NCCPA PANCE Exam Questions

Correct answer: A 22-year-old IV drug user

Candida albicans is the most common form of pathogenic Candida species and is part of the normal flora of human hosts. During times of immunosuppression, however, it can become an opportunistic pathogen. Candidal endocarditis occurs most often through direct inoculation at the time of surgery, injection/IV drug use, or in late-stage HIV disease. Approximately 50% of cases involve non-albicans Candida species and are resistant to treatment.

A 45-year-old uncontrolled diabetic is at risk for Candidal infections due to the stress of chronic illness. Cutaneous disease, mucosal disease of the mouth and esophagus, and vulvovaginal disease are the most common manifestations. 

A 62-year-old with leukemia undergoing aggressive chemotherapy is most likely at risk for hepatosplenic candidiasis due to low WBC counts.

A 55-year-old with an indwelling catheter is at an increased risk for Candidal fungemia, which can be life-threatening.

Correct answer: Magnesium

This patient presents with symptoms and EKG findings consistent with paroxysmal supraventricular tachycardia (PSVT). This is the most common paroxysmal tachycardia and usually occurs in persons without structural problems. The most common presenting complaint is that of a "racing heart." In a stable patient, PSVT may be treated with Valsalva maneuvers (bearing down, coughing, breath-holding) or carotid sinus massage. The initial medication of choice in treating PSVT is adenosine via rapid IV push. If ineffective, B-blockers or calcium-channel blockers may be used. Patients with signs of instability should be treated with synchronized cardioversion. Sustained or recurrent PSVT should be referred for treatment with catheter ablative surgery.

Magnesium is not used for PSVT. It is commonly given for management of Torsades de Pointes (polymorphic ventricular tachycardia).

Correct answer: Mastoiditis

Inadequate treatment of acute otitis media can lead to mastoiditis. Signs and symptoms include a spiking fever with postauricular pain, erythema, and the development of a fluctuant, painful mass near the mastoid process. Diagnosis can be confirmed with CT scan, and IV antibiotics and myringotomy should be done both for culture of the causative agent and drainage as initial treatment. This is followed by a course of oral antibiotics. If these measures are ineffective, surgical mastoidectomy is indicated.

Rupture of the tympanic membrane (TM) can happen with acute otitis media. It will lead to otorrhea and an abrupt decrease of pain in the affected ear. Repeated infections and ruptures can be damaging to the TM, but rupture of the TM is not the result of an inadequately treated infection.

Conductive hearing loss is often found with acute otitis media, but it is not a complication of an inadequately treated infection.

Chronic otitis media can occur in the setting of repeated episodes of acute otitis media. It is generally not a complication of a single, inadequately treated infection.

Correct answer: Stasis ulcers

Stasis ulcers arise due to chronic venous insufficiency in the lower extremities. Elevation and compression help stimulate venous return and are essential for treatment. Whirlpool debridement, gentian violet application, and Unna boot dressings are also helpful.

Diabetic ulcers typically occur due to a combination of peripheral neuropathy and peripheral arterial disease. Smoking cessation, exercise, debridement, and proper wound care are necessary elements of treatment, as well as tight control of blood glucose.

Arterial ulcers are also due to peripheral arterial disease. Treatment is very similar to that of diabetic ulcers (see above).

Decubitus ulcers are due to impaired blood supply caused by localized pressure. Therefore, they are easily prevented and treated by frequent repositioning, massage, and frequent monitoring in those with limited mobility. Good nutrition, proper wound care, debridement, and measures to reduce friction and compression are also important factors in treatment.

Correct answer: Supplemental oxygen

In the management of symptomatic patients with COPD, the goal of treatment is to improve their functional state as well as to relieve symptoms. The single most important intervention is smoking cessation. However, supplemental oxygen is the only therapy that has been shown to alter the course of COPD in those with resting hypoxemia.

Anticholinergic inhalers, such as ipratropium and tiotropium have been shown to be superior to B-adrenergic agonists in achieving bronchodilation in patients with COPD.

