Free PANCE Practice Test: 60 Questions With Explanations
Sixty original, unofficial PANCE-style questions, weighted by content category to the NCCPA PANCE Content Blueprint in effect since January 2025. Answer a question, then read its explanation — or set your own 60-minute timer and do all 60 first, which matches the pace of one PANCE block.
Practice questions
Question 1 of 60
A 34-year-old man has had sharp substernal chest pain for 2 days. It worsens when he lies flat or breathes in deeply and eases when he sits up and leans forward. He had an upper respiratory infection 10 days ago. Temperature is 37.9 °C (100.2 °F), blood pressure 128/78 mm Hg, and pulse 96/min. A scratchy, three-component sound is heard at the left lower sternal border while he leans forward. ECG shows diffuse concave ST-segment elevation across most limb and precordial leads with PR-segment depression; aVR shows ST depression and PR elevation. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: B. Acute pericarditis
Positional pleuritic pain relieved by leaning forward, a three-component friction rub, and diffuse ST elevation with PR depression after a viral illness support acute pericarditis. A is wrong because an inferior STEMI usually produces ST elevation in an inferior coronary territory, rather than this diffuse pattern with PR depression. C classically causes abrupt tearing pain radiating to the back, often with a pulse or blood-pressure difference between arms. D can cause pleuritic pain but doesn't explain this pericardial rub and ECG pattern. E causes one-sided decreased breath sounds and hyperresonance, not a rub.
Review takeaway: Diffuse ST elevation plus PR depression plus a rub means pericarditis, not a coronary territory.
Cardiovascular System · Formulating the Most Likely Diagnosis · Source: ACC, New Concise Clinical Guidance Addresses Evaluation and Management of Pericarditis (2025)
Question 2 of 60
A 27-year-old man arrives after a motorcycle crash. He is in severe respiratory distress. Blood pressure is 78/40 mm Hg, pulse 132/min, and oxygen saturation 84% on a nonrebreather mask. His trachea is deviated to the left, breath sounds are absent on the right, the right chest is hyperresonant, and his neck veins are distended. Which of the following is the most appropriate next step?
Answer and explanation
Answer: E. Immediate decompression of the right chest
Hypotension, hypoxia, tracheal deviation away from the affected side, absent breath sounds, hyperresonance, and distended neck veins point to a tension pneumothorax. In a patient this unstable with these signs of tension pneumothorax, decompression must not wait for imaging. A is reasonable in a stable patient whose signs could reflect a simple pneumothorax, but here it delays treatment of obstructive shock. B delays care even more and takes an unstable patient out of the resuscitation area. C treats cardiac tamponade, which doesn't cause tracheal deviation, absent breath sounds on one side, or hyperresonance. D doesn't release the trapped air causing the shock, and delaying decompression risks cardiac arrest.
Review takeaway: Unstable plus the signs of tension pneumothorax means decompress first; do not delay decompression for imaging.
Pulmonary System · Clinical Intervention · Surgical topic · Source: Coccolini F, et al. Thoracic trauma WSES–AAST guidelines. World Journal of Emergency Surgery. 2025
Question 3 of 60
A 61-year-old woman with type 2 diabetes and heart failure with reduced ejection fraction (LVEF 30%, NYHA class II) takes metformin 1,000 mg twice daily, sacubitril–valsartan, carvedilol, and spironolactone. Her hemoglobin A1c is 7.9%, eGFR is 62 mL/min/1.73 m², and potassium is 4.6 mEq/L. Which of the following is the most appropriate medication to add?
Answer and explanation
Answer: C. Empagliflozin
For people with type 2 diabetes and heart failure, an SGLT2 inhibitor is recommended to reduce heart-failure hospitalization and cardiovascular death, regardless of A1c; it also lowers glucose. A is avoided because thiazolidinediones cause fluid retention and should not be used in symptomatic heart failure. B is avoided because saxagliptin has been associated with more heart-failure hospitalizations. D and E lower glucose but offer no heart-failure benefit and add hypoglycemia risk.
