Integrating Diagnostic Tests — Integrate diagnostic imaging, laboratory values, and other medical tests into physical therapy decision-making. - National Physical Therapy Examination NPTE

SECTION 1

Historical Context & Motivation

Physical therapy has evolved dramatically over the past century, shifting from a profession focused almost exclusively on manual techniques and exercise prescription to one that embraces a comprehensive, systems-based model of patient evaluation. Early physical therapists relied entirely on observation and palpation, with little access to the diagnostic data that physicians used to guide medical decision-making. The integration of diagnostic imaging, laboratory values, and other medical test results into physical therapy practice has been driven by the expansion of direct access legislation, the growth of evidence-based practice, and the need for physical therapists to serve as skilled diagnosticians capable of identifying red flags and modifying treatment plans accordingly.

1895 • Discovery of X-rays

Wilhelm Röntgen discovers X-rays, launching the era of diagnostic imaging. Within decades, radiographs become the standard for evaluating fractures, joint degeneration, and skeletal abnormalities — information that would eventually inform physical therapy interventions.

1950s • Rehabilitation Medicine Matures

Post–World War II rehabilitation efforts expand the scope of physical therapy. Therapists begin receiving reports from physicians that include radiographic findings and blood work, prompting early interdisciplinary collaboration in treatment planning.

1970s–1980s • CT and MRI Revolutionize Imaging

Computed tomography (CT) and magnetic resonance imaging (MRI) provide unprecedented soft-tissue detail. Physical therapists gain access to information about disc herniations, ligament tears, and rotator cuff pathology, directly shaping exercise selection and manual therapy approaches.

2005–Present • Direct Access & Autonomous Practice

All 50 U.S. states adopt some form of direct access, allowing patients to see physical therapists without a physician referral. This legislative shift demands that PTs competently interpret diagnostic test results to screen for non-musculoskeletal pathology and make appropriate referrals.

2020s • Point-of-Care & AI-Assisted Diagnostics

Emerging technologies including point-of-care ultrasound and AI-assisted image interpretation further blur the lines between diagnostic and rehabilitative roles, reinforcing the need for PTs to integrate diagnostic data fluently into clinical reasoning.

The central question that this lesson addresses is straightforward yet clinically vital: How does a physical therapist systematically interpret diagnostic imaging, laboratory values, and special tests to inform safe, effective, and individualized treatment decisions? Answering this question requires not only knowledge of what each test measures, but also an understanding of test characteristics such as sensitivity and specificity, the clinical significance of abnormal findings, and the appropriate circumstances for physician referral.

SECTION 2

Core Principles & Definitions

Integrating diagnostic tests into physical therapy decision-making rests on several foundational principles. A physical therapist does not order most imaging or laboratory studies independently, but the profession demands competent interpretation of results already present in the medical record, as well as knowledge of when to recommend further testing. The following core concepts provide the framework for this integration.

Clinical Correlation over Isolated Findings

A diagnostic finding is only meaningful when correlated with the patient's history, symptoms, and physical examination. For example, MRI-identified disc bulges are present in up to 52% of asymptomatic individuals; isolated imaging abnormalities do not dictate treatment.

Sensitivity vs. Specificity

Sensitivity measures a test's ability to identify true positives (ruling out disease when negative — SnNOut), while specificity measures its ability to identify true negatives (ruling in disease when positive — SpPIn). Understanding these properties prevents over- or under-reliance on any single test.

Red Flag Screening

Laboratory values and imaging results may reveal red flags — signs of serious underlying pathology such as malignancy, infection, or fracture — that necessitate immediate medical referral rather than physical therapy intervention.

Diagnostic Test Categories

Tests fall into three broad categories: diagnostic imaging (X-ray, MRI, CT, ultrasound, bone scan), laboratory tests (CBC, ESR, CRP, metabolic panels), and special medical tests (EMG/NCS, pulmonary function tests, cardiac stress tests). Each provides unique clinical information.

Evidence-Based Integration

Test results must be weighed according to clinical practice guidelines and best available evidence, not interpreted in isolation. Pre-test probability, likelihood ratios, and clinical prediction rules guide the integration of diagnostic data into the plan of care.

