NCCPA PANCE Exam Questions

Correct answer: ventricular septal defect (VSD) - diastolic murmur

A VSD is the most common of all congenital heart defects. It produces a systolic murmur that is best heard at the left lower sternal border (LLSB).

Correct answer: A proton pump inhibitor (PPI) such as omeprazole (Prilosec)

An acid-suppressant PPI is the most powerful anti-GERD medication. They are considered first-line treatment for those with moderate to severe disease or in patients who are unresponsive to H2 blockers (mild disease) or those who have evidence of erosive gastritis. They bring both symptomatic relief and promote healing of eroded tissue.

A histamine (H2) blocker is a useful treatment in mild GERD for symptomatic relief and may be used in conjunction with a PPI for the relief of significant nighttime symptoms.

Prokinetic agents are useful in delayed gastric emptying which may produce symptoms of GERD, but these agents are not of use in uncomplicated, primary GERD.

Prostaglandin analogs may be used as prophylactic therapy for a patient with a history of gastroduodenal ulcers who needs daily NSAID therapy, has a history of complications (bleeds), needs chronic steroids or anticoagulants, or has other significant co-morbidities.

Correct answer: Hodgkin disease

Hodgkin disease refers to a group of cancers characterized by enlargement of the lymphoid tissue, spleen, and liver. It is diagnosed by the presence of Reed-Sternberg cells in lymph node tissue biopsy. Patients present with painless cervical, supraclavicular, or mediastinal lymphadenopathy (stage A). Diagnosis is common between the ages of 15 and 45, peaking in the 20s and again after age 50. Constitutional (Stage B) symptoms include fever, night sweats, weight loss, pruritus, and fatigue and indicate a poor prognosis.

Non-Hodgkin lymphoma is a group of cancers wherein 90% of cases are derived from B lymphocytes. There are generally two clinical divisions of these cancers: indolent and aggressive. Indolent lymphomas tend to convert to aggressive disease. Diffuse or isolated, painless, and persistent lymphadenopathy is the most common presentation. Bone marrow involvement is frequent. Common extra-lymphatic sites are the GI tract, skin, bone, and bone marrow. Fever, night sweats, weight loss, pruritus, and fatigue are less likely than with Hodgkin disease but do occur in intermediate and high-grade disease. Peak onset is in the 20s and again after 50 years of age.

Multiple myeloma is a malignancy of plasma cells, producing an abundance of monoclonal paraprotein (M-protein). Replacement of bone marrow leads to pancytopenia, osteolysis with bone pain, osteoporosis, hypercalcemia, and pathologic fractures. Bone pain (particularly in the low back or ribs), anemia, and infection are common presentations. Less common are renal failure, spinal cord compression (due to plasmacytomas), and hyperviscosity syndromes. Median age at diagnosis is 65 years. The hallmark of multiple myeloma is a monoclonal spin of serum protein electrophoresis and the presence of the Bence-Jones protein in the urine.

Acute myelogenous leukemia (AML) is characterized by an increased production of abnormal leukocytes and leukocyte precursors in the circulation and bone marrow. Presenting complaints include gingival bleeding, epistaxis, and menorrhagia due to thrombocytosis as well as recurrent Gram-negative or fungal infections secondary to neutropenia. Symptoms of anemia, thrombocytopenia, gingival hyperplasia, rashes, or cranial nerve palsies may also occur. Slow, progressive onset of lethargy, anorexia, and dyspnea is common. Median age at onset is 60 years. Auer rods (rod-shaped structures in cell cytoplasm) are diagnostic for AML.

Correct answer: Histologic grading using the Gleason system will provide his prognosis.

Prostate cancer is a common, slow-growing malignancy of adenomatous cells. Many cases are not clinically apparent. On exam, the prostate may be enlarged, nodular, and asymmetric. Symptoms of urinary obstruction or irritative voiding are possible, as is bone pain from metastasis or spinal cord impingement if vertebrae are involved. PSA will be elevated, and biopsy will confirm the diagnosis and allow histologic grading. The Gleason grading system is based on the architectural pattern and can provide prognostic information. 

Greater than 95% of all prostate cancers are adenocarcinomas. Of them, 75% originate in the peripheral zone (outer portion), 20% in the transitional zone (portion surrounding the urethra), and 5% in the central zone (the portion of the prostatic urethra with ejaculatory ducts).

Appropriate treatment for prostate cancer depends on the staging. Low-grade, well-differentiated tumors may not require any treatment, whereas higher-grade tumors tend to be more aggressive and should be managed as such. Radical retropubic prostatectomy, brachytherapy, external beam radiation therapy, hormonal manipulation using orchiectomy, antiandrogens, LH-releasing agonists, or estrogens may be used depending on the specifics of each case. Chemotherapy generally has only limited usefulness.