Review takeaway: Type 2 diabetes plus heart failure: add an SGLT2 inhibitor; avoid TZDs and saxagliptin.
Endocrine System · Pharmaceutical Therapeutics · Sources: American Diabetes Association, Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2026; American Diabetes Association, Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026
Question 4 of 60
A 4-week-old first-born boy has had 5 days of forceful, nonbilious vomiting right after nearly every feed. He seems hungry right after vomiting and has lost weight since his 2-week visit. A firm, olive-sized mass is palpable in the right upper abdomen just above the umbilicus. Serum sodium is 134 mEq/L, potassium 3.0 mEq/L, chloride 88 mEq/L, and bicarbonate 33 mEq/L. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: D. Hypertrophic pyloric stenosis
Projectile nonbilious vomiting starting around 3–8 weeks, a hungry infant, an olive-shaped mass, and a hypochloremic, hypokalemic metabolic alkalosis (from losing gastric acid) are classic. Ultrasound is the test of choice, and fluids and electrolytes are corrected before pyloromyotomy. A typically causes bilious vomiting, and C usually presents within the first days of life. B causes effortless spitting up in a thriving infant. E usually affects older infants with episodic colicky pain; bloody "currant jelly" stools are a late, less common sign.
Review takeaway: Nonbilious projectile vomiting at 3–8 weeks plus hypochloremic alkalosis means pyloric stenosis.
Gastrointestinal System/Nutrition · Formulating the Most Likely Diagnosis · Pediatric · Surgical topic · Sources: University of Hawaiʻi JABSOM, Case Based Pediatrics: Hypertrophic Pyloric Stenosis; University of Hawaiʻi JABSOM, Case Based Pediatrics: Intestinal Atresias, Duplications and Microcolon; Royal Children's Hospital Melbourne, Clinical Practice Guideline: Intussusception
Question 5 of 60
A 58-year-old woman whose preferred language is Spanish and who has limited English proficiency returns to discuss a breast biopsy result. Her 14-year-old daughter is with her and offers to interpret. The patient says that is fine. The clinic is subject to Section 1557's language-access requirements. Which of the following is the most appropriate action?
Answer and explanation
Answer: A. Arrange a qualified medical interpreter
A biopsy result needs accurate, private communication. Federal rules for covered health programs require offering a qualified interpreter and bar relying on a minor child to interpret, except temporarily in an emergency involving an imminent threat to someone's safety or welfare while a qualified interpreter is being found. This isn't an emergency. B puts a child in the position of relaying possible cancer news and risks errors and omissions. C uses someone not shown to be a qualified medical interpreter. D doesn't communicate in the patient's language. E mistakes nodding for understanding.
Review takeaway: Non-emergency conversation plus limited English proficiency means a qualified interpreter, never a child.
Professional Practice · Source: 45 CFR § 92.201, Meaningful access for individuals with limited English proficiency — paragraphs (c)(1) and (e)(3)
Question 6 of 60
A 19-year-old soccer player planted his foot and pivoted, felt a "pop" in his right knee, and could not keep playing. The knee swelled within 2 hours. Which of the following examination maneuvers most directly assesses the injury you suspect?
Answer and explanation
Answer: E. Lachman test
A noncontact pivot, an audible pop, and rapid swelling from bleeding into the joint point to an anterior cruciate ligament (ACL) tear. The Lachman test — pulling the tibia forward with the knee bent 20–30° — assesses ACL integrity through anterior tibial translation. A and D test the menisci. B tests the medial collateral ligament. C tests the posterior cruciate ligament, usually injured by a direct blow to the front of the tibia.
Review takeaway: Pivot, pop, and fast swelling mean ACL; use Lachman to assess anterior tibial translation.