Graded aerobic physical exercise should be encouraged in COPD patients, but it will not alter the disease course.

Short-acting inhaled B-adrenergic agonists are useful for the relief of symptoms during acute exacerbations of dyspnea.

Correct answer: Prominent “a” waves

Hypertrophic cardiomyopathy demonstrates massive hypertrophy, small left ventricle, systolic anterior mitral motion, and diastolic dysfunction. Dyspnea and angina are common complaints. A sustained pulse of maximal impact or triple apical impulse, loud S₄ gallop, variable systolic murmur, a bisferiens carotid pulse, and jugular venous pulsations with a prominent “a” wave are likely.

An S₃ gallop may occur in dilated cardiomyopathy.

Dyspnea is common in all cardiomyopathies.

Pulmonary hypertension is commonly found in patients with restrictive cardiomyopathy.

Correct answer: Tap along the facial nerve just anterior to the ear

Acquired hypoparathyroidism is most commonly encountered following a parathyroidectomy or thyroidectomy. Signs and symptoms of hypocalcemia may develop within hours of surgery, so careful monitoring of thyroidectomy patients is warranted. The Chvostek sign is a contraction of the eye, mouth, or nose muscles that is elicited by tapping along the course of the facial nerve just anterior to the ear. 

Tapping along the radial nerve and compression of the upper arm are not used to test for hypocalcemia. Compression of the forearm that produces a spasm of the wrist and hand is known as the Trousseau sign and is another bedside test that is useful in evaluating for signs of hypocalcemia.

Correct answer: sarcoidosis

Aspiration of a foreign body may be any of the following: gastric contents, inert material, toxic material, or poorly chewed food. The degree of injury and/or sequelae depends on the substance that is aspirated. An episode of choking and coughing or unexplained wheezing or hemoptysis should raise the suspicion of foreign body aspiration. Bronchoscopy can aid in the diagnosis and is the treatment of choice for removal of the object. Misdiagnosis or delayed diagnosis may lead to suppurative complications such as ARDS, pneumonia, and bronchiectasis.

Sarcoidosis is an idiopathic multiorgan disease that is not related to foreign body aspiration.

Correct answer: The single most important clinical setting in which ARDS occurs, accounting for a majority of cases, is multiple transfusions.

The underlying abnormality in ARDS is increased permeability of the alveolar-capillary membranes; this leads to the development of protein-rich pulmonary edema. Three clinical settings account for 75% of ARDS cases: sepsis syndrome, multiple trauma, and aspiration of the gastric contents. Of these, sepsis syndrome is the single most important. Other causes include shock, toxic inhalation, multiple transfusions, and near-drowning. Treatment includes identification and specific treatment of the underlying precipitating event as well as any secondary conditions. To compensate for the severe respiratory dysfunction, oxygen should be delivered via endotracheal intubation with positive pressure ventilation and low levels of positive end-expiratory pressure (PEEP). The hypoxia is often refractory to treatment and, therefore, the mortality rate of ARDS is high.

Correct answer: Addison's disease

Adrenal insufficiency, also known as Addison's disease, can be primary due to autoimmune destruction of the adrenal cortex (80% of cases) or secondary due to pituitary causes (low ACTH). Common manifestations of Addison's disease reflect decreased cortisol levels. Weight loss, fatigue, postural hypotension and dizziness, muscle and joint pain, GI symptoms, amenorrhea, emotional changes, and sensory hypersensitivities are common. In addition to the skin pigmentation changes (found in primary only), other findings include delayed DTRs, small heart, hyperplasia of the lymphoid tissue, scant axillary and pubic hair, and hypogonadism. Laboratory findings include hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, and low BUN. Neutropenia, mild anemia, relative lymphocytosis, and eosinophilia may also occur. 

Cushing's syndrome is due to the increased production of cortisol. Findings generally include central obesity, moon facies, buffalo hump, and supraclavicular fat pads in addition to hyperpigmented striae. HTN, hyperglycemia, hypokalemia, and disorders of calcium metabolism with hypercalciuria are common findings.

