Free PANCE practice questions

Question 1

A 58-year-old man presents to the emergency department with 40 minutes of substernal chest pressure radiating to his left arm, associated with diaphoresis and nausea. He has hypertension and type 2 diabetes. Blood pressure is 148/92 mm Hg, pulse 96/min. ECG shows 2 mm ST-segment elevation in leads II, III, and aVF. The nearest facility with cardiac catheterization capability is 30 minutes away. Which of the following is the most appropriate next step in management?

• A. Administer sublingual nitroglycerin and discharge if pain resolves
• B. Administer aspirin and arrange immediate transfer for primary percutaneous coronary intervention
• C. Administer intravenous fibrinolytic therapy and admit to the intensive care unit
• D. Start a heparin infusion and schedule catheterization within 72 hours
• E. Obtain serial troponins and repeat the ECG in 6 hours

Question 2

A 54-year-old woman presents to the emergency department with sudden-onset right-sided pleuritic chest pain and dyspnea that began 2 hours ago. She underwent a total knee arthroplasty 8 days ago and has been less mobile since. Blood pressure is 118/74 mm Hg, pulse 114/min, respirations 24/min, and oxygen saturation 90% on room air. The right calf is 3 cm larger in circumference than the left and tender to palpation. Lungs are clear to auscultation. ECG shows sinus tachycardia. Which of the following is the most likely diagnosis?

• A. Acute pericarditis
• B. Community-acquired pneumonia
• C. Acute coronary syndrome
• D. Spontaneous pneumothorax
• E. Pulmonary embolism

Question 3

A 22-year-old man presents with 18 hours of abdominal pain that began periumbilically and has migrated to the right lower quadrant, accompanied by anorexia, nausea, and a temperature of 38.1°C (100.6°F). He has focal tenderness with guarding one-third of the way from the anterior superior iliac spine to the umbilicus. Which of the following additional physical examination findings would most support the suspected diagnosis?

• A. Costovertebral angle tenderness on the right
• B. Inspiratory arrest during deep palpation of the right upper quadrant
• C. Periumbilical ecchymosis
• D. High-pitched, rushing bowel sounds with visible peristalsis
• E. Right lower quadrant pain elicited by palpation of the left lower quadrant

Question 4

A 55-year-old house painter reports 3 months of gradually worsening right shoulder pain that is worst when reaching overhead and often wakes him when he rolls onto that side at night. On examination he has a painful arc between 60 and 120 degrees of abduction, a positive Hawkins-Kennedy sign, and pain with resisted abduction. When you support his arm at 90 degrees of abduction and ask him to hold it, the arm drifts downward and he cannot maintain the position. Which examination finding most strongly suggests a full-thickness supraspinatus tear rather than isolated subacromial impingement?

• A. Pain reproduced with passive forward flexion of the shoulder
• B. Tenderness to palpation over the acromioclavicular joint
• C. The painful arc between 60 and 120 degrees of abduction
• D. The positive Hawkins-Kennedy impingement sign
• E. The inability to hold the abducted arm against gravity (positive drop-arm test)

Question 5

A 19-year-old woman with type 1 diabetes presents with 1 day of vomiting and abdominal pain after running out of insulin. She is tachycardic with deep, rapid respirations. Laboratory studies show glucose 486 mg/dL (70–99 mg/dL), arterial pH 7.18, bicarbonate 12 mEq/L (22–28 mEq/L), an elevated anion gap, and potassium 5.4 mEq/L (3.5–5.0 mEq/L). Intravenous isotonic saline has been started and she is producing urine. Which of the following is the most appropriate next step in pharmacologic management?

• A. Withhold insulin until the serum potassium is fully corrected to the mid-normal range
• B. Start a dextrose-containing infusion immediately to prevent hypoglycemia before any insulin
• C. Give a single dose of subcutaneous long-acting insulin and recheck glucose in 6 hours
• D. Begin an intravenous regular insulin infusion and add potassium to the fluids once serum potassium falls below 5.3 mEq/L
• E. Administer intravenous sodium bicarbonate to correct the acidemia

Question 6

A 47-year-old woman presents with a headache that began abruptly while she was gardening, reaching maximum intensity within seconds. She describes it as the worst headache of her life and had a brief loss of consciousness at onset. She now has neck stiffness, photophobia, and one episode of vomiting. Temperature is 37.1°C (98.8°F), blood pressure 162/94 mm Hg. Neurologic examination shows no focal deficits. Which of the following is the most likely diagnosis?

• A. Subarachnoid hemorrhage
• B. Bacterial meningitis
• C. Acute ischemic stroke
• D. Tension-type headache
• E. Migraine headache

Question 7

A 64-year-old man with diabetes presents with fever, confusion, and a suspected urinary source of infection. Temperature is 39.2°C (102.6°F), blood pressure 84/48 mm Hg, pulse 122/min, respiratory rate 26/min. Serum lactate is 4.2 mmol/L (reference < 2.0). Blood and urine cultures are obtained. After starting fluid resuscitation, which of the following is the most appropriate next step in management?

• A. Start narrow-spectrum antibiotics targeting only common uropathogens
• B. Delay antibiotics until a CT of the abdomen and pelvis is completed
• C. Administer broad-spectrum empiric intravenous antibiotics within the first hour
• D. Give oral antibiotics and arrange outpatient follow-up
• E. Wait for culture and sensitivity results before starting antibiotics

Question 8

A 58-year-old fair-skinned man presents with a mole on his upper back that his wife says has changed over the past few months. On examination the lesion is 9 mm across, with an irregular notched border, asymmetric shape, and areas of brown, black, and blue-gray pigmentation. It is otherwise asymptomatic. Which of the following is the most likely diagnosis?

• A. Seborrheic keratosis
• B. Benign compound nevus
• C. Basal cell carcinoma
• D. Melanoma
• E. Dermatofibroma