NCCPA PANCE Exam Questions

Correct answer: Topical retinoids

This patient's presentation is consistent with mild acne. He has predominantly comedones and few inflammatory lesions. Topical retinoids work very well in this type of acne. Other acceptable topical medications are azelaic acid and salicylic acid.

Topical clindamycin is a medication for inflammatory acne lesions such as papules, pustules, nodules, or cysts. It does not work on mild, comedonal acne.

Oral tetracycline is a systemic medication that is appropriate for cystic acne and more severe forms of inflammatory acne that also involve the trunk and shoulders.

Oral trimethoprim-sulfamethoxazole may be used as a second-line systemic medication, but again, should be used only in more severe cases of cystic acne or inflammatory acne of the trunk and shoulders.

Correct answer: Giant cell arteritis

This patient has a central retinal artery occlusion that has caused his vision loss. It is an ophthalmic emergency that should be treated immediately; however, his history of polymyalgia rheumatica should prompt you to evaluate for and rule out giant cell arteritis as the cause of this thrombotic event. Giant cell arteritis causes a systemic inflammation of the medium and large vessels; most frequently, it involves the temporal artery and other extracranial branches of the carotid artery. Other clinical features include unilateral temporal headache, scalp tenderness, jaw claudication, fever, throat pain, and elevated inflammatory markers. Diagnosis is confirmed by temporal artery biopsy.

Diabetes mellitus can cause retinopathy and blindness, but it would likely not be an underlying cause of central retinal artery occlusion. It is not generally related to polymyalgia rheumatica.

Hypertension can cause retinopathy and blindness as well, but it is not typically the underlying cause of central retinal artery occlusion. It is not generally related to polymyalgia rheumatica.

Glaucoma is a condition of increased intraocular pressure (IOP) with optic nerve damage. It may be acute or chronic. Types include angle-closure and open-angle. Angle-closure glaucoma can cause a sudden, painful loss of visual acuity and blindness. Open-angle glaucoma is a chronic, asymptomatic process that over time can lead to optic nerve damage and blindness. Glaucoma is not generally related to polymyalgia rheumatica.

Correct answer: both disorders demonstrate manic and mixed episodes

Bipolar I disorder and bipolar II disorder differ in that manic and mixed episodes are not present in bipolar II disorder. Bipolar I disorder is characterized by the occurrence of one or more manic or mixed episodes, which often cycle with depressive episodes, but the latter is not required for diagnosis. It is commonly known as manic depression. Bipolar II disorder is characterized by at least one or more major depressive episodes and at least one hypomanic episode.

Because bipolar II disorder only includes hypomanic episodes, which are similar to but less severe than manic episodes, and there tends to be less social and occupational impairment in bipolar II disorder. Hypomanic symptoms do not usually include psychotic symptoms, racing thoughts, or excessive psychomotor agitation, which are often a major feature of the manic episodes of bipolar I disorder.

Treatment for both disorders is the same. Mood stabilizers (i.e. lithium, valproic acid, olanzapine, or carbamazepine) are effective. Gabapentin, topiramate, and lamotrigine also show beneficial effects. Acute mania can be treated with second-generation antipsychotics (i.e. risperidone, aripiprazole, quetiapine, or ziprasidone) or benzodiazepines. Acute depressive episodes can be treated with SSRIs or quetiapine. Olanzapine concurrently with fluoxetine may also be effective. Secondary treatment measures include electroconvulsive therapy (ECT), MAOIs, or TCAs. Family, group, supportive, interpersonal, and/or cognitive therapy is essential.

Correct answer: A 67-year-old male with diabetes, hypertension, and dyslipidemia who currently takes ASA daily and shows ST-segment deviation and elevated cardiac enzymes

In the TIMI, one point is given for each of the following factors:

• Age 65 years or older
• Three or more risk factors for CAD
• The use of aspirin within the last seven days
• Known CAD with stenosis of 50% or greater
• More than one episode of rest angina within the last 24 hours
• ST-segment deviation
• Elevated cardiac markers

Scores of 3 or more are considered to be high risk.

