Welcome to episode 75 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).

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.

I hope you enjoy this free audio component to the examination portion of this site. The full board review 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 5-year-old girl is brought to the emergency department after drinking a bottle of drain cleaner. It is unknown how much the child drank. She has a past medical history of Down syndrome and obesity. The patient’s vitals are unremarkable. Physical exam is notable for a child in no acute distress. She is tolerating her oral secretions and is interactive. Inspection of the oropharynx is unremarkable. Which of the following is the appropriate management of this patient?

Answer: B. Endoscopy 

Ingestion of caustic fluids (acid or alkali) such as drain cleaner may lead to esophageal damage and stricture. Any patient presenting after caustic ingestion should have an endoscopy performed between 12 and 24 hours of presentation. Injury due to ingestion of alkaline fluids such as drain/oven cleaner occurs rapidly in the first minutes to hours and is characterized by liquefactive necrosis of the esophageal tissue. Subsequently, esophageal strictures form due to scarring of the affected tissue. Patients should immediately be resuscitated following the ABC’s (airway, breathing, and circulation). Subsequent management involves endoscopy (typically within 12 to 24 hours of ingestion) to assess the extent of the damage and plan any further treatment that may be needed.

Incorrect Answers:

Review NCCPA Blueprint Topic: Ingestion of toxic substances or foreign bodies

2. A 27-year-old man presents to the emergency department after a motor vehicle collision. The patient was a front seat unrestrained driver in a head-on collision. The patient’s echocardiogram (ECG) is notable only for sinus tachycardia. His temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is given 2 liters of Ringer lactate solution and morphine. Initial workup demonstrates that the patient’s pulmonary capillary wedge pressure and troponins are elevated. The patient is currently complaining of chest pain. Physical exam is notable for an uncomfortable young man with bruising over his chest wall. Which of the following is the most likely diagnosis?

Answer: A. Cardiac contusion

This patient is presenting after blunt chest trauma (which is common in motor vehicle accidents) with chest pain, elevated troponins, and an elevated pulmonary capillary wedge pressure suggesting a diagnosis of a cardiac contusion. A cardiac contusion is a blunt injury to the heart which can disrupt the mechanical and electrical function of the heart. There will typically be visible signs of chest trauma such as bruising and the patient will often complain of chest pain and dyspnea. The ECG can be unremarkable, demonstrate sinus tachycardia, or even demonstrate more severe dysrhythmias such as supraventricular tachycardia, atrial fibrillation, and a right bundle branch block. Initial cardiac troponins can be elevated. In the setting of any ECG abnormality or elevated troponins, patients with a suspected diagnosis of a cardiac contusion should be admitted to the hospital and observed until clinically stable with normalization of their troponins.

Incorrect Answers:

Review NCCPA Blueprint Topic: Chest/Rib Fractures and Trauma

3. A 33-year-old woman presents to her primary care PA for a wellness check-up. She states that recently she has been feeling well other than headaches that occur occasionally, which improve with ibuprofen and rest. She has a past medical history of hypertension and headaches and is currently taking hydrochlorothiazide. Her temperature is 99.2°F (37.3°C), blood pressure is 157/108 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam reveals a young woman who appears healthy. A normal S1 and S2 are auscultated on cardiac exam, and her lungs are clear with good air movement bilaterally. From her previous visit, it was determined that she has an elevated aldosterone and low renin level. Laboratory values are ordered as seen below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.7 mEq/L
HCO3-: 29 mEq/L
BUN: 20 mg/dL
Creatinine: 1.1 mg/dL

Which of the following is the most likely diagnosis?

Answer: E. Primary hyperaldosteronism

This patient is presenting with hypertension refractory to a diuretic with a decreased potassium, a decreased renin level, and an increased aldosterone level suggesting a diagnosis of primary hyperaldosteronism.

