NCCPA PANCE Exam Questions

Correct answer: An otherwise healthy 18-month old not previously vaccinated

The PPSV, also known as Pneumovax, contains antigens of 23 common strains of pneumococcus. Studies have shown efficacy ranging from 51% to 86% in its ability to reduce serious pneumococcal disease. Current recommendations are for vaccination of children aged two to five years who haven't been previously immunized, persons aged 65 years or older, or any person with a chronic illness that increases the risk of community-acquired pneumonia (CAP), including cardiopulmonary diseases, sickle cell disease, tobacco abuse, splenectomy, and liver disease. Children under the age of two years should be vaccinated with the pneumococcal conjugate (PCV-13) in a series of four doses that may be started at the age of two months.

Correct answer: Metoprolol (Lopressor, Toprol)

Class II antiarrhythmic drugs are B-blockers. These are used to slow AV conduction and are used in the treatment of supraventricular tachycardia. They may also be used to prevent ventricular fibrillation in susceptible patients. Examples of this class include metoprolol, esmolol, and propranolol.

Verapamil is an example of a class IV antiarrhythmic. Class IV drugs are slow calcium channel blockers, and they are used in the treatment of supraventricular tachycardia. Diltiazem is another drug in this class.

Amiodarone, along with sotalol, dofetilide, and ibutilide are Class III antiarrhythmic drugs. They are potassium channel blockers that prolong action potentials. These drugs are helpful in the treatment of refractory V-tach and supraventricular tachycardia. Although grouped together, each of these medications has its own specific indications.

Lidocaine is a class Ib antiarrhythmic drug. It shortens repolarization and is therefore used in the treatment of V-tach, prevention of V-fib, and symptomatic premature ventricular beats.

Correct answer: her use of hydroxychloroquine (Plaquenil)

This patient has cataracts, an opacity of the natural lens of the eye due to a progressive increase in the proportion of insoluble protein. Cataracts may involve a small part of the lens or the entire lens. They can be caused by age (senile), trauma, congenital causes, systemic disease, or medications. Hydroxychloroquine is a disease-modifying antirheumatic drug (DMARD) used to treat autoimmune conditions such as systemic lupus erythematosus. It is known to cause ocular toxicity, which manifests as changes in the retina, cornea, and ciliary body, but not the lens (i.e. cataracts). 

Long-term prednisone use has been associated with the formation of cataracts.

The statin family of lipid-lowering drugs has been associated with the increased risk of cataracts.

Having diabetes, even a well-controlled disease, can be a risk factor for the development of cataracts.

Correct answer: transfusion

This patient has polycythemia vera, which is a slowly progressive bone marrow disorder characterized by an increased number of RBCs and increased total blood volume. The presence of the JAK2 mutation is diagnostic for the primary (genetic) type. Secondary causes include chronic hypoxia, cigarette smoking, living at high altitudes, and renal tumors. Median age at presentation is 60, and 60% of patients are male. In addition to the symptoms listed for this patient, tinnitus, fullness in the face and head, and weakness are also common. Epistaxis is usually the presenting complaint. Transfusion is not indicated in polycythemia vera.

Phlebotomy is the treatment of choice for polycythemia vera. Hydroxyurea may be indicated as myelosuppressive therapy. Low-dose aspirin should be recommended as these patients have thrombocytosis and are at increased risk for thrombotic events.

Correct answer: Moderate to severe mental retardation, hyperactivity, seizures, autism

Phenylketonuria is an inborn error of metabolism. All states screen for the disorder in newborn infants as testing is inexpensive and the disorder is treatable. It affects one in every 12,000 live births. It is due to a rare autosomal recessive inability to metabolize the protein phenylalanine. If undiagnosed, phenylalanine and its metabolites accumulate within the central nervous system. Diagnosis after the age of three leads to irreversible brain damage. Long-term complications include moderate to severe mental retardation, hyperactivity, seizures, and autism. It is treatable by eliminating phenylalanine and a life-long diet low in protein.

Congenital adrenal hyperplasia can produce virilized females and males with ambiguous genitalia. Infants often present with salt-wasting and adrenal crisis early in life.

Hypothyroidism of a newborn can produce lethargy, mental retardation, eczema, and failure to thrive. Rarely is there a goiter on examination. However, affected infants may have a thick tongue. Up to 75% of affected infants are asymptomatic during the first two months of life.

