal abscess is likely to present with buttock or coccyx pain and rectal fullness. Fever is much more likely. 

Anorectal fistula is a chronic complication of anorectal abscess. It is an open tract between two epithelium-lined areas and will commonly occur in those with deeper abscesses. The lack of anal discharge is the feature in this patient that makes a fistula the less likely diagnosis. Fistulas generally produce discharge and pain when the tract becomes occluded. Tracts should not be explored on examination as they may open new tracts.

Stage I internal hemorrhoids are located in the anal canal and may bleed with defecation. They will not produce rectal fullness, coccyx pain, or fever.

A pilonidal cyst is an abscess in the sacrococcygeal cleft that is associated with subsequent sinus tract development. The clinical presentation is usually a male (four times more likely than females), obese or hirsute, less than 40 years of age who has a painful, fluctuant area at the sacrococcygeal cleft. There is no rectal fullness or fever.

Correct answer: Ventricular tachycardia

Ventricular tachycardia is defined as three or more consecutive ventricular premature beats. It is a frequent complication of acute myocardial infarction and dilated cardiomyopathy. As with all ventricular arrhythmias, dizziness, syncope, and sudden death are possible. A pulse may or may not be present. An electrocardiogram will reveal a broad QRS complex tachycardia.

Ventricular fibrillation is similar to ventricular tachycardia, except an electrocardiogram will reveal no discernable p waves or QRS complexes.

Ventricular premature beats are common and typically benign. Ischemia and electrolyte disturbances are common causes. Patients may be aware of skipped beats or be asymptomatic.

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. Most patients will typically complain of a “racing heart.” As with all supraventricular arrhythmias, patients may present with palpitations, angina, fatigue, and other symptoms of heart failure. Electrocardiogram will reveal tachycardia.

Atrial fibrillation will present with palpitations, angina, fatigue, and other symptoms of heart failure. Electrocardiogram will reveal no discernable p waves in an irregularly irregular rhythm.

Correct answer: Primary vaginal neoplasms are rare and far less common than cervical or vulvar neoplasms.

Neoplasia of the vulva and vagina is the rarest of the gynecologic neoplasms. Of these, primary vaginal neoplasms are rare and far less common than cervical or vulvar neoplasms.

The most common vulvar malignancy is squamous cell carcinoma. They typically occur in postmenopausal women with a mean age at diagnosis of 65 years of age.

Most vaginal intraepithelial neoplasms occur in the upper one-third of the vagina and are asymptomatic. If there are presenting symptoms, they are usually postmenopausal bleeding or bloody discharge.

Primary vaginal cancer is typically treated with radiotherapy. Surgery is usually required for most vaginal neoplasms. Topical 5-fluorouracil along with local excision and laser therapy may be used to treat early lesions of the vulva.

Correct answer: Tetanus vaccine and tetanus toxoid

Tetanus is due to Clostridium tetani spores that are ubiquitous in the soil. When present in a wound, they germinate, and the bacteria produce the neurotoxin tetanospasmin which interferes with neurotransmission at the spinal synapses of inhibitory neurons. The result is uncontrolled spasms and hyperreflexia. Trismus, neck stiffness, dysphagia, and irritability are common. Asphyxia can develop with spasms of the glottis and respiratory muscles if untreated. In a patient with uncertain tetanus status and a major wound, tetanus vaccine and tetanus toxoid should be given. This confers passive immunity. Penicillin is also given to all patients to eradicate toxin-producing organisms.

Tetanus immune globulin is given if the patient is symptomatic for tetanus. It alone does not provide proper immunization. 

Tetanus toxoid can be administered after immune globulin for convalescing tetanus patients.

Tetanus immune globulin and a tetanus booster would be incorrect in this scenario. However, in a patient with a major wound and up-to-date immunization status, if it has been over five years since the last booster, another booster should be given.