Correct answer: Hirschsprung's disease

Toxic megacolon is extreme dilation and immobility of the colon. It represents a true emergency. Fever, prostrations, severe cramps, and abdominal distention are the main symptoms. Exam findings include a rigid abdomen with localized, diffuse, and/or rebound tenderness. Decompression of the colon is required. Hirschsprung's disease is a congenital aganglionosis of the colon that leads to functional obstruction/toxic megacolon in a newborn and therefore is not a cause of this problem in an adult patient.

In adults, toxic megacolon may occur as a complication of ulcerative colitis, Crohn's disease, pseudomembranous colitis, and specific infectious causes such as amebiasis, Shigella sp., Campylobacter sp. and Clostridium difficile.

Correct answer: Aspirin

This patient's presentation is consistent with the diagnosis of a nasal polyp. In a patient with asthma and nasal polyps, the use of aspirin is contraindicated due to the possibility of severe bronchospasm. The combination of asthma, nasal polyps, and aspirin is known as the Samter triad.

Corticosteroid nasal spray is the initial treatment of choice and should be tried for three months. It can reduce the size of the polyp and reduce the need for surgical intervention. Oral steroids may also be of use as well. Antihistamines are not contraindicated but will not improve the nasal polyps. Oxymetazoline nasal spray is not contraindicated, but it will not improve the nasal polyp.

Correct answer: Clindamycin (Cleocin) plus gentamicin

This patient presents with symptoms and findings consistent with endometritis. Endometritis most commonly occurs after cesarean section or when membranes are ruptured more than 24 hours before delivery. It will most commonly present two to three days postpartum. Causative bacteria vary, but anaerobic streptococci are the most common cause. Urinalysis should be done to rule out UTI. Clindamycin plus gentamicin should be administered until the patient is afebrile for 24 hours. Ampicillin may be added if there is no clinical response in 24 to 48 hours. Metronidazole is added if there are signs of sepsis. A single dose of antibiotic at the time of cord clamping reduces the incidence of endometritis.

IV oxytocin or ergonovine maleate are first-line treatments for early postpartum hemorrhage. Methylergonovine or prostaglandins are other first-line treatments as well. Early postpartum hemorrhage presents within 24 hours of delivery and is defined as blood loss requiring transfusion or a 10% decrease in hematocrit between admission and the postpartum period. Causes include abnormal involution of the placental site, cervical or vaginal lacerations, and/or retained portions of the placenta. The patient's primary complaints will include increased bleeding.

Ultrasonography is indicated if retained placental fragments are suspected. This may be a cause of both early and late (24 hours to six weeks) postpartum hemorrhage.

Surgical intervention is required when postpartum hemorrhage (early or late) does not respond to conventional treatment or if it is severe.

Correct answer: Ultrasonography is the test of choice for establishing her diagnosis

This patient presents with signs and symptoms of placenta previa. It occurs when the placenta partially or completely covers the cervical os and is present in up to 0.3% to 0.5% of pregnancies. Risk factors include advanced age, smoking, high parity, and any process that could induce scarring of the lower uterine segments (prior cesarean deliveries). Painless vaginal bleeding is the hallmark of placenta previa. It is often diagnosed before 20 weeks gestation on routine ultrasound, but in this patient's case, she had not received routine prenatal care. Ultrasonography is the test of choice for establishing the diagnosis of placenta previa. Hemodynamically unstable patients should be managed emergently; stable patients may be treated with watchful waiting. Transfusion may be necessary. Cesarean section is the preferred method of delivering the infant in cases of placenta previa.

The most common cause of third-trimester bleeding is abruptio placentae, which is the premature separation of a normally implanted placenta after the 20th week of gestation but before birth. Painful vaginal bleeding is the presenting symptom in 85% of all cases.

Digital examination of the cervix is contraindicated in placenta previa because it can incite severe bleeding.

Delivery of the fetus and placenta is the definitive treatment for abruptio placentae, as complications can include compromise of placental blood flow to the fetus and maternal hemorrhage, renal failure, coagulation failure (DIC), and death. A cesarean section is most often required.

Correct answer: Anterolateral

A patient with clinical symptoms of acute myocardial infarction should always have a 12-lead EKG to determine the presence of an acute coronary syndrome. The presence of ST-segment elevation of greater than one millimeter in two contiguous leads confirms the diagnosis of ST-segment myocardial infarction (STEMI). The location of these changes on the EKG can be a clue as to the location of the myocardial damage. In an anterolateral infarct, you will typically see these changes in the lateral precordial leads V4, V5, V6.

An inferior wall infarct will likely demonstrate changes in leads II, III and aVF.

Posterior wall infarcts show changes in V1 and V2.