Myxedema crisis is a life-threatening hypothyroidism that produces a coma or severely altered mental status/obtundation, CO2 retention, severe hypothermia, hypoventilation, hyponatremia, hypoglycemia, hypotension, rhabdomyolysis, and acute kidney injury.

Pheochromocytoma usually presents with hypertension, headache, palpitations, and sweating. It is a catecholamine-secreting tumor of the adrenal gland. Hypertensive crisis may also be the presentation.

Correct answer: Paroxysmal supraventricular tachycardia

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 symptoms like that of paroxysmal supraventricular tachycardia, but is more common in older adults and will present with no discernable p waves on electrocardiogram. Excessive alcohol intake is a common cause (“Holiday heart”).

Atrial flutter may also present the above symptoms, but it will present with a “saw-tooth” pattern on electrocardiogram.

Atrial premature beats will be seen on electrocardiogram and are typically benign, not requiring treatment if asymptomatic.

Correct answer: Ultrasonography should be used to confirm the diagnosis prior to intervention.

This patient has a history and clinical findings consistent with testicular torsion, which is a surgical emergency. It occurs when the testis is abnormally twisted on its spermatic cord, compromising arterial supply and venous drainage, which can lead to testicular ischemia and loss of the testicle. While Doppler ultrasonography will show decreased blood flow to the affected spermatic cord and testis, the diagnosis of testicular torsion is clinical. Manual or surgical (preferred) detorsion should be performed as soon as it is suspected.

Testicular torsion is most common in prepubertal and postpubertal young males ages 12 to 18, especially those with a history of cryptorchidism (late descent of the testes).

If the affected testicle is corrected within a six-hour time frame, there is a greater chance of salvaging the testicle. Surgical detorsion and orchiopexy are the definitive therapies.

While testicular torsion will require emergent surgical intervention for the affected testicle, it must be followed by elective surgery (orchiopexy) on the contralateral testicle (the right in this patient scenario) as it is also at risk for torsion in the future.

Correct answer: Pulmonary angiogram

This patient presents with signs and symptoms of a pulmonary embolus (PE). She has recently been sedentary on a long plane ride, and she is on estrogen replacement therapy. Risk factors for PE revolve around the Virchow triad: hypercoagulable state, venous stasis, and vascular intimal inflammation or injury. Other specific risk factors for PE include surgery (orthopedic, abdominal, pelvic), cancer, oral contraceptives, and pregnancy. Other presenting symptoms of PE may include cough and hemoptysis. The exam finding of Homans' sign (for deep vein thrombosis) lacks sensitivity and specificity. Pulmonary angiography remains the gold standard/definitive test for the diagnosis of PE, but it is reserved for cases in which the diagnosis is uncertain after other, non-invasive methods of testing.

Spiral CT has now replaced ventilation-perfusion scanning as the initial, non-invasive method of detecting a suspected PE.

Ventilation-perfusion scans may still be used if CT is unavailable or contraindicated. It will show impaired perfusion and normal ventilation.

Arterial blood gas (ABG) may be drawn and will show acute respiratory alkalosis secondary to hyperventilation. It is not a specific test for the diagnosis of PE.

Correct answer: Folic acid deficiency and Howell-Jolly bodies

Anemia from folic acid deficiency will demonstrate macro-ovalocytes, hypersegmented polymorphonuclear cells, and Howell-Jolly bodies (nuclear DNA remnants) on a peripheral blood smear.

Anemia due to Fe deficiency will demonstrate no changes early in the disease course. Later, however, the peripheral blood smear may show hypochromic red cells, anisocytosis, and poikilocytosis. Hypersegmented neutrophils are seen in vitamin B12 deficiency.

Anemia due to vitamin B12 deficiency shows hypersegmented (more than six lobes) neutrophils, anisocytosis, poikilocytosis, and macro-ovalocytes on a peripheral blood smear. Basophilic stippling of RBCs may be seen in lead poisoning or sideroblastic anemia.