Musculoskeletal System · History Taking and Performing Physical Examination · Sources: Sokal PA, et al. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated. Knee Surgery, Sports Traumatology, Arthroscopy. 2022; Stanford Medicine 25, Knee Exam
Question 7 of 60
A 24-year-old woman has mucopurulent cervical discharge. A nucleic acid amplification test (NAAT) is positive for Neisseria gonorrhoeae; the chlamydia result is still pending. She weighs 68 kg, is not pregnant, and has no drug allergies. Which of the following is the most appropriate treatment today?
Answer and explanation
Answer: C. Ceftriaxone 500 mg IM plus doxycycline for 7 days
CDC recommends ceftriaxone 500 mg IM as a single dose for uncomplicated cervical, urethral, or rectal gonorrhea in people under 150 kg, plus doxycycline 100 mg twice daily for 7 days when chlamydia hasn't been excluded — as here, with the result pending. A is the older regimen CDC replaced. B is not a recommended regimen. D is not appropriate empiric treatment without documented susceptibility because fluoroquinolone resistance is widespread. E treats gonorrhea but leaves possible chlamydia untreated.
Review takeaway: Uncomplicated cervical gonorrhea in a nonpregnant adult under 150 kg: ceftriaxone 500 mg IM; add 7 days of doxycycline unless chlamydia is ruled out.
Infectious Diseases · Pharmaceutical Therapeutics · Source: CDC STI Treatment Guidelines, Gonococcal Infections Among Adolescents and Adults — recommended regimen for uncomplicated infection
Question 8 of 60
A 36-year-old man had a diarrheal illness 3 weeks ago. Over the past 4 days he has developed tingling in both feet and symmetric leg weakness that has climbed to his thighs; today he can't rise from a chair without using his arms. Knee and ankle reflexes are absent. Sensation is mildly decreased in both feet. Cerebrospinal fluid shows protein 160 mg/dL (reference 15–45) and 2 white cells/µL. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: D. Guillain-Barré syndrome
Rapidly rising, symmetric weakness with absent reflexes after a gastrointestinal infection, plus high CSF protein with a normal cell count (albuminocytologic dissociation), fits Guillain-Barré syndrome. Watch breathing closely; IVIG or plasma exchange is the disease-specific treatment. A causes central nervous system signs such as brisk reflexes, not absent ones. B causes fatigable weakness with normal reflexes and sensation, often with drooping eyelids or double vision. C causes descending paralysis that starts with the cranial nerves. E produces a sensory level on the trunk and bladder problems.
Review takeaway: Ascending weakness plus areflexia plus high CSF protein with normal cells means GBS; monitor breathing.
Neurologic System · Formulating the Most Likely Diagnosis · Source: European Academy of Neurology/Peripheral Nerve Society Guideline on Diagnosis and Treatment of Guillain–Barré Syndrome. 2023 (PDF)
Question 9 of 60
A 31-year-old woman with heavy menstrual periods reports 3 months of fatigue. Hemoglobin is 9.8 g/dL and mean corpuscular volume is 72 fL. Which single laboratory test best confirms the most likely cause of her anemia?
Answer and explanation
Answer: E. Serum ferritin
Microcytic anemia with heavy menses suggests iron deficiency. Ferritin reflects the body's iron stores, and a low ferritin confirms iron deficiency. A swings with recent intake and inflammation. B rises in iron deficiency but is less specific than ferritin. C looks for thalassemia or other hemoglobin disorders, which are less likely here. D shows how the marrow is responding, not the cause.
Review takeaway: For suspected iron deficiency, ferritin is the single most useful test.
Hematologic System · Using Diagnostic and Laboratory Studies · Source: British Society of Gastroenterology Guidelines for the Management of Iron Deficiency Anaemia in Adults. 2021 (PDF)
Question 10 of 60
A 27-year-old woman with migraine headaches preceded by a shimmering visual aura asks for highly effective reversible contraception. She would also like lighter periods. Blood pressure is 118/74 mm Hg, and she doesn't smoke. Which of the following is the most appropriate method?