Galactosemia causes an inability to digest lactose and galactose. It will induce neonatal jaundice with nausea and vomiting. Hepatic dysfunction, liver enlargement, mental retardation, cataracts, and eventual death will result if left untreated. Elimination of these two sugars from the diet is effective management.

Correct answer: It can be prevented by the use of nebulized pentamidine (Nebupent).

PJP is caused by a fungus found in the lungs of many humans and animals. It is transmitted through the air and lies dormant in the alveoli. Sporadic cases are found in patients with abnormal cellular immunity, which is caused by cancer, severe malnutrition, immunosuppressive drugs, irradiation, or in those with HIV/AIDS and a CD4 count of fewer than 200 cells/uL. It presents with fever, shortness of breath, and a nonproductive cough. Nebulized pentamidine can be used to prevent PJP, and it may be used either IV or IM as an alternative in active PJP.

PJP is the most common opportunistic infection in HIV disease. It is an AIDS indicator disease and usually occurs when the CD4 count falls below 200 cells/uL.

The treatment of choice is trimethoprim-sulfamethoxazole (TMP-SMX). Empiric treatment is started for immunocompromised patients who present with a cough or dyspnea. Steroids can be added in those with a PaO2 of less than 70 mm Hg to promote oxygenation and prevent degeneration. Dapsone and pentamidine are alternatives for those who are allergic to sulfa.

In PJP, the clinical and physical exam findings are disproportionate to the imaging results. Between 5% and 10% of patients have a normal chest radiograph. If findings are noted, interstitial infiltrates that are either heterogeneous, miliary, or patchy may be seen.

Correct answer: The upper outer quadrant

Breast cancer most often presents as a single, non-tender, firm, immobile mass; 45% occurs in the upper outer quadrant, and 25%  under the nipple and areola.

Less common presentations of breast cancer include retraction, nipple discharge, dimpling, breast shrinkage or enlargement, skin thickening, peau d'orange, fixed mass, eczematous changes, axillary lymph node enlargement, palpable supraclavicular nodes, ulcerations, or arm edema.

Correct answer: Grave's disease

This patient's scenario is highly suggestive of central retinal vein occlusion which is due to an underlying thrombotic event. A workup for thrombosis is indicated. Risk factors for the development of central retinal vein occlusion include diabetes, hyperlipidemia, glaucoma, and hyperviscosity states, such as polycythemia vera and leukemia.

Grave's disease is an autoimmune disease affecting TSH receptors and is the underlying cause of hyperthyroidism in 80% of all cases. It is the only form of hyperthyroidism that is associated with inflammation of the eyes, upper eyelid retraction, lid lag with a downward gaze, swelling of the tissue around the eyes, and protrusion or bulging of the eyes. However, it is not a risk factor for central retinal vein occlusion.

Correct answer: Her WBC count at the time of diagnosis

This child has classic signs and symptoms of acute lymphocytic leukemia (ALL). Eighty percent of all cases of ALL occur in children ages three to seven years old. Most of the clinical findings are related to the replacement of normal bone marrow with abnormal WBCs. Gingival bleeding and menorrhagia, along with epistaxis, may be presenting complaints. Neutropenia predisposes to frequent infections, most commonly those caused by Gram-negative bacteria or fungi. A CBC will show pancytopenia with circulating blasts. A bone marrow biopsy will show more than 20% blasts. There may also be hyperuricemia. Cytogenic studies are the most powerful prognostic factors. 

Although she is a bit older than the normal age range of three to seven years for ALL, her age is a prognostic factor for her success with chemotherapy (induction plus consolidation therapy). Greater than 50% of children with ALL treated with chemotherapy can be cured. However, age is not the most powerful prognostic indicator.

Her WBC count at the time of diagnosis is a prognostic factor of how well she will do with chemotherapy.

The presence of terminal deoxynucleotidyl transferase is diagnostic for ALL. It is not a prognostic indicator.

Auer rods can be seen in AML (not ALL).

Correct answer: Rock-hard stool in the rectal vault

This patient has symptoms and exam findings of fecal impaction. Elderly patients are at increased risk of this problem due to age-related changes in bowel function, immobility, inadequate hydration, and medication use. It generally occurs in the rectum but can occur higher in the colon as well. Abdominal pain, rectal discomfort, anorexia, nausea, and vomiting can occur but are non-specific. Headache and a neural sense of illness are common, and acute confusional states may appear. Incontinence of small amounts of water and semi-formed stool may occur as leakage passes by a large impaction. Rock-hard stool in the rectal vault on examination is diagnostic.