A 67-year-old male with diabetes, hypertension, and dyslipidemia who currently takes ASA daily and shows ST-segment deviation and elevated cardiac enzymes scores a 5.

A 55-year-old diabetic with known coronary artery disease who shows 50% stenosis of his left anterior descending (LAD) coronary artery scores a 1.

A 70-year-old obese, physically inactive woman with a positive family history scores a 2.

A 60-year-old smoker with two episodes of angina at rest in the past 24 hours scores a 1.

Correct answer: Liver abscess

Liver abscess generally is due to Entamoeba histolytic or coliform bacteria. It may occur after travel or secondary to intra-abdominal infection. Generally, a liver abscess will present with fever and abdominal pain. There is no elevation of alpha-fetoprotein. 

Cirrhosis will present with all of these symptoms in addition to weakness, nausea, vomiting, and anorexia. There may also be menstrual changes, loss of libido, impotence, and gynecomastia. Late-stage disease may also present with ascites, pleural effusions, peripheral edema, ecchymosis, esophageal varices, and hepatic encephalopathy. 

Hepatocellular carcinoma will present will all of these late in the disease process. There may also be abdominal swelling, weakness, and upper abdominal pain.

Chronic hepatitis C may demonstrate elevated alpha-fetoprotein levels. Of those with the disease, only 20% to 30% will progress to serious liver disease. This occurs most often in the setting of concomitant alcohol use or coinfection with HIV. For these reasons, presentation can vary widely at the time of diagnosis.

Correct answer: Haemophilus influenzae

Laryngitis is a common sequela of an upper respiratory infection. It presents with hoarseness and cough. Pain is atypical. The most common etiology is viral. However, bacterial causes also occur and commonly involve Haemophilus influenzae and Moraxella catarrhalis.

Group A B-hemolytic streptococci is the cause of bacterial pharyngitis.

Streptococcus pneumoniae is commonly implicated in otitis media, bacterial conjunctivitis, and acute bacterial sinusitis.

Staphylococcus aureus is commonly the cause of blepharitis, hordeola, and chronic otitis media.

Correct answer: A child with spiking fevers, myalgias, polyarthralgia, and a typical salmon-pink maculopapular rash that may be elicited with scratching (Koebnerization) that appears along with the fever in the evening

Still's disease is also known as juvenile idiopathic arthritis (JIA)/juvenile rheumatoid arthritis (JRA) and is a systemic form of the disease that may also feature hepatosplenomegaly, lymphadenopathy, leukocytosis, pericarditis, and myocarditis. The articular findings may be rare in these patients. This form is responsible for approximately 15% of all JIA/JRA cases.

A child with arthritis that involves four or fewer medium to large joints and an increased risk of asymptomatic uveitis that may lead to blindness if the child has a positive antinuclear antibody test (ANA) is characteristic of the pauciarticular form of JIA/JRA. This form is the most common, present in 50% of all cases.

A child with asymmetric arthritis involving five or more of the small and large joints and systemic symptoms of low-grade fever, fatigue, rheumatoid nodules, and anemia is typical of the polyarticular form of JIA/JRA. This type most closely resembles adult RA and is present in 35% of all cases.

A child with a history of rash consisting of erythematous plaques covered with a fine, silvery scale on the scalp, elbows, and knees that suddenly develops swelling and arthritis in the hands and feet, "sausage fingers," pitting of the nails, and onycholysis describes psoriatic arthritis. Although not typical in children, anyone with a history of skin disease may be at risk for joint involvement and should be regularly monitored for signs and symptoms of its development as the arthritis typically follows the cutaneous disease by months to years. Five to 10% of all patients with psoriasis will develop psoriatic arthritis.

Correct answer: Order laboratory studies including a CBC and CMP, fasting glucose, B12 level, TSH, ACTH, and cortisol levels

This patient's presentation is consistent with new-onset vitiligo. Vitiligo causes the destruction of melanocytes causing affected skin to lose its pigmentation. It can occur at any age and affects males and females equally. There is a positive family history in 30% of patients affected. Although this patient does not complain of other systemic symptoms, a laboratory workup to rule out underlying causes of vitiligo is the next correct step in his evaluation. Addison's disease, thyroid disorders, diabetes mellitus, and pernicious anemia can all be associated with vitiligo. It may also occur idiopathically.