Primary hyperaldosteronism occurs when the adrenal gland produces excess aldosterone. Aldosterone has the effect in the kidney of absorbing sodium (and thus water) and wasting potassium and hydrogen. Thus, hyperaldosteronism can lead to hypertension, hypokalemia, and a metabolic alkalosis. In primary hyperaldosteronism, the high blood pressure is detected by the kidney, and thus renin levels are decreased in the setting of an elevated aldosterone.

Incorrect Answers:

Summary: Primary hyperaldosteronism presents with hypertension, a decreased renin and potassium level, a metabolic alkalosis, and an increased aldosterone level.

Review NCCPA Blueprint Topic: Secondary hypertension

4. A 24-year-old man is brought in to the emergency room after being retrieved by firefighters from a burning building. The patient is responding coherently to questions but reports pain secondary to a burn on his leg. He states he also has a headache and feels dizzy. His temperature is 98.5°F (36.9°C), blood pressure is 129/66 mmHg, pulse is 126/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for a confused young man with dry and flushed skin. The cardiopulmonary exam reveals a normal S1 and S2, as well as clear breath sounds bilaterally. The patient’s neurological exam is within normal limits. Towards the end of his exam, the patient begins vomiting. The dermatologic exam reveals a superficial burn covering 1% of the patient’s body over his right leg. Which of the following is the best next step in management for this patient?

Answer: A. 100% oxygen

This patient is presenting after being rescued from a fire with confusion, headache, nausea, vomiting, and flushed skin suggesting a diagnosis of carbon monoxide poisoning which should be treated with 100% oxygen.

Carbon monoxide exposure is common in fires and in patients who heat their house with an old-fashioned wood stove. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen thus displacing it leading to symptoms. Carbon monoxide poisoning presents with confusion, headache, altered mental status, nausea, vomiting, and cherry-red skin. Pulse oximetry is often normal in these patients as the device detects hemoglobin bound to oxygen or carbon monoxide similarly. A carboxyhemoglobin level can be obtained to confirm the diagnosis in these patients; however, patients presenting with a clinical picture supportive of carbon monoxide poisoning should be treated with 100% (or hyperbaric) oxygen. Sequelae of carbon monoxide poisoning should be treated supportively, including dantrolene for increased muscle activity or benzodiazepines for seizure activity.

Incorrect Answers:

Summary: The treatment of carbon monoxide poisoning is 100% oxygen.

Review NCCPA Blueprint Topic: Burns (ReelDx)

5. A 42-year-old woman is brought to the emergency department after a motor vehicle accident. She complains of lower back pain and some minor abdominal pain. The patient has a past medical history of obesity and type II diabetes. Her current medications include atorvastatin, metformin, and glyburide. A FAST exam is performed in the trauma bay and does not reveal any signs of intra-abdominal bleeding. Her temperature is 98.2°F (36.8°C), blood pressure is 130/77 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air. Ultrasound findings are notable for multiple gallstones in the gallbladder. The patient is given naproxen. Which of the following is the best next step in management?

Answer: E. Supportive therapy

This patient is presenting with asymptomatic gallstones discovered incidentally. Asymptomatic gallstones do not need to be managed with a cholecystectomy. 

Acute cholecystitis classically presents with right upper quadrant abdominal pain that presents in a fat, fertile, female in her forties. Once the diagnosis is confirmed with ultrasound, “cooling off” of the gallbladder is necessary (keeping the patient NPO and IV fluids) followed by a cholecystectomy that hospital visit. However, if asymptomatic gallstones are discovered incidentally, there is no indication for cholecystectomy. These patients should be managed conservatively.

Incorrect Answers:

Review NCCPA Blueprint Topic: Cholelithiasis (ReelDx + Lecture)

6. A 60-year-old woman presents to the emergency department with dizziness. She states it started this morning when she woke up from bed and was severe causing her to vomit. The episode resolved in 1 minute. The patient has a past medical history of hypertension, diabetes, obesity, and atrial fibrillation treated with warfarin and metoprolol. She recently recovered from a cold a few days ago. Her temperature is 99.0°F (37.2°C), blood pressure is 174/99 mmHg, pulse is 115/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for a well-appearing woman. Her neurological exam including cranial nerves and gait is within normal limits. The patient is laid flat in the bed which causes an episode of dizziness with notable nystagmus and vomiting. She feels better after 1 minute. The patient’s ECG is within normal limits. Lab values are notable for an INR of 3.5. Which of the following is the most likely etiology of this patient’s symptoms?