While fecal impaction can progress to bowel obstruction, which would be suspected with a lack of bowel sounds, this patient is afebrile with normal vital signs and an essentially normal abdominal exam. These findings make obstruction much less likely.

FOB testing would not be positive in a patient with suspected fecal impaction. This finding is more common in neoplastic disease, diverticulitis, some inflammatory diarrheas, and inflammatory bowel disease.

WBCs in the stool would be found in a patient with inflammatory diarrhea. Most patients with these conditions will be febrile with symptoms of purulent, bloody diarrhea.

Correct answer: Pelvic muscle exercises can help manage uterine prolapse.

Pelvic organ prolapse refers to the protrusion of the pelvic organs into or out of the vagina. Prolapse may result from excessive stretching of the pelvic fascia, ligaments, and muscles during pregnancy, labor, and delivery; from increased intra-abdominal pressure; or from iatrogenic factors. The risk of uterine prolapse increases up to 50% after menopause. Anterior vaginal prolapse includes cystoceles or cystourethroceles, and posterior vaginal prolapse includes enteroceles and rectoceles.

Uterine prolapse is more common in Hispanic and white women when compared to Asian- and African-American women.  

The grading of a prolapse ranges from 0 (no descent) to 4 (through the hymen). Pelvic muscle exercises (often called Kegel exercises) are a non-surgical management approach. Additional non-surgical management includes weight reduction, smoking cessation, and vaginal pessary use. If non-surgical management fails, a hysterectomy may be considered.  

Correct answer: Diarrhea

Vitamin C is essential for collagen synthesis, hormone function, and neurotransmitter synthesis. Toxicity often presents with diarrhea.

Bleeding gums is associated with vitamin C deficiency. Together with poor wound healing and petechiae, these symptoms are better known as scurvy.

Hair loss is a sign of vitamin A toxicity along with skin disorders and teratogenicity.

Myalgias may signal vitamin E toxicity along with inhibition of vitamin K (bleeding), headaches, and weakness.

Correct answer: Cessation of alcohol use

This patient presents with symptoms and findings consistent with chronic pancreatitis. Chronic pancreatitis is intermittent and presents with symptoms similar to acute pancreatitis with the addition of fat malabsorption and steatorrhea late in the disease. Almost 90% of cases in the U.S. are caused by alcohol abuse. The treatment of chronic pancreatitis is the same as for acute episodes, and as such, analgesics and antibiotics may be of use, as well as a low-fat diet. The only definitive treatment for chronic pancreatitis is the cessation of alcohol use. 

Surgical resection of part of the pancreas may give symptomatic relief of pain, but it is not a definitive treatment for the condition.

Correct answer: Bullous myringitis

Atypical community-acquired pneumonia presents very differently from community-acquired pneumonia (CAP). The typical presentation is a low-grade fever with relatively mild pulmonary symptoms that are self-limited and occur in young, otherwise healthy adults. Non-productive cough, myalgia, and fatigue are all common symptoms. The most common cause of atypical CAP is Mycoplasma pneumoniae. Other causes include influenza A and B, adenoviruses, Chlamydia pneumonia, Legionella species, and Moraxella species. The finding of a reddened tympanic membrane or bullous myringitis is a rare but unique feature of Mycoplasma-induced atypical CAP.

Unilateral lower lung infiltrates or diffuse infiltrates on chest x-ray are a common finding for any form of atypical CAP.

Elevated procalcitonin levels can occur in the setting of pro-inflammatory stimulus and, therefore, may be a sign of a bacterial origin rather than a viral one for CAP and atypical CAP. It is not specific to Mycoplasma-induced disease.

Air bronchograms are a common radiographic finding in a patient with CAP.

Correct answer: Culture of the breast milk

This patient has mastitis, which most often occurs in lactating women and is caused by Staphylococcus aureus. Fifty percent of all cases are due to S. aureus, so a culture of purulent material or breast milk is not usually done.

Continued breastfeeding is fine as the source of the infection is likely to be the infant's oropharynx.

Treatment for mastitis includes hot compresses as well as a penicillinase-resistant antibiotic (cloxacillin, dicloxacillin, nafcillin) or a cephalosporin.

Correct answer: Foreign body obstruction

Unilateral purulent rhinitis is indicative of a nasal foreign body obstruction. Other presentations can include persistent sinusitis or a blocked nasal passage. Infants and children are prone to putting small objects or food into body orifices.