A KOH prep and biopsy for tissue culture are not needed since there is no underlying fungal or bacterial cause suspected in vitiligo.

A punch biopsy is not necessary to confirm the diagnosis of vitiligo in this case as the patient's active lesions will stand in stark contrast to his surrounding skin. In a Caucasian, a punch biopsy may be of help if the lesions cannot be clearly identified, but a Wood's lamp exam is an easier, less-invasive way to visualize vitiligo in those with lighter skin.

Vitiligo can be progressive and psychologically devastating, especially to affected patients with darker skin. Every attempt to identify an underlying cause should be made. Referral to a dermatologist for repigmentation therapy should be considered if the correction of underlying causes does not help or in idiopathic cases.

Correct answer: Spiral computed tomography (CT) scan

This patient is at an elevated risk of deep vein thrombosis (DVT)/pulmonary embolism (PE) given his recent history of hip surgery and advanced age. The symptoms of acute onset dyspnea accompanied by unilateral chest pain are highly suspicious for PE; physical exam of these patients may be unremarkable or reveal crackles and an accentuated pulmonary component of S2. His chest x-ray and EKG demonstrate the non-specific changes that accompany an acute PE, so the next test that should be ordered for this patient is a spiral CT. This will allow for visualization of the occluded vessel and confirm the diagnosis.

A ventilation-perfusion scan is helpful in cases of suspected PE where CT scan is not available or is contraindicated, but it is no longer the initial method used to identify a PE. 

An echocardiogram may show changes consistent with right ventricular dysfunction and pressure overload which may be suggestive of a PE, but the spiral CT is the next test to order for this patient given his clinical scenario.

The plasma dimerized plasmin fragment (D-dimer) test is a fibrin degradation product that is elevated in the presence of thrombus. An elevated test is not specific for a DVT/PE, but a negative test (<500 ng/dL) does help rule out a PE. However, most hospitalized patients have an elevated D-dimer. Therefore, given the high clinical suspicion of PE, the spiral CT is the correct test to order for this patient.

Correct answer: The initial therapy of choice is IV magnesium.

Torsades de Pointes is also known as polymorphic ventricular tachycardia (V-tach). It is a V-tach in which the QRS complex twists around the baseline. The EKG will show a continuously changing axis or "turning of points." While it may occur spontaneously, patients with hypokalemia or hypomagnesemia may be susceptible to developing this arrhythmia. Drugs that prolong the QT interval may also precipitate episodes. It is an unstable form of ventricular tachycardia that requires correction with IV magnesium as it may degenerate into ventricular fibrillation. Isoproterenol infusion and overdrive pacing may be indicated after initial therapy, and recurrent episodes may require the placement of a permanent pacemaker.

Correct answer: She is of normal intelligence.

This patient has dwarfism. Achondroplastic dwarfs are the most common type, and the syndrome affects one in every 15,000 to 40,000 newborns. It is the result of the failure to ossify cartilage. They may have delayed motor milestones and will fall below normal height standards, but their intelligence is normal. Neurologic complications, bowing of the legs, obesity, dental problems, and frequent otitis media are commonly seen. Disorders of the achondroplasia group are all caused by mutations in the FGFR3 gene.

Correct answer: Cigarette smoking

This patient presents with a history suggestive of and findings consistent with chronic bronchitis predominate chronic obstructive pulmonary disease (COPD). Chronic bronchitis is a disease characterized by a chronic cough that is productive of phlegm occurring on most days for three months of the year for two or more consecutive years without an otherwise defined acute cause. Although causes of COPD include environmental/occupational pollutants, recurrent upper respiratory infections in addition to eosinophilia, bronchial hyperresponsiveness, and α1-antitrypsin deficiency, cigarette smoking is the most contributory cause of the disease.

