Welcome to episode 85 of the Audio PANCE and PANRE PA Board Review Podcast.

Join me as I cover ten PANCE and PANRE Board review questions from the SMARTYPANCE course content following the NCCPA™ content blueprint (download the FREE cheat sheet).

Special from today’s episode:

This week we will be covering ten general board review questions based on the NCCPA PANCE and PANRE Content Blueprints. 

Below you will find an interactive exam to complement the podcast.

Below you will find an interactive exam to complement the podcast.

I hope you enjoy this free audio component to the examination portion of this site. The full board review course includes over 2,000 interactive board review questions and is available to all members of the PANCE and PANRE Academy and Smarty PANCE.

If you can’t see the audio player click here to listen to the full episode.

The following questions are linked to NCCPA Content Blueprint lessons from the Smarty PANCE and PANRE Board Review Website. If you are a member, you will be able to log in and view this interactive video lesson.

1. A 14-hour-old boy has failed to pass stool and is vomiting greenish fluid. He was born at 40 weeks gestation with no complications during delivery or pregnancy. His temperature is 97.6°F (36.4°C), blood pressure is 64/34 mmHg, pulse is 140/min, respirations are 33/min, and oxygen saturation is 98% on room air. The child is currently breastfeeding and appears irritable. Physical exam is notable for a distended and non-tender abdomen. The rectal exam is unremarkable. An abdominal radiograph demonstrates distended loops of bowel. What is the most likely diagnosis?

Answer: A. Cystic fibrosis

Cystic fibrosis (CF) commonly presents with meconium ileus, characterized by bilious vomiting, distended loops of bowel on radiography, and failure to pass meconium. CF is an autosomal recessive disease and is common in Caucasians. Neonates with CF commonly present with failure to thrive, respiratory compromise, and meconium ileus. In meconium ileus, abnormally thick meconium results in bowel obstruction, perforation, or volvulus. CF is diagnosed by the sweat chloride test or genetic testing. Radiography in ileus can demonstrate distended loops of bowel from the obstruction.

Review NCCPA Blueprint Topic: Cystic fibrosis

2. A 34-year-old female presents to her ophthalmologist with 6 hours of blurry vision in her right eye. She reports severe pain with eye movement that has not been relieved with NSAIDs. She feels that she has been generally healthy all her life, although she does note one week of right arm weakness during the previous year that resolved without treatment. On exam, she has no noted ocular secretions. On her fundal exam, you note blurred borders on the optic disc. Which of the following additional findings is likely to be present in this patient?

The answer is B. Elevated IgG in the cerebrospinal fluid (CSF)

This patient’s clinical presentation is consistent with multiple sclerosis (MS), which is associated with an elevated IgG in the CSF.

MS is associated with oligoclonal bands on CSF evaluation in 80% of cases. The bands result from IgG overproduction, likely as a result of the autoimmune processes that occur in MS. Patients with MS frequently present first with symptoms of optic neuritis, which include loss of vision or blurry vision (usually unilateral), with severe pain with eye movement. The prognosis of MS differs drastically from patient to patient, but most commonly has a relapsing-remitting course.

Incorrect Answers:

Review NCCPA Blueprint Topic: Multiple sclerosis (ReelDx + Lecture)

3. A 43-year-old man is brought to the emergency department after having a seizure. His wife states that the patient has been struggling with alcohol abuse and has recently decided to “quit once and for all”. Physical exam is notable for a malnourished patient responsive to verbal stimuli. He has moderate extremity weakness, occasional palpitations, and brisk deep tendon reflexes (DTRs). EKG demonstrates normal sinus rhythm and a prolonged QT interval. What nutritional deficiency most likely contributed to these findings?

The answer is D. Magnesium

This patient in this vignette demonstrates a constellation of findings related to the complications of hypomagnesemia. Although alcohol withdrawal may present with seizures, the constellation of brisk DTRs, weakness, and prolonged QT suggest hypomagnesemia. The treatment for this patient will be multi-faceted, with magnesium repletion a necessity.

Hypomagnesemia (<1.5 mg/dL) is a potentially serious condition that may be difficult to recognize due to non-specific manifestations. Mild signs of hypomagnesemia include: generalized weakness, fatigue, nausea and vomiting. As deficiency progresses patients may complain of numbness, cramping, and dysphagia. Physical exam findings may reveal increased DTRs and fasciculations. If hypomagnesemia is acute in onset and/or severe, patients may develop altered mental status, seizures, or cardiac conduction abnormalities. Low magnesium levels also have the potential to affect other electrolyte levels. In patients with hypomagnesemia it is not uncommon to see hypokalemia (K+ conductance changes increasing renal losses) and hypocalcemia (due to PTH resistance).