Answer: A. Canalithiasis

This patient is presenting with intermittent, severe vertigo which is provoked by position changes which is most consistent with benign paroxysmal positional vertigo (BPPV). BPPV is commonly caused by canalithiasis.

Benign paroxysmal positional vertigo (BPPV) is a common form of peripheral vertigo that results from a dislodged piece of otolith (called otoconia when dislodged) causing disturbances in the semicircular canals. The presentation of BPPV involves sudden and episodic vertigo with head movements that lasts for seconds to minutes accompanied by nausea and vomiting. Physical exam will demonstrate a horizontal nystagmus with specific head postures (such as the Dix-Hallpike maneuver). Treatment involves repositioning exercises (such as the Epley maneuver) as well as meclizine or diphenhydramine for symptomatic control.

Incorrect Answers:

Summary: Benign paroxysmal positional vertigo is commonly caused by canalithiasis.

Review NCCPA Blueprint Topic: Vertigo (ReelDx + Lecture)

7. An 18-year-old male presents to his primary care provider with his parents for a sports physical. He was last seen in the clinic several months ago when he was diagnosed with attention deficit hyperactivity disorder (ADHD). He was started on methylphenidate at that time, and the patient now reports improvement in his ability to concentrate in school and at home. He hopes to play baseball in college and has begun lifting weights daily in preparation for baseball season. The patient reports that he eats a healthy diet to fuel his exercise regimen. His parents have no concerns and are pleased with the recent improvement in his grades. On physical exam, the patient has tall stature with average muscle mass for his age. He has no dysmorphic features. His chest has a normal appearance other than mild gynecomastia. The patient has sparse facial hair and a moderate amount of coarse pubic hair that extends across the pubis and spares the medial thighs. His testes are small and firm. Due to the latter, laboratory testing is performed and reveals the following:

Which of the following is the most likely etiology of this patient’s presentation?

Answer: E. Meiotic nondisjunction

This patient presents with tall stature, gynecomastia, and small testes with elevated FSH and LH, which suggests a diagnosis of Klinefelter syndrome. Klinefelter syndrome is usually caused by meiotic nondisjunction that results in a 47,XXY genotype.

Klinefelter syndrome is the most common cause of primary hypogonadism. Patients with Klinefelter syndrome present with tall stature, neurocognitive difficulties (ADHD) and features of hypogonadism including gynecomastia, small testes, small phallus, hypospadias, underdeveloped secondary sex characteristics, and cryptorchidism. Patients without hypospadias or cryptorchidism are often not diagnosed until after puberty, when the symptoms of gynecomastia and small testes become more prominent. Because the hypogonadism in Klinefelter syndrome is caused by testicular fibrosis, laboratory results demonstrate a low testosterone and elevated FSH and LH.

Incorrect Answers:

Summary: Klinefelter syndrome results in primary hypogonadism and presents with tall stature, gynecomastia, small testes, a small phallus, hypospadias, and cryptorchidism.

Review NCCPA Blueprint Topic: Hypogonadism

8. A 65-year-old man presents to the emergency department for sudden weakness. The patient states that he was at home enjoying his morning coffee when his symptoms began. He says that his left arm suddenly felt very odd and weak thus prompting him to come to the ED. The patient has a past medical history of diabetes, COPD, hypertension, anxiety, alcohol abuse, and PTSD. He recently fell off a horse while horseback riding but claims to not have experienced any significant injuries. He typically drinks 5-7 drinks per day and his last drink was yesterday afternoon. His current medications include insulin, metformin, atorvastatin, lisinopril, albuterol, and fluoxetine. His temperature is 99.5°F (37.5°C), blood pressure is 177/118 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 93% on room air. On physical exam, you note an elderly man who is mildly confused. The cardiopulmonary exam demonstrates bilateral expiratory wheezes and a systolic murmur along the right upper sternal border that radiates to the carotids. Neurological exam reveals cranial nerves II-XII as grossly intact with finger-nose exam mildly abnormal on the left and heel-shin exam within normal limits. The patient has 5/5 strength in his right arm and 3/5 strength in his left arm. The patient struggles to manipulate objects such as a pen with his left hand. The patient is given a dose of diazepam and started on IV fluids. Which of the following is the most likely diagnosis in this patient?