Correct answer: Mitral stenosis

The murmur associated with mitral stenosis is a low-pitched, mid-diastolic murmur that can range from grade 1 to 4. It is best heard with the patient in the left lateral decubitus position and in full exhalation at the apex. There is little to no radiation. S1 is accentuated, and there may be an opening snap that follows S2.

Mitral regurgitation produces a pansystolic, medium- to high-pitched blowing murmur that ranges from soft to loud that is best heard at the apex and radiates to the left axilla. S2 is often decreased, and there may be a prolonged apical impulse.

Tricuspid regurgitation will produce a pansystolic, medium blowing murmur of varying intensity that is best heard at the left lower sternal border (LLSB) that radiates to the right sternum and xiphoid area. It may be accentuated with inspiration. 

Aortic stenosis produces a mid-systolic, medium-pitched, harsh murmur that is best heard at the 2nd right intercostal space (RICS). It radiates to the neck and left sternal border (LSB) and may be accentuated with the patient sitting and leaning forward. It is a loud murmur of grades 4 to 6 and often associated with a thrill.

Correct answer: Propylthiouracil (PTU)

PTU is the drug of choice to treat any hyperthyroid patient who is also pregnant or breastfeeding. It can be associated with a variety of issues including arthritis, lupus, aplastic anemia, thrombocytopenia, and hepatic necrosis. While it does cross the placenta and affect fetal thyroid function, it does so to a lesser extent than the other thiourea, methimazole (MMI). Surgical thyroidectomy is also acceptable treatment for symptomatic, hyperthyroid, pregnant patients, but they should be euthyroid prior to the procedure.

Propranolol is the beta-blocker of choice to treat symptomatic, non-pregnant hyperthyroid patients, thyroid storm, and periodic paralysis associated with thyrotoxicosis. It is not the treatment of choice for pregnant patients.

Methimazole (MMI) is a thiourea that is generally preferred over PTU to treat hyperthyroidism given its dosing convenience and decreased risk of hepatic necrosis, but not in pregnant patients. It, too, crosses the placenta and can affect fetal thyroid function, more so than PTU.

An iodinated contrast agent can provide temporary treatment for hyperthyroidism as it can drop T3 levels by more than 50% in a 24-hour period. While it may give relief to highly symptomatic patients, due to the risk to the fetus's thyroid function, it should not be used in pregnant or breastfeeding patients.

Correct answer: A methacholine challenge test

Intermittent symptoms of wheezing, dyspnea, chest tightness, and cough are highly suspicious for the diagnosis of asthma. Other clues may be a history of atopies such as allergic rhinitis and eczema. In a patient with these symptoms, spirometry is helpful in establishing a diagnosis. A greater than 10% increase in the FEV1 after bronchodilator therapy is very supportive of an asthma diagnosis. However, in patients in which spirometry is nondiagnostic, a histamine or methacholine challenge test can be used. Also known as a bronchial provocation test, it may simulate the airway reactivity during a patient's symptomatic periods. An FEV1 decrease of more than 20% with this test is diagnostic for asthma.

A sweat chloride test is used in the workup of suspected cystic fibrosis (CF). CF is also an obstructive airway disease (like asthma), but patients will typically present with a long history of chronic lung disease, pancreatitis, and/or infertility. Cough, excess sputum, decreased exercise tolerance, sinus pain, purulent nasal discharge, steatorrhea, diarrhea, and abdominal pain are all common CF symptoms. Spirometry usually shows a mixed obstructive and restrictive pattern.

A ventilation-perfusion scan is a diagnostic test for suspected pulmonary embolism (PE). Symptoms of PE include a sudden onset of pleuritic chest pain, dyspnea, cough, hemoptysis, diaphoresis, and a sense of impending doom. It will show normal ventilation with impaired perfusion. A normal scan rules out clinically significant thromboembolism.

A high-resolution chest CT can be used to aid in the diagnosis of bronchiectasis which is an abnormal, permanent dilation of the bronchi and destruction of the bronchial walls. It may occur in the setting of cystic fibrosis (CF), recurrent infections (TB, fungal infection, or lung abscess), or obstruction (tumor). Patients often present with chronic purulent sputum that is often foul-smelling, hemoptysis, chronic cough, and recurrent pneumonia. Results will demonstrate dilated, tortuous airways.