Anteroseptal infarcts will also show changes in V1 and V2.

Correct answer: Auscultate at the left lower sternal border (LLSB) with the patient in full inspiration

The pansystolic murmur associated with tricuspid regurgitation is best heard at the LLSB and will increase slightly with inspiration. Inspiration will increase right-sided murmurs as it increases negative intrathoracic pressure, increasing venous return/right-sided preload.

Auscultation at the 2nd right intercostal space (RICS) with the patient sitting and leaning forward is a technique that may accentuate the mid-systolic murmur of aortic stenosis.

Auscultation at the 2nd to 4th left intercostal space (LICS) with the patient sitting and leaning forward in full exhalation will accentuate the murmur of aortic regurgitation. This murmur is a soft systolic, diastolic decrescendo murmur.

Auscultation at the apex with the patient in left lateral decubitus position in full exhalation will accentuate the mid-diastolic murmur of mitral stenosis.

Correct answer: Hypothalamic-pituitary insufficiency

Primary amenorrhea is defined as the absence of spontaneous menstruation by age 16 years with secondary sex characteristics, or the absence of menstruation by age 14 without secondary sex characteristics. The diagnosis is divided into four main categories based on karyotype and clinical features. In this patient's scenario, the lack of breast development combined with a low FSH and LH is indicative of hypothalamic-pituitary insufficiency. Her karyotype would be 46, XX.

Gonadal dysgenesis, or Turner's syndrome, would also present with a lack of breast development, but the exam often also reveals a short, webbed neck. Labs would demonstrate a high FSH. The karyotype for this disorder is 45, XO as there is a partial or missing second X chromosome.

Androgen insensitivity presents with normal breast development and high testosterone. Patients may have complete or partial external female sex characteristics and undescended testes. The karyotype is 46, XY, which is genetically male.

Imperforate hymen can be diagnosed on physical examination. Patients will have normal breast development and no lab abnormalities. The karyotype is 46, XX.

Correct answer: 1% lindane lotion or cream 

This child's examination and history of symptoms are consistent with scabies infection. It is an intensely pruritic infestation due to Sarcoptes scabiei, an eight-legged mite. Lesions will concentrate on the hands, wrists, genitalia, and axilla, but can be widespread. Excoriations are common. Burrows and vesicles with or without crusting in the web spaces and around the belt and sock line are classic for scabies. Microscopy of a tissue scraping of a burrow can show a mite and/or eggs which confirms the diagnosis. 1% lindane lotion or cream can be used to treat scabies, but can be toxic and should be avoided in children under the age of two, patients with extensive dermatitis, and those who are pregnant or lactating.

5% permethrin lotion or cream is an appropriate treatment for this patient. Although it is highly effective, treatment should be repeated in seven days to confirm the eradication of the mites. 

Topical steroids are appropriate for this patient, as she seems very uncomfortable and bothered by her pruritus. This treatment would be short-term and not sufficient alone, as it does not address the underlying infestation.

Oral antihistamines are also appropriate for symptomatic relief for this patient, but again, are not sufficient alone as they do not treat the underlying cause.

Correct answer: the sphenoid

This patient presents with all the symptoms and physical exam findings of a blow-out fracture of the orbital floor. CT examination would be diagnostic and help delineate the extent of the damage. The sphenoid bone comprises part of the posterior orbit and is the location of the optic foramen.

The maxillary, palatine, and zygomatic bones all form the orbital floor and can be affected in a blow-out fracture.

Correct answer: Ventricular septal defect

This child is presenting with symptoms of congestive heart failure. Ventricular septal defect may present with signs of congestive heart failure if the pathology is severe enough; some patients may be asymptomatic. It is the most common of all congenital heart defects. A systolic murmur, best heard at the lower left sternal border, is common.

Coarctation of the aorta may also present with symptoms of congestive heart failure in infants. Older children may have systolic hypertension, a murmur, or underdeveloped lower extremities. A difference between arterial pulses and blood pressure in the upper and lower extremities is pathognomonic.

Patent ductus arteriosus is also a non-cyanotic congenital defect but will typically have a machinery murmur and wide pulse pressure.

Tetralogy of Fallot is a cyanotic congenital defect.

Correct answer: Three sets of blood cultures at least one hour apart

Infective endocarditis is an infection of at least one cardiac valve. Infective endocarditis in intravenous drug users is most commonly caused by S. aureus and affects the tricuspid valve. Streptococcus viridans, Staphylococcus aureus, and enterococci are more common in patients who are not intravenous drug users. Most patients will have a stable murmur, but this may be absent in right-sided infections. Palatal, conjunctival, or sublingual petechiae, splinter hemorrhages, Osler nodes (painful, violaceous, raised lesions on the fingers, toes, or feet), Janeway lesions (painless red lesions on the palms or soles), and Roth spots (exudative lesions in the retina) are common.