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KEY TAKEAWAY

Think of diagnostic tests as ingredients in a recipe rather than the recipe itself. An MRI showing a meniscal tear is one ingredient; the patient's symptoms, functional limitations, age, activity level, and clinical examination are the other ingredients. Only by combining all of them can you create the right treatment plan — just as flour alone does not make bread. The physical therapist's role is that of the chef: synthesizing all available information to produce a coherent, individualized plan of care.

SECTION 3

Visual Explanation — The Diagnostic Integration Framework

The Diagnostic Integration Framework illustrates how patient history, physical examination findings, and diagnostic test results converge at the clinical correlation decision node. From there, the clinician either identifies red flags requiring referral or confirms that the condition is appropriate for physical therapy management.

The diagram above represents the clinical reasoning pathway every physical therapist should follow when diagnostic data is available. Notice that imaging results and laboratory values do not enter the framework at the top — they serve as supplementary data that enriches the picture already formed by the patient interview and hands-on examination. This hierarchy is intentional: diagnostic tests are tools that confirm or refine a clinical hypothesis, not substitutes for the clinical reasoning process itself. At the clinical correlation node, the therapist asks whether the diagnostic findings match the subjective and objective data. When they do not align — for example, a patient reporting acute, severe low back pain with unexplained weight loss and an elevated erythrocyte sedimentation rate (ESR) — the pathway should divert toward medical referral rather than rehabilitation.

SECTION 4

How Diagnostic Tests Inform PT Decision-Making

Sensitivity, Specificity, and Clinical Utility

Before integrating any diagnostic test result, the clinician must appreciate the test's statistical properties. Two metrics are foundational: sensitivity and specificity. These properties describe how well a test distinguishes between individuals who have a condition and those who do not. In clinical shorthand, a highly sensitive test that yields a negative result helps rule out disease (SnNOut), while a highly specific test that yields a positive result helps rule in disease (SpPIn).

SENSITIVITY

Sensitivity = True Positives / (True Positives + False Negatives)

A sensitivity of 0.95 means the test correctly identifies 95% of individuals who truly have the condition. A negative result on a highly sensitive test provides strong evidence that the condition is absent.

SPECIFICITY

Specificity = True Negatives / (True Negatives + False Positives)

A specificity of 0.90 means the test correctly identifies 90% of individuals who do not have the condition. A positive result on a highly specific test provides strong evidence that the condition is present.

POSITIVE LIKELIHOOD RATIO

+LR = Sensitivity / (1 − Specificity)

The positive likelihood ratio (+LR) indicates how much a positive test result increases the odds that the patient has the condition. A +LR > 10 is considered strong evidence for ruling in a diagnosis. For example, MRI for complete ACL tears has a +LR of approximately 11.

Diagnostic Imaging Modalities in PT Practice

Different imaging modalities visualize different tissue types with varying degrees of accuracy. Radiographs (X-rays) excel at visualizing cortical bone and are the first-line imaging study for suspected fractures, joint space narrowing in osteoarthritis, and spinal alignment abnormalities. Magnetic resonance imaging (MRI) provides superior soft-tissue contrast and is the gold standard for evaluating ligament injuries, meniscal tears, disc herniations, and rotator cuff pathology. Computed tomography (CT) offers detailed cross-sectional bone imaging and is particularly useful for complex fractures, spinal stenosis assessment, and pre-surgical planning. Diagnostic ultrasound is gaining traction in PT practice for real-time evaluation of tendons, muscles, and joint effusions. Finally, bone scintigraphy (bone scan) uses radioactive tracers to detect areas of increased metabolic activity, making it valuable for identifying stress fractures, metastatic disease, and occult infections.

Laboratory Values Relevant to Physical Therapy

While physical therapists do not order blood work, they must recognize abnormal laboratory values that alter exercise safety and treatment progression. A low hemoglobin (Hgb) or hematocrit (Hct) level may indicate anemia, predisposing the patient to fatigue and reduced exercise tolerance. Elevated international normalized ratio (INR) values suggest increased bleeding risk, which modifies the appropriateness of aggressive soft-tissue mobilization or deep-tissue techniques. Platelet counts below 20,000/µL are generally considered a contraindication to resistive exercise, while values between 20,000 and 50,000/µL warrant only gentle active exercise. Inflammatory markers such as C-reactive protein (CRP) and ESR may signal systemic inflammation, infection, or autoimmune flare requiring medical management before aggressive rehabilitation.