Incorrect Answers:

Review NCCPA Blueprint Topic: Fluid and Electrolyte Disorders (PEARLS)

4. A 17-year-old female presents to her physician’s office after noticing a round lump in her left breast 2 months ago. She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses. It is otherwise painless, and the patient denies any discharge or skin changes. She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast. The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use. On exam, the breasts appear symmetric and normal. A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast. There is slight tenderness to deep palpation of the mass. There is no axillary lymphadenopathy on either side. Which of the following is the most likely outcome of this patient’s condition?

The answer is D. This mass will most likely decrease in size or disappear over time

This patient is a young female with a round, mobile mass that seems to respond to hormonal fluctuations, most likely a fibroadenoma, a benign mass common in reproductive-aged women. In adolescents, the majority of lesions will diminish or completely resolve over time, so only reassurance and observation are required. 

Classic fibroadenomas are relatively small (2-3 cm in size), in the upper outer quadrant of one or both breasts, and feel rubbery to palpation. They are generally painless but may become tender around the time of menses, as in this patient. There should be no skin changes, breast drainage, or lymphadenopathy. For an adolescent patient without concerning features or strong family history of premenopausal breast cancer in multiple first-degree relatives, there is no increased risk of malignancy from fibroadenomas. Fat necrosis is also a possible diagnosis in this softball player, as many patients do not recall a specific inciting trauma. However, given that the mass has been present for 2 months and undergoes hormonal changes, fibroadenoma is still the most likely diagnosis. Either way, the mass should eventually resolve and ultrasound is only indicated if the patient is older or there is persistence or change in the mass (Illustration A). Ultrasound is preferred in young women due to high breast density and the radiosensitivity of their tissues, but if the patient is over 35, mammography may also be performed. It would show a “popcorn” appearance (Illustration B). Upon confirmation of the diagnosis, either by imaging findings or core needle biopsy, surgical excision can be performed only if the patient experiences significant symptoms. Otherwise, routine follow-up is sufficient.

Incorrect Answers:

Review NCCPA Blueprint Topic: Fibroadenoma

5. A 26-year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination, her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis?

The answer is B. Endometriosis

With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or “chocolate cyst”. The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia.

Incorrect answers:

Review NCCPA Blueprint Topic: Endometriosis (Lecture)

6.  A healthy 29-year-old woman at 30-weeks gestational age has gained 35lbs since becoming pregnant. She complains of several weeks of bilateral numbness and tingling of her palms, thumbs, index, and middle fingers that is worse at night. She also notes weakness gripping objects at the office. Which nerve is most likely affected?

The answer is A. Median nerve

This clinical presentation is consistent with carpal tunnel syndrome (CTS), the most common entrapment neuropathy, caused by compression of the median nerve as it travels under the flexor retinaculum. During pregnancy, increased edema causes a narrowing of the carpal tunnel, which predisposes the entrapment of the median nerve. The median nerve is responsible for sensory and motor distribution of the thumb, index, middle and radial half of the ring finger. Hallmark symptoms of CTS include numbness and paresthesias in the median nerve distribution. Weakness and atrophy of the thenar muscles may be evident if CTS is left untreated.

Incorrect Answers:

Review NCCPA Blueprint Topic: Carpal Tunnel Syndrome

7. A 55-year-old female comes to the ED complaining of moderate right eye pain, headache, and acute onset of blurry vision, which she describes as colored halos around lights. She was watching a movie at home with her husband about an hour ago when the pain began. On the physical exam of her right eye, her pupil is mid-dilated and unresponsive to light. Her right eyeball is firm to pressure. Intraocular pressure (IOP) measured with a tonometer is elevated at 36mmHg. Which of the following is the most appropriate emergency treatment?