Allergic rhinitis would yield exam findings of bilateral clear, watery nasal discharge, pale, boggy, bluish nasal mucosa, and bilateral congestion. Other signs and symptoms may include allergic shiners, itchy or watery eyes, sneezing, dry cough, and a horizontal nasal crease (the allergic salute).

Acute sinusitis typically follows an upper respiratory infection and findings include a unilateral or bilateral purulent nasal discharge, facial pain and pressure, moderate to severe nasal congestion, and fever. It may be either bacterial or viral in origin.

Vasomotor rhinitis is caused by the increased secretion of mucus from the nasal mucosa and may be precipitated by changes in temperature or humidity, odors, or alcohol. It may also be the result of a neurovascular imbalance. Symptoms are usually labile and clear quickly. They include congestion and rhinorrhea. Exam findings show bogginess of the nasal mucosa.

Correct answer: The use of restraints

Delirium is characterized by alteration of consciousness, waxing and waning of symptoms, psychomotor retardation or agitation, and decreased attention span. It is a commonly encountered iatrogenic problem that occurs in elderly hospitalized patients. It is most common with surgical admissions, especially orthopedic and urologic procedures. Delirium is a medical emergency that needs to be evaluated promptly as it is associated with poor outcomes; morbidity and mortality rates range from 35% to 40% even at one-year discharge from an acute care facility. A complete physical exam and digital rectal exam should be performed looking for underlying causes.

Identifying and treating reversing factors is key. These may include unnecessary medications, pain, infection, anemia, dehydration, congestive heart failure, electrolyte imbalance, CNS oxygenation, sensory deprivation, fecal impaction, and urinary retention. Encouraging family visitation, removing/avoiding restraints when possible, mobilization, assistance with feeding, reducing noise, and providing familiar surroundings (eyeglasses, hearing aids, etc.) may all be helpful. Lorazepam and haloperidol in small doses are acceptable to permit a full evaluation.

Correct answer: Hydrocele

A hydrocele is a mass of the fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis. They are soft, non-tender, and hemiscrotal. Diagnosis can be made by transillumination.  Ultrasound is rarely necessary but can help differentiate between hydrocele, spermatocele, and testicular tumors.

Testicular torsion is considered a urological emergency. Testicular torsion is an abnormal twisting of the spermatic cord; compromising the arterial supply and venous drainage of the testis. If not quickly corrected, it can lead to testicular ischemia. It presents as a sudden onset of severe unilateral pain and scrotal swelling. Transillumination is not present with testicular torsion. 

A varicocele is the formation of venous varicosity within the pampiniform plexus of the spermatic vein. Varicoceles occur more frequently on the left than the right due to the increased length of the left spermatic vein and because its juncture to the left renal vein forms a right angle. It presents as a chronic, non-tender mass that does not transilluminate. It has the consistency of a "bag of worms," increases in size with Valsalva, and decreases in size with elevation of the scrotum or the supine position.

Testicular cancer is the most common malignancy in young men. In more than 90% of patients, it will present with painless, solid, testicular swelling. Patients may also complain of a feeling of heaviness in the affected testicle. Occasionally, if there is pain, testicular cancer can be misdiagnosed as epididymitis or orchitis.

Correct answer: Left-sided presbycusis

These test findings are consistent with a left-sided, sensorineural hearing loss such as presbycusis.

Right-sided presbycusis would have the same Rinne test findings of air conduction greater than bone conduction bilaterally, but lateralization of the Weber test would be to the unaffected left ear.

Right-sided cerumen impaction would produce results consistent with right-sided conductive hearing loss. Rinne test would show greater bone conduction than air conduction on the right side as well as lateralization of the Weber test to the right side.

Left-sided cerumen impaction would produce results consistent with a left-sided conductive hearing loss. Rinne test would show greater bone conduction than air conduction on the left side as well as lateralization of the Weber test to the left side.

Correct answer: Bronchial gland tumor

This patient likely had a carcinoid tumor, which is also called carcinoid adenoma or bronchial gland tumor. 10% of patients present with carcinoid syndrome with symptoms of flushing, diarrhea, wheezing, and hypotension. CT and octreotide scintigraphy are very useful in localizing these tumors, and surgical excision carries a very good prognosis. These lesions are typically resistant to radiation and chemotherapy. Octreotide may be useful in limiting both the progression of the disease and controlling the symptoms of carcinoid syndrome.