SECTION 5

Detailed Breakdown — Key Lab Values & Imaging Modalities

This matrix illustrates which imaging modality best visualizes each tissue type. Note that MRI consistently provides excellent visualization across most soft-tissue structures, while X-ray remains the first-line study for cortical bone pathology. Physical therapists should use this matrix to understand why specific imaging was ordered and what it can — and cannot — reveal.

Critical Lab Values for Exercise Safety

Lab Value	Normal Range	PT Clinical Significance	Action Threshold
Hemoglobin (Hgb)	M: 13.5–17.5 g/dL; F: 12.0–16.0 g/dL	Low values indicate anemia → reduced O₂ carrying capacity → decreased exercise tolerance, fatigue, dizziness	< 8 g/dL: only gentle AROM; < 10 g/dL: avoid vigorous aerobic exercise
Platelet Count	150,000–400,000/µL	Low counts (thrombocytopenia) increase bleeding risk during manual therapy, resistive exercise, and functional mobility training	< 20,000: only AROM; 20,000–50,000: gentle active exercise; > 50,000: progress as tolerated
INR	0.8–1.2 (therapeutic on warfarin: 2.0–3.0)	Elevated INR indicates anticoagulation → increased bleeding and bruising risk with soft-tissue mobilization	> 3.0: avoid aggressive manual therapy; > 3.5: hold exercise and notify physician
WBC Count	4,500–11,000/µL	Elevated WBC may indicate infection or inflammation; very low WBC (neutropenia) increases infection risk — use strict precautions	< 1,000 (ANC): protective isolation, limit exposure; significantly elevated: screen for infection
Blood Glucose	Fasting: 70–100 mg/dL	Hypo- or hyperglycemia affects exercise safety for diabetic patients; exercise can lower glucose further	< 70 or > 250 mg/dL (with ketones): defer exercise; 100–250 mg/dL: proceed with monitoring
ESR / CRP	ESR: 0–20 mm/hr; CRP: < 1.0 mg/dL	Nonspecific inflammatory markers; elevation may signal infection, autoimmune flare, or malignancy — context-dependent	Markedly elevated with unexplained symptoms: refer for further medical workup

Key laboratory values physical therapists must monitor and their clinical action thresholds.

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Clinical Pearl

Always check the date of laboratory results. Lab values from weeks ago may not reflect the patient's current status, particularly for patients undergoing chemotherapy, anticoagulation therapy, or treatment for acute infections. When in doubt, request updated labs before initiating or progressing exercise.

SECTION 6

Worked Example — Integrating Diagnostic Data into a Plan of Care

Consider a 58-year-old female presenting with insidious onset of left knee pain over the past four months. She reports morning stiffness lasting approximately 20 minutes, difficulty ascending and descending stairs, and a history of bilateral knee osteoarthritis. Her physician has ordered a standing AP radiograph and basic blood work. The following worked example demonstrates how to integrate these results into the physical therapy plan of care.

Case: Left Knee Pain with Available Imaging and Lab Values

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Step 1 — Review the Radiograph Report

The standing AP radiograph reveals Kellgren-Lawrence Grade III changes of the left medial tibiofemoral compartment: moderate joint space narrowing, definite osteophyte formation, and mild subchondral sclerosis. There is no evidence of fracture, dislocation, or destructive lesion. This finding is consistent with moderate osteoarthritis and is appropriate for physical therapy management.

KL Grade III OA — moderate, no red flags identified on imaging
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Step 2 — Review Laboratory Values

The patient's lab work reveals: Hgb 13.2 g/dL (within normal limits for females), ESR 14 mm/hr (normal), CRP 0.6 mg/dL (normal), fasting glucose 118 mg/dL (mildly elevated, consistent with pre-diabetes), and platelet count 245,000/µL (normal). The normal ESR and CRP help rule out an inflammatory arthropathy or active infection as the source of knee pain. The mildly elevated fasting glucose suggests monitoring during exercise for glucose management.

No lab-based contraindications; monitor glucose during exercise; inflammatory arthritis unlikely
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Step 3 — Correlate with Clinical Examination

Physical examination reveals: left knee flexion ROM 5°–115° (right knee 0°–130°), crepitus with passive flexion, mild medial joint line tenderness, no effusion, no ligamentous laxity, negative McMurray test. The clinical findings are congruent with the radiographic diagnosis of medial compartment OA. The absence of effusion, ligament laxity, or meniscal signs provides additional confidence that the presentation is degenerative rather than traumatic.