An echocardiograph is essential in the diagnosis of infective endocarditis. Ideally, before antibiotic treatment is started, three sets of blood cultures at least one hour apart should be obtained. This helps confirm a specific pathogen and appropriate antibiotic regimen.

A chest x-ray may be helpful in determining cardiac abnormality or the presence of pulmonary infiltrates, but will not affect antibiotic choice in infective endocarditis.

An electrocardiogram is not helpful in the diagnosis of infective endocarditis.

Correct answer: Order home blood pressure monitoring/recording

This patient is most likely suffering from “white coat” hypertension. If her blood pressure is within a normal range at her local grocery store, her blood pressure should remain in a normal range upon home monitoring as well. A 24-hour ambulatory blood pressure monitoring order is appropriate, as is home blood pressure monitoring.

The patient should return after a few weeks with this data and have her blood pressure repeated; however, a repeat visit/blood pressure check without home monitoring may falsely diagnose the patient with hypertension.

Pharmacological therapy should be reserved for patients who are diagnosed with hypertension and should be used in conjunction with lifestyle modifications.

Correct answer: Cervical mucus method and basal body temperature method

Together, the cervical mucus method and basal body temperature method are known as the "symptothermal" method, which is probably the most reliable periodic abstinence method. The cervical mucus method relies on daily evaluation of the cervical mucus. Fertile mucus resembles an egg white. The basal body temperature method requires daily vaginal or rectal temperature evaluation prior to sexual activity. A slight drop in temperature occurs 24 to 36 hours after ovulation, then rises slightly and plateaus for the rest of the cycle. 

Coitus interruptus is an ineffective and unreliable birth control method that should never be recommended. The calendar method predicts the day of ovulation based on average menstrual patterns and is based on the relative constancy of the luteal phase, which is 14 days. Sexual activity should be avoided from just before the time of ovulation until two to three days after.

Basal body temperature alone is probably not the best option. Combination with the calendar method can be up to 95% effective; however, actual failure rates are 25% due to compliance issues.

Correct answer: Ischemic stroke

Papilledema is defined as an increase in intracranial pressure. The findings include a swollen-appearing disc with blurred margins and obliteration of the vessels. Patients with papilledema may be asymptomatic or complain of transient alterations in vision. Papilledema has many causes, but the underlying mechanism of an increase in intracranial pressure will be common to all of them. Ischemic strokes do not cause an increase in intracranial pressure, and therefore you will not find papilledema in these patients on physical examination.

Malignant hypertension is an acutely elevated blood pressure that typically presents with papilledema and signs and symptoms of encephalopathy and/or nephropathy.

An acute subdural hematoma is the formation of a clot between the surface of the brain and the innermost layer dura mater. Because this acts as an intracranial, mass-occupying lesion, it will cause an increase in intracranial pressure triggering the finding of papilledema.

Pseudotumor cerebri is an increase in intracranial pressure that mimics symptoms of a tumor or mass but has negative findings on imaging. It may be idiopathic or related to a medication or underlying disease process.

Correct answer: Campylobacter jejuni

The signs and symptoms given in this scenario describe Guillain-Barre syndrome or acute idiopathic polyneuropathy. In addition to an ascending, symmetric polyneuropathy, it may produce significant autonomic dysfunction and be life-threatening if the muscles of respiration or swallowing are involved. Clinical and epidemiological evidence seems to indicate a relationship with a preceding infection of the lungs or gastrointestinal (GI) tract.

Although all the answer choices given may be possible causes, Campylobacter jejuni infection is the most common precipitant. It is important to note, however, that in about half of all cases of Guillain-Barre, no preceding infection is confirmed.

Correct answer: Hypertrophic cardiomyopathy

Some patients with hypertrophic cardiomyopathy are asymptomatic, while others may experience dyspnea, angina, syncope, and arrhythmias. On physical examination, a sustained PMI or triple apical impulse, loud S₄ gallop, variable systolic murmur, a bisferiens carotid pulse, and a prominent “a” wave can be seen. ECG may show nonspecific ST- and T-wave changes, exaggerated septal Q waves, and left ventricular hypertrophy.

Dilated cardiomyopathy will typically present with dyspnea, an S₃ gallop, pulmonary crackles, and increased jugular venous pressure. ECG may show nonspecific ST- and T-wave changes, conduction abnormalities, and ventricular ectopy.

Restrictive cardiomyopathy may also present with dyspnea on exertion and peripheral edema. Low-voltage changes on ECG are common.

Takotsubo cardiomyopathy (stress-induced cardiomyopathy) has symptoms common to that of an acute myocardial infarction (e.g., retrosternal chest pain). Nonspecific ECG changes can occur.