Correct answer: Hypertension Stage 2

Hypertension Stage 2 is defined as a blood pressure reading of ≥140 systolic OR ≥90 diastolic.

Correct answer: Elevated liver function tests (LFTs)

This child has a history and symptoms suggestive of Reye syndrome. It is a dangerous, rapidly fatal condition that has a 30% fatality rate. It is defined as a fatty liver with encephalopathy, and it may develop two to three weeks after the onset of influenza A or varicella infection, especially if aspirin is ingested. It rarely occurs in those older than 18 years of age. Clinical manifestations include vomiting, lethargy, jaundice, seizures, and changes in mental status. Labs will show hypoglycemia, increased liver enzymes, and ammonia levels along with a prolonged prothrombin time (PT). Treatment is supportive.

Correct answer: Take either a daily NSAID or aspirin 30 minutes prior

Niacin reduces the long-term risk of CAD by reducing production of VLDL, lowering LDL, and increasing HDL. It may also help to reduce triglycerides, making it a very useful medication to treat hyperlipidemia. However, prostaglandins-induced niacin flushing is a common side effect that deters many from the use of this medication. Taking either a daily NSAID or aspirin 30 minutes prior to niacin helps to mitigate this, making the medication more tolerable. Extended-release forms may also help. 

Liver enzymes must be monitored with HMG-CoA inhibitors (statins), and creatine phosphokinase levels should be checked if a patient experience myalgias on these medications.

Constipation and gas are a common side effect of bile acid sequestrants.

Niacin can be taken in combination with a statin (HMG-CoA inhibitor), but it is effective as monotherapy as well. Taking niacin with a statin may increase the risk of myositis.

Correct answer: Anti-SCL-70 antibody

Scleroderma is characterized by the deposition of collagen in the skin and, less commonly, the kidney, heart, lungs, and stomach. Its cause is unknown. The peak age of onset is between 30 and 50 years, and females are affected more frequently than males (4:1). There are two types: diffuse (affects the skin, heart, lungs, GI tract, and kidneys) and limited (affects just the skin; usually the face, neck, and distal elbows and knees). Patients may present with changes and swelling in the fingers and hands that spread to the face and trunk. Raynaud's phenomenon (vasospasm of the digital arteries) is seen in more than 75% of patients. The anti-SCL-70 antibody is associated with diffuse disease and portends a poor prognosis.

Anticentromere antibody is associated with CREST syndrome associated with limited scleroderma. Findings include calcinosis cutis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasias.

ANA is present in 90% of patients with diffuse scleroderma, but it does not impact the prognosis of the disease.

Anti-cyclic citrullinated peptide (anti-CCP), although non-specific, is present in 95% of patients with rheumatoid arthritis (RA). It is typically not elevated in scleroderma.

Correct answer: Aortic stenosis

Aortic stenosis impedes the ejection function of the left side of the heart. It is the most common valvular disease and the second most frequent cause for cardiac surgery. Like all valvular disorders, aortic stenosis will commonly present with dyspnea, fatigue, and decreased exercise tolerance. Cough, rales, paroxysmal nocturnal dyspnea, or hemoptysis are possible. Common causes include rheumatic heart disease, connective tissue disorders, infection, senile degeneration, and congenital defects. On cardiac auscultation, a mid-systolic loud murmur with a thrill (grade 4-6) can be heard at the second right intercostal space, which is intensified by having the patient sit and lean forward.

Aortic regurgitation is the retrograde blood flow into the left ventricle. A systolic and diastolic decrescendo best heard at the second to fourth left intercostal space is common.

Mitral stenosis will impede the blood flow between the left atrium and ventricle, resulting in a mid-diastolic low pitch murmur best heard at the apex with the patient in the left lateral position.

Mitral valve prolapse will often present in thin females with minor chest wall deformities and mid-systolic clicks.