Clinical findings corroborate radiographic diagnosis — high confidence in OA as primary diagnosis
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Step 4 — Formulate the Plan of Care

Based on the integrated findings, the plan of care includes: (1) progressive quadriceps and hip abductor strengthening to offload the medial compartment, (2) low-impact aerobic conditioning (cycling, aquatic therapy) to manage pre-diabetic glucose levels and improve cardiovascular fitness, (3) manual therapy for ROM restoration targeting the 5° extension deficit, (4) patient education regarding joint protection strategies and weight management. Aggressive plyometrics and high-impact activities are avoided given the moderate OA grade.

Individualized POC addressing OA, ROM deficit, and glucose management — no referral needed
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Step 5 — Establish Red Flag Monitoring Parameters

During the course of treatment, the therapist monitors for: sudden increase in joint swelling (possible hemarthrosis or inflammatory flare), night pain unrelieved by position changes (possible avascular necrosis or malignancy), worsening symptoms disproportionate to activity level, and any constitutional symptoms such as fever or unexplained weight loss. Any of these findings would warrant immediate physician communication and potential re-imaging.

Continuous red flag surveillance throughout the episode of care

SECTION 7

Strengths & Limitations of Common Diagnostic Tests

No single diagnostic test is perfect, and understanding the inherent strengths and limitations of each modality is essential for accurate clinical reasoning. A physical therapist who recognizes that an X-ray cannot visualize early stress fractures or that MRI findings may overestimate pathology in asymptomatic populations is better equipped to make sound treatment decisions and appropriate referrals.

Test / Modality	Key Strengths	Key Limitations
X-ray	Low cost, widely available, excellent for cortical bone, quick acquisition, low radiation dose	Poor soft-tissue contrast, cannot visualize early stress fractures, 2D imaging misses some fracture patterns, radiation exposure
MRI	Superior soft-tissue resolution, no ionizing radiation, multiplanar imaging, gold standard for ligament/tendon/disc pathology	High cost, long acquisition time, claustrophobia, metal contraindications, high false-positive rate in asymptomatic individuals
CT Scan	Excellent bony detail, fast acquisition, 3D reconstruction capability, useful for complex fractures and spinal stenosis	Higher radiation dose than X-ray, moderate soft-tissue contrast, cost, contrast dye risks for some studies
Ultrasound	Real-time imaging, no radiation, portable, excellent for tendons and effusions, allows dynamic assessment, low cost	Operator-dependent, poor deep-tissue penetration, cannot image through bone, limited field of view
Bone Scan	Highly sensitive for metabolic bone activity, whole-body screening, detects stress fractures early, identifies metastatic lesions	Poor specificity (cannot distinguish between causes of increased uptake), radiation exposure, delayed imaging (hours after injection)
EMG / NCS	Differentiates neuropathic from myopathic conditions, localizes nerve lesion, quantifies severity, aids prognosis for nerve recovery	Uncomfortable/painful, operator-dependent, cannot detect pathology in first 2–3 weeks after acute nerve injury, limited to peripheral nerves

Strengths and limitations of diagnostic modalities commonly encountered in physical therapy practice.

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KEY TAKEAWAY

Think of diagnostic tests as different lenses on a camera. A wide-angle lens (like an X-ray) gives you a broad view of the bony architecture but misses fine details in soft tissue. A macro lens (like MRI) reveals intricate soft-tissue structures but can also show 'noise' — incidental findings with no clinical significance. A thermal lens (like a bone scan) detects areas of metabolic activity but cannot tell you the cause. The skilled clinician selects and interprets the right lens for the clinical question at hand, always correlating the image with the full clinical picture.

SECTION 8

Connection to Advanced Clinical Reasoning & Differential Diagnosis

The integration of diagnostic tests into physical therapy extends beyond basic test interpretation into the domain of differential diagnosis and advanced clinical reasoning. At the novice level, a therapist may simply read an imaging report and accept its conclusions. At the expert level, the therapist uses diagnostic data as one element in a Bayesian reasoning process, adjusting the pre-test probability of various diagnoses based on test characteristics and patient presentation. This is where concepts like likelihood ratios, clinical prediction rules (CPRs), and post-test probability become essential.