Answer and explanation
Answer: D. Levonorgestrel IUD
Migraine with aura is U.S. Medical Eligibility Criteria (U.S. MEC) category 4 — an unacceptable health risk — for combined hormonal contraception because of stroke risk. That rules out A, B, and C, which all contain estrogen. The levonorgestrel IUD is highly effective and usually makes periods lighter. E is also safe and effective, but copper IUDs often make bleeding and cramping heavier — the opposite of her goal.
Review takeaway: Migraine with aura means no combined hormonal contraception; choose a progestin or nonhormonal method that fits her goals.
Reproductive System · Pharmaceutical Therapeutics · Sources: CDC, U.S. Medical Eligibility Criteria for Contraceptive Use, 2024: Combined Hormonal Contraceptives; CDC, U.S. Medical Eligibility Criteria for Contraceptive Use, 2024: Intrauterine Devices; CDC, U.S. Selected Practice Recommendations for Contraceptive Use, 2024: Intrauterine Contraception
Question 11 of 60
A 45-year-old woman taking sertraline for depression started tramadol 2 days ago for back pain. She now has agitation, sweating, diarrhea, and tremor. Temperature is 38.6 °C (101.5 °F) and pulse is 118/min. Pupils are dilated. Reflexes are brisk, with inducible clonus at both ankles that is more pronounced in the legs than the arms. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: B. Serotonin syndrome
Adding a serotonergic drug (tramadol) to an SSRI, rapid onset, tremor with hyperreflexia, and inducible clonus with agitation and sweating meet the Hunter criteria for serotonin toxicity. Stop the offending drugs and give supportive care. A develops over days after dopamine-blocking drugs, with "lead-pipe" rigidity and slowed reflexes. C causes dry, flushed skin and urinary retention, not sweating and diarrhea. D follows volatile anesthetics or succinylcholine. E follows cessation or a substantial reduction of heavy, prolonged drinking; that history is not given here.
Review takeaway: New serotonergic drug plus clonus and hyperreflexia means serotonin syndrome; rigidity and slow onset suggest NMS.
Psychiatry/Behavioral Science · Formulating the Most Likely Diagnosis · Sources: Frank C. Recognition and Treatment of Serotonin Syndrome. Canadian Family Physician. 2008; American Society of Addiction Medicine, Clinical Practice Guideline on Alcohol Withdrawal Management
Question 12 of 60
A 67-year-old man with stage 4 chronic kidney disease who takes lisinopril and spironolactone reports generalized weakness. Serum potassium is 7.1 mEq/L. ECG shows peaked T waves and a QRS duration of 140 ms. Which of the following should be given first?
Answer and explanation
Answer: A. IV calcium gluconate
With ECG changes — especially a widened QRS — the first priority is protecting the heart with IV calcium, which stabilizes the cardiac membrane within minutes but doesn't lower potassium. Then shift potassium into cells and remove it from the body. C shifts potassium into cells and comes right after calcium. B and E remove potassium slowly and don't protect the heart now. D may be needed, but it takes time to set up and isn't the first step.
Review takeaway: Hyperkalemia with ECG changes: calcium first to protect the heart, then shift, then remove.
Renal System · Clinical Intervention · Source: Lindner G, et al. Acute Hyperkalemia in the Emergency Department: A Summary From a KDIGO Conference. European Journal of Emergency Medicine. 2020
Question 13 of 60
A 74-year-old woman is newly diagnosed with nonvalvular atrial fibrillation. She has hypertension and type 2 diabetes. Creatinine clearance is 68 mL/min, and she has no history of bleeding. Which of the following is the most appropriate therapy to reduce her stroke risk?