Answer: A. Timolol ophthalmic solution

Acute angle-closure glaucoma, also known as narrow-angle glaucoma, presents with sudden onset blurry vision, hardened eyeball, and increased IOP. First-line emergency treatment includes alpha 2 selective adrenergic agonists, beta-blockers, or carbonic anhydrase inhibitors. Acute angle-closure glaucoma is caused by relative pupillary block of aqueous humor as it flows from the posterior to the anterior chamber through the iris-lens channel (the canal of Schlemm). Sudden attacks are more likely to occur when the pupil is partially dilated, for example, being in a darkened room such as a movie theater, or when eye drops are taken that dilate the pupil. If not treated immediately, it can damage the optic nerve and result in permanent vision loss within hours. Risk factors include certain medications (dilating drops, anticholinergic, antidepressants).

Incorrect Answers:

Review NCCPA Blueprint Topic: Glaucoma (Lecture)

8. A 68-year-old woman presents to your office for her annual check-up. Her vitals are HR 85, T 98.8 F, RR 16, BP 125/70. She has a history of smoking 1 pack a day for 35 years but states she quit five years ago. She had her last pap smear at age 64 and states all of her pap smears have been normal. She had her last colonoscopy at age 62, which was also normal. Which is the following is the next best test for this patient?

The answer is B: Chest CT scan

The patient presents between the ages of 55 and 80 and has quit smoking within the last 15 years. She should undergo an annual low dose chest CT scan for lung cancer screening.

Cigarette smoking is the leading cause of preventable death in the United States and significantly contributes to deaths from cancer along with cardiovascular and pulmonary diseases. Smoking not only harms adults but also results in the deaths of about 1,000 infants annually. The USPSTF report on the guidelines for lung cancer screening states that age, total cumulative exposure to tobacco smoke, and years since quitting smoking are the most important risk factors for lung cancer. They report that annual screening for lung cancer with low-dose CT in a defined population of high-risk persons can prevent a substantial number of lung cancer–related deaths as evidenced by large randomized controlled trials.

Incorrect Answers:

Review NCCPA Blueprint Topic: Substance-related and addictive disorders (ReelDx)

9. A 22-year-old man presents to the emergency room complaining of pain upon urination and a watery discharge from his penis. It started a few days ago and has been getting progressively worse. His temperature is 98.0°F (36.7°C), blood pressure is 122/74 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a tender urethra with discharge. Gram stain of the discharge is negative for bacteria but shows many neutrophils. Which of the following is the most likely infectious etiology of this patient’s symptoms?

The answer is A. Chlamydia trachomatis

This patient is presenting with a tender urethra with a discharge and a negative Gram stain suggesting a diagnosis of urethritis from Chlamydia trachomatis.

Urethritis in men presents with dysuria and urethral discharge with numerous neutrophils on urethral swab. Urethritis in men is most commonly caused by 2 categories of sexually transmitted infections. In gonococcal urethritis, patients present with purulent discharge and gram-negative diplococci on Gram stain, with N. gonorrhoeae as the offending agent. In nongonococcal urethritis, patients present with watery discharge which shows no bacteria on Gram stain (it is intracellular). Chlamydia is the most common offending agent in nongonococcal urethritis and is the most common cause of urethritis overall. Azithromycin is a good choice for the treatment of nongonococcal urethritis because it covers Chlamydia and other common causative organisms. It is often given with ceftriaxone which offers double coverage for N. gonorrhoeae.

Incorrect Answers

Review NCCPA Blueprint Topic: Chlamydia (Lecture)

10. A 6-year-old boy is admitted with a one-week history of diarrhea, which was sometimes bloody and originally began after a birthday party. He has become lethargic and has not been eating or drinking. His vital signs are as follows: T 38.5 C, HR 135, BP 82/54. Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation. Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count < 10,000. PT and PTT are within normal limits. Which of the following would be expected on a peripheral blood smear?

The answer is B. Fragmented red blood cells

The boy in this vignette most likely has hemolytic uremic syndrome (HUS), which is characterized by microangiopathic hemolytic anemia with schistocytes.

HUS usually occurs in children and is caused by an E. coli 0157:H7 infection. The classic presentation follows an acute diarrheal illness. HUS is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. The presentation is similar to thrombotic thrombocytopenic purpura (TTP) but without the fever and neurologic symptoms. The key differentiating factor, in this case, is diarrhea + elevated BUN. Keep in mind that in HUS uremia is elevated to a greater extent than TTP. On the other hand, TTP presents with more neurologic signs, and will not be preceded by diarrhea on the PANCE exam.

Incorrect Answers:

Review NCCPA Blueprint Topic: Infectious Diarrhea (ReelDx + Lecture)

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