Concept	Foundational Level	Advanced Level
Test Interpretation	Reading imaging reports and lab values, recognizing normal vs. abnormal	Applying sensitivity, specificity, and likelihood ratios to modify diagnostic probability; understanding Bayesian reasoning
Red Flag Screening	Identifying common red flags (fever, unexplained weight loss, night pain) and referring to physician	Using clinical prediction rules (e.g., Ottawa Ankle Rules, Canadian C-Spine Rules) to determine imaging necessity and interpret multi-system presentations
Treatment Modification	Adjusting exercise intensity based on lab value thresholds (e.g., platelet counts, blood glucose)	Integrating longitudinal lab trends with functional outcomes to guide prognosis and discharge planning; recognizing medication-lab interactions
Imaging Correlation	Correlating imaging findings with primary diagnosis from referral source	Critically appraising imaging findings in the context of base rates of asymptomatic findings; recommending further imaging based on clinical suspicion

Progression from foundational to advanced diagnostic integration competencies.

As the profession continues to evolve, physical therapists are increasingly expected to function as autonomous practitioners capable of primary screening. Advanced clinical reasoning incorporates hypothesis-oriented algorithms where the therapist generates multiple diagnostic hypotheses, selects the most appropriate tests to confirm or refute each hypothesis, and iteratively narrows the differential until the most likely diagnosis is identified. In the NPTE context, examinees should expect questions that require them to interpret diagnostic data, recognize when findings are incongruent with the working diagnosis, and determine the appropriate next step — whether that is proceeding with therapy, requesting additional tests, or making an emergent referral.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

A patient's MRI report reveals a disc bulge at L4–L5. The patient denies low back pain and presents with isolated right shoulder dysfunction following a rotator cuff repair. How should the physical therapist interpret the MRI finding in the context of this patient's plan of care?

Show answer

The disc bulge at L4–L5 is an incidental finding that does not correlate with the patient's current presentation. Research demonstrates that disc bulges are present in a large proportion of asymptomatic individuals, particularly in older adults. The physical therapist should note the finding in the chart for future reference but should not modify the shoulder rehabilitation plan based on this incidental lumbar finding. Treatment should remain focused on the post-operative rotator cuff repair. If the patient later develops lumbar symptoms, the MRI finding becomes clinically relevant and would warrant further investigation.

Question 2: BASIC CALCULATION

A special test has a sensitivity of 0.92 and a specificity of 0.85 for detecting complete ACL tears. Calculate the positive likelihood ratio (+LR). Based on this value, how useful is a positive test result for ruling in the diagnosis?

Show answer

The positive likelihood ratio is calculated as: +LR = Sensitivity / (1 − Specificity) = 0.92 / (1 − 0.85) = 0.92 / 0.15 = 6.13. A +LR of 6.13 indicates that a positive test result is approximately six times more likely to occur in a patient with a complete ACL tear than in one without. While values above 10 are considered strong evidence for ruling in a diagnosis, a +LR of 6.13 is considered moderate to good. This means a positive result meaningfully shifts the post-test probability upward but should be combined with additional clinical findings — such as Lachman test results, pivot shift test, joint effusion, and mechanism of injury — before confirming the diagnosis.

Question 3: INTERMEDIATE

A 72-year-old male patient undergoing outpatient physical therapy for total knee arthroplasty rehabilitation presents for his session. His most recent lab work (obtained yesterday) shows: Hgb 9.2 g/dL, platelet count 38,000/µL, INR 2.4, and fasting glucose 105 mg/dL. Which of these values should modify today's treatment session, and how?

Show answer

Multiple lab values require treatment modification. First, the hemoglobin of 9.2 g/dL is below normal, indicating moderate anemia; the therapist should reduce aerobic exercise intensity and monitor for signs of dizziness, dyspnea, and excessive fatigue. Second, the platelet count of 38,000/µL falls within the 20,000–50,000 range, meaning only gentle active exercise is appropriate — resistive exercise, aggressive stretching, and deep tissue mobilization should be avoided due to bleeding risk. Third, the INR of 2.4 is within the therapeutic range for patients on warfarin (2.0–3.0), which is expected post-TKA, but the therapist should still avoid aggressive soft-tissue mobilization techniques. Fourth, the fasting glucose of 105 mg/dL is mildly elevated but within a safe range for exercise (100–250 mg/dL), so exercise may proceed with monitoring. The session should be modified to include gentle AROM and AAROM exercises with close vital sign monitoring.