Answer and explanation
Answer: E. Apixaban
Her CHA₂DS₂-VASc score is 4 (age 65–74 = 1, female = 1, hypertension = 1, diabetes = 1), well above the threshold at which oral anticoagulation is recommended. For atrial fibrillation without a mechanical valve or moderate-to-severe mitral stenosis, a direct oral anticoagulant is recommended over warfarin. A and B are inferior for stroke prevention, and two antiplatelets add bleeding without matching an anticoagulant's benefit. C leaves a high stroke risk untreated. D uses a target that's too low; the warfarin goal in atrial fibrillation is an INR of 2.0–3.0.
Review takeaway: Count CHA₂DS₂-VASc; when anticoagulation is indicated, a DOAC is preferred over warfarin unless there is a mechanical heart valve or moderate-to-severe mitral stenosis.
Cardiovascular System · Pharmaceutical Therapeutics · Source: Joglar JA, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation
Question 14 of 60
A 63-year-old woman leaves a dark movie theater with sudden severe pain in her right eye, a frontal headache, nausea, vomiting, and blurred vision with halos around lights. The right eye has redness concentrated around the cornea, a hazy cornea, and a mid-dilated pupil that reacts poorly to light. The eye feels firm. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: A. Acute angle-closure glaucoma
Dim light dilates the pupil and can close a narrow drainage angle, causing a sudden rise in eye pressure: severe pain, halos, nausea and vomiting, a cloudy cornea, a fixed mid-dilated pupil, and a firm eye. It needs pressure-lowering treatment and ophthalmology care right away. B causes pain and light sensitivity with a small pupil. C causes discharge without vision loss or pupil changes. D doesn't cause a red eye or an abnormal pupil. E causes sudden painless vision loss.
Review takeaway: Painful red eye with halos and a mid-dilated pupil is angle closure until proven otherwise.
Eyes, Ears, Nose, and Throat · Formulating the Most Likely Diagnosis · Source: American Academy of Ophthalmology EyeWiki, Primary vs. Secondary Angle Closure Glaucoma
Question 15 of 60
A 46-year-old man with no symptoms, no personal history of polyps or inflammatory bowel disease, and no family history of colorectal cancer asks about colon cancer screening. Which of the following is the most appropriate recommendation?
Answer and explanation
Answer: D. Begin screening now
USPSTF recommends colorectal cancer screening for adults 45 to 75, with several acceptable tests and intervals. A reflects the older starting age. B isn't a screening test; CEA is used to monitor known cancer. C describes evaluating symptoms, not screening. E is too frequent for someone at average risk with no findings.
Review takeaway: Average-risk colorectal screening starts at 45.
Gastrointestinal System/Nutrition · Health Maintenance, Patient Education, and Preventive Measures · Sources: USPSTF, Colorectal Cancer: Screening (May 18, 2021); National Library of Medicine, MedlinePlus: CEA Test
Question 16 of 60
A 19-year-old college student first noticed a single 3-cm, salmon-colored oval patch with a fine collar of scale on his trunk. Nine days later, many smaller oval lesions appeared on his back, with their long axes following the skin's cleavage lines. Itching is mild. He is otherwise well. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: D. Pityriasis rosea
A "herald patch" followed by smaller oval lesions in a Christmas-tree pattern along cleavage lines is classic pityriasis rosea, which clears on its own over weeks. A usually shows a few expanding ring-shaped plaques with scaly, raised borders; a KOH prep confirms it. B causes small, drop-shaped plaques, often after strep throat, without a herald patch. C can look like pityriasis rosea — check syphilis serology if his history suggests exposure risk or his palms and soles are involved. E causes coin-shaped eczema plaques, often on the arms and legs.
Review takeaway: Herald patch then a Christmas-tree eruption means pityriasis rosea; consider syphilis testing when risk exists.
Dermatologic System · Formulating the Most Likely Diagnosis · Sources: Villalon-Gomez JM. Pityriasis Rosea: Diagnosis and Treatment. American Family Physician. 2018; CDC STI Treatment Guidelines: Syphilis; American Academy of Dermatology, Psoriasis: Signs and Symptoms
Question 17 of 60
A 22-year-old woman with type 1 diabetes has vomited for 2 days. Glucose is 486 mg/dL, venous pH 7.12, bicarbonate 9 mEq/L, β-hydroxybutyrate 6.8 mmol/L, and potassium 2.9 mEq/L. A liter of isotonic crystalloid is running. Which of the following is the most appropriate next step?