Answer: E. Lacunar stroke

This patient is presenting with risk factors and symptoms suggestive of a diagnosis of a lacunar stroke. 

Lacunar strokes typically occur in patients with risk factors such as hypertension, diabetes, old age, and smoking. The basal ganglia, pons, and subcortical white matter are commonly affected. The pathophysiology occurs secondary to a small penetrating artery occlusion from hypertensive arteriolar sclerosis, lipohyalinosis, or microatheroma formation. Patients present with neurological deficits that can include pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, or dysarthria-clumsy hand syndrome.

Incorrect Answers:

Review NCCPA Blueprint Topic: Stroke (ReelDx + Lecture)

9. A 26-year-old woman presents to the emergency department with abdominal pain. She states that she was walking up the stairs at work when she felt sudden and severe abdominal pain followed by nausea and vomiting. Her past medical history is noncontributory and she is not currently taking any medications. Her temperature is 99.7°F (37.6°C), blood pressure is 122/78 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for an absence of abdominal tenderness, a left adnexal mass, and left adnexal tenderness. A transvaginal ultrasound demonstrates free fluid surrounding the ovary with edema and the presence of doppler flow. A urinary pregnancy test is negative. The patient’s symptoms persisted after ibuprofen and acetaminophen. Which of the following is the best next step in management?

Answer: B. Laparoscopy

This patient is presenting with sudden onset abdominal pain, nausea, vomiting, and free fluid around the ovary with normal blood flow which is still concerning for ovarian torsion that should be managed with laparoscopy. Ovarian torsion occurs when the ovary twists around its blood supply causing ischemia and necrosis. Patients are typically young women who experience sudden/severe abdominal or vaginal pain, blood per vagina, a left adnexal mass with adnexal tenderness, and a negative urine pregnancy test. The best initial test is a transvaginal ultrasound with Doppler which can show blood flow to the ovary as well as ovarian enlargement and edema (signs of ischemia). Even in the setting of normal blood flow, torsion is possible as the ovary may twist and untwist. Patients presenting with symptoms concerning for ovarian torsion should be managed with laparoscopy to definitively treat and salvage the ovary.

Incorrect Answers:

Summary: Ovarian torsion should be treated with laparoscopy. 

Review NCCPA Blueprint Topic: Ovarian torsion

10. A 72-year-old man is brought into the emergency department by emergency medical services. He looks disheveled and states that he is homeless. He has bruising over his arms and legs and states that he does not have a regular source of nutrition. He denies prior medical conditions but states that he still smokes one pack of cigarettes per day. On exam, the patient’s vital signs are normal, but he appears extremely malnourished. His gums are swollen and bleeding and his tongue is unusually smooth. The hair on his arms is pinwheel-shaped. What is the most likely cause?

Answer: C. Vitamin C deficiency

An elderly, malnourished, cigarette-smoking male with swollen gums, bruising, and corkscrew hair is most likely suffering from vitamin C deficiency.

Though vitamin C deficiency, or scurvy, is uncommon in the developed world, cases in developing countries still exist. Typically, these cases occur in those who are very old or very young due to the inability to feed themselves properly. Since vitamin C, or ascorbic acid, is found in citrus fruits and green vegetables, deficiency in these foods or consumption of these foods with denatured vitamins (due to over-boiling) can result in deficiency. Those who smoke cigarettes have also been found to be more deficient in vitamin C.

Incorrect Answers:

Review NCCPA Blueprint Topic: Hypervitaminosis/hypovitaminosis

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