Correct answer: Topiramate (Topamax)

This patient describes symptoms consistent with migraine without aura, formerly called a common migraine. The pain is usually described as a unilateral throbbing or pulsating pain, and there is usually a family history of the disorder. Common triggers include chocolate, red wine, hard cheeses, monosodium glutamate, hormonal changes, exertion, dehydration, fatigue, changes in sleep patterns, and stress. Topiramate, along with B-blockers, tricyclic antidepressants, calcium channel blockers, NSAIDs, or valproic acid may be appropriate prophylaxis for frequent migraine headaches, but it generally is not used as an abortive therapy.

Appropriate abortive therapies for migraine headaches include aspirin, acetaminophen, NSAIDs, triptans, isometheptene, and ergotamine. Any of these may be used with caffeine as an adjunctive agent, as well.

Correct answer: Propranolol (Inderal)

This patient has symptoms of benign essential (familial) tremor. Its cause is unknown, but it is often inherited in an autosomal dominant manner. It may begin at any age, is enhanced by stress, and typically manifests as a rhythmic, 6- to 8-Hz, to-and-fro movement of the upper extremities. The head may also be involved, which is known as titubation. Laryngeal muscles may be affected which may affect speech. Low doses of a B-blocker such as propranolol are typically the treatment of choice for those affected in certain circumstances, and intermittent dosing adequately controls symptoms.

Primidone is an anticonvulsant that may be useful if propranolol fails or in combination with propranolol in treating benign essential tremors.

Chlorpromazine is an antipsychotic medication that may be useful in treating the dyskinesia associated with Huntington's disease.

Small quantities of alcohol commonly provide dramatic, although temporary, relief of benign essential tremor but would not be an appropriate treatment for this patient given his occupation.

Correct answer: ipratropium bromide (Atrovent)

Asthma medications are divided into two groups: long-term control and quick-relief medications. Ipratropium bromide, along with short-acting inhaled B2-agonists (rescue medication) and systemic corticosteroids, is considered a quick-relief medication. 

Long-term control medications for asthma include corticosteroids (inhaled), cromolyn, nedocromil, long-acting bronchodilators, leukotriene modifiers, and theophylline.

Correct answer: A 58-year-old male with a known history of poorly controlled hypertension and atherosclerosis

95% of all episodes of epistaxis are due to anterior bleeding from Kisselbach's plexus. However, 5% are due to posterior bleeds from Woodruff's plexus. Risk factors for posterior bleeds include hypertension and atherosclerosis. With posterior bleeds, it can be more difficult to control and locate the source of bleeding. The use of posterior packing is difficult and carries a high risk of complications. Therefore, in this setting, specialist evaluation and inpatient monitoring are recommended. Surgery to ligate the nasal arterial supply is indicated in life-threatening cases of continued bleeding.

95% of anterior bleeds can usually be treated with direct pressure (patient sitting slightly forward and pinching the anterior nares for 15 minutes). If unsuccessful, topical anesthetics and vasoconstrictors (cocaine, lidocaine, oxymetazoline) can be used to visualize the source of anterior bleeds, and chemical cautery (silver nitrate) or electrocautery can be used if identified. Anterior packing of the nares may also be used if direct pressure fails. Risk factors for anterior bleeds include nasal trauma, dry nasal mucosa, hypertension, nasal cocaine use, and/or alcohol use. Therefore, this patient likely has an anterior bleed that does not require specialist intervention or inpatient care.

Oxygen by nasal cannula is a known cause of dryness of the nasal mucosa, which is a risk factor for an anterior bleed. Topical moisturizing products may be recommended to help reduce recurrent episodes.

Children are prone to anterior bleeds due to nose-picking.

Correct answer: 10 to 15 grams

Diet is central to the management of type 1 DM. It must be individualized to the patient's activity level, food preferences, and need to attain or maintain an ideal body weight. Patients with type 1 DM should follow a well-balanced diet and may apply the principles of carbohydrate counting. This means that for every 10 to 15 grams of carbohydrates ingested, 1 unit of short- or rapid-acting insulin will need to be administered for optimal blood glucose levels. The use of short- or rapidly-acting glucose is in addition to the patient's basal insulin needs.