Answer and explanation
Answer: C. Replace potassium first and hold insulin
Insulin drives potassium into cells. Starting it with a potassium of 2.9 risks dangerous hypokalemia and arrhythmia, so the 2024 consensus report says to replace potassium and wait on insulin until potassium is above 3.5 mmol/L (the same number in mEq/L). A is the next step only once potassium is safe. B is considered only for severe acidosis with pH below 7.0. D isn't initial treatment for severe DKA. E is reserved for marked phosphate depletion or specific complications.
Review takeaway: In DKA, check potassium before insulin; below 3.5, replace potassium first.
Endocrine System · Clinical Intervention · Source: Umpierrez GE, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024
Question 18 of 60
A 14-year-old boy woke 3 hours ago with sudden severe left scrotal pain, nausea, and vomiting. The left testis sits higher than the right with a horizontal orientation and is extremely tender. The cremasteric reflex is absent on the left. Which of the following is the most appropriate next step?
Answer and explanation
Answer: D. Immediate surgical exploration
Sudden severe pain, vomiting, a high-riding horizontal testis, and an absent cremasteric reflex make testicular torsion highly likely. The chance of saving the testis drops sharply after about 6 hours, so strong clinical suspicion calls for immediate surgical exploration; imaging must not delay surgery. A, B, and C pursue other causes and lose time. E delays a time-critical diagnosis; Doppler ultrasound helps only when the diagnosis is uncertain and won't delay care.
Review takeaway: High suspicion for torsion means the operating room, not a scan that delays surgery.
Genitourinary System · Clinical Intervention · Pediatric · Surgical topic · Sources: Sharp VJ, et al. Testicular Torsion: Diagnosis, Evaluation, and Management. American Family Physician. 2013; European Association of Urology, Paediatric Urology Guideline: Acute Scrotum
Question 19 of 60
A 68-year-old man who smokes has a right pleural effusion and unintended weight loss. Thoracentesis results: pleural fluid protein 4.0 g/dL and lactate dehydrogenase (LDH) 260 U/L. Serum protein is 6.5 g/dL and serum LDH is 200 U/L (laboratory upper limit of normal 225 U/L). Which interpretation is correct?
Answer and explanation
Answer: B. Exudate
Light's criteria call an effusion an exudate if any one is met: pleural/serum protein above 0.5 (4.0 ÷ 6.5 ≈ 0.62), pleural/serum LDH above 0.6 (260 ÷ 200 = 1.3), or pleural LDH above two-thirds of the serum upper limit of normal (260 > 150). All three are met. In a smoker with weight loss, cancer is a leading concern. Heart failure and cirrhosis in A and C typically cause transudates. D is wrong because glucose isn't part of Light's criteria. E requires high pleural triglycerides or chylomicrons, which weren't measured.
Review takeaway: Any one of Light's three criteria makes an exudate; check both ratios and the LDH threshold.
Pulmonary System · Using Diagnostic and Laboratory Studies · Sources: British Thoracic Society Clinical Statement on Pleural Procedures. 2023; American Family Physician, Pleural Effusion: Diagnostic Approach in Adults. 2023
Question 20 of 60
In a randomized trial lasting 3 years, a cardiovascular event occurred in 12% of the placebo group and 8% of the treatment group. How many patients must be treated for 3 years to prevent one event?
Answer and explanation
Answer: C. 25
The absolute risk reduction (ARR) is 12% − 8% = 4 percentage points, or 0.04. The number needed to treat (NNT) is 1 ÷ ARR = 1 ÷ 0.04 = 25. A mistakes the ARR percentage for the NNT. D comes from the relative risk reduction (4 