Anemia of chronic disease typically shows unremarkable or mildly abnormal RBC morphology on a peripheral blood smear. Heinz bodies (denatured hemoglobin) and bite cells are seen in hemolytic episodes associated with G6PD deficiency.

Correct answer: Shaking chills

 The typical malarial attack occurs in three stages: shaking chills (the cold stage), followed by fever (the hot stage), and finally, diaphoresis (the sweating stage).

Plasmodium species are the organisms responsible for malaria. Transmission occurs via the bite of the Anopheles mosquito. The mosquito ingests the parasite, and it is there that the sporozoite matures and then is transferred to humans via saliva. The sporozoites first invade the hepatocytes and mature there as tissue schizonts. The schizonts then escape the liver and invade the RBCs, where they multiply and cause rupture of the cell within 48 hours. As this cycle continues, the release of tissue necrosis factors and cytokines contribute to the symptoms of fatigue, headache, dizziness, GI complaints, myalgias, arthralgias, backache, and dry cough. There may be liver and spleen enlargement if the symptoms continue for more than four days.

Correct answer: Methylmalonic acid (MMA)

In a patient with macrocytic anemia (MCV >100) who has poor nutritional status, it is imperative to determine the underlying cause as folate supplementation in someone with vitamin B12 deficiency may mask the symptoms and prolong diagnosis, thereby causing irreversible neurologic damage. MMA levels will give you a definitive answer as to the underlying cause of the patient's anemia, as it is not elevated in folate deficiency but will be in vitamin B12 deficiency.

Homocysteine levels should be checked in a patient with macrocytic anemia. They will be elevated with both folate and vitamin B12 deficiency.

Serum folate will be low in folate deficiency but normal in vitamin B12 deficiency.

Serum vitamin B12 will be low in vitamin B12 deficiency, but it may be normal to low in folate deficiency as well.

Correct answer: furosemide (Lasix)

Drug-induced lupus can produce a clinical lupus-like syndrome that very closely mimics the disease. Patients may have arthritis, cutaneous manifestations, and serositis. Work-up should include anti-histone antibodies, which will often be positive. Common medications that trigger it are procainamide, hydralazine, isoniazid, methyldopa, quinidine, and chlorpromazine.

Furosemide is not typically associated with drug-induced lupus.

Correct answer: Orthopnea

Right-sided heart failure causes systemic vascular congestion and is characterized by distended neck veins, tender or non-tender hepatic congestion, decreased appetite, nausea, and dependent pitting edema. The most common cause of right-sided failure is left-sided failure. The most predominant features are peripheral edema and hepatomegaly. Orthopnea is a common symptom of left-sided failure.

Correct answer: Chronic otitis media

A cholesteatoma is an abnormal growth of skin behind the TM in the middle ear. It may occur as a result of repeated episodes of infection of the middle ear and/or chronic eustachian tube dysfunction. It can enlarge over time and cause damage to the structures of the middle ear. Perforation of the TM with discharge and foul odor, along with hearing loss, aural pressure, and pain, are all common. Surgical excision is curative.

Acute otitis media may be a factor in the formation of a cholesteatoma, but the lesion itself leads to the diagnosis of chronic otitis media.

Cholesteatomas are almost always the result of repeated middle ear infections and chronic eustachian tube dysfunction. They rarely present at birth. While they can cause hearing loss due to ossicular damage, they are not a cause of congenital hearing loss.

Otosclerosis is an abnormal bony growth of the middle ear that can be inherited or spontaneous. It does not cause vertigo. 

Correct answer: tinea versicolor

Tinea versicolor, also known as pityriasis versicolor, is a skin infection due to Malassezia furfur, a yeast colonizer of human skin.

Tinea pedis, cruris, and corporis are all due to superficial skin infection from the three most common fungal dermatophytes affecting humans which are Trichophyton, Microsporum, and Epidermophyton.