Question 4: APPLIED

A 45-year-old female is referred to physical therapy with a diagnosis of 'right shoulder impingement syndrome.' Her X-ray was negative for fracture. During the initial evaluation, she reports progressive right shoulder pain over 3 months, 10-pound unintentional weight loss, night pain that awakens her from sleep, and fatigue. Her ESR is 42 mm/hr and CRP is 3.8 mg/dL. What is the most appropriate course of action?

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This clinical presentation contains multiple red flags that suggest a more serious underlying pathology than mechanical impingement. The combination of unintentional weight loss (10 pounds), progressive night pain that disrupts sleep, systemic fatigue, a markedly elevated ESR (42 mm/hr vs. normal < 20), and elevated CRP (3.8 mg/dL vs. normal < 1.0) raises concern for possible malignancy, infection, or systemic inflammatory disease. While the X-ray was negative for fracture, plain radiographs may not reveal early destructive lesions or soft-tissue masses. The most appropriate course of action is to defer physical therapy treatment and immediately communicate these findings to the referring physician, recommending advanced imaging (MRI with contrast) and further laboratory investigation. It would be inappropriate to initiate a standard impingement rehabilitation program given the constellation of red flags.

Question 5: CRITICAL THINKING

A 30-year-old marathon runner presents with a 6-week history of progressive right tibial pain that worsens with running and improves with rest. Initial X-rays taken 2 weeks after symptom onset were negative. The patient was told by another provider that 'the X-ray is normal so nothing is wrong.' The patient's pain has since worsened, and she now has point tenderness over the mid-tibia. Discuss the limitations of the initial imaging decision, recommend the most appropriate next diagnostic step, and explain how the results would influence your physical therapy management.

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This case highlights a critical limitation of plain radiography in the context of stress fractures. X-rays have relatively low sensitivity for early stress fractures, often appearing normal for the first 2–3 weeks after symptom onset because periosteal callus formation — the radiographic hallmark of bone healing — has not yet occurred. The initial negative X-ray at 2 weeks was likely a false negative rather than a true negative, making the conclusion that 'nothing is wrong' clinically unsound. Given the progressive symptoms, point tenderness over the tibia, and high-risk history (distance runner, likely repetitive loading), the most appropriate next step is MRI of the right tibia, which is the gold standard for stress fracture detection due to its sensitivity to bone marrow edema. A bone scan is a reasonable alternative if MRI is unavailable. If MRI confirms a tibial stress fracture, the physical therapy plan must include: immediate activity modification with cessation of running and impact-loading activities, a structured non-weight-bearing or protected weight-bearing program depending on fracture severity and location, aquatic therapy or upper-body conditioning to maintain cardiovascular fitness, and a graded return-to-running protocol over 6–12 weeks once the fracture has healed. The clinician should also screen for contributing factors such as nutritional deficiencies (vitamin D, calcium), relative energy deficiency in sport (RED-S), and biomechanical factors amenable to correction.

SUMMARY

Lesson Summary

Summary

Integrating diagnostic tests into physical therapy decision-making requires a systematic approach that places clinical correlation at its center. The physical therapist must understand the appropriate indications and limitations of each imaging modality — from the bone-focused clarity of X-rays to the soft-tissue precision of MRI — and must recognize that incidental findings in asymptomatic individuals are common and should not drive treatment. Laboratory values such as hemoglobin, platelet count, INR, WBC, blood glucose, ESR, and CRP carry direct implications for exercise safety, with specific thresholds governing when to proceed, modify, or defer physical therapy interventions.

Core statistical concepts — sensitivity (SnNOut), specificity (SpPIn), and likelihood ratios — enable the therapist to weigh diagnostic evidence appropriately. The clinician must maintain vigilant red flag screening throughout the episode of care, recognizing when laboratory and imaging findings — combined with subjective complaints such as unexplained weight loss, night pain, or constitutional symptoms — warrant immediate referral rather than rehabilitation. Mastery of these concepts prepares the physical therapist to function as a confident, autonomous practitioner and is essential for success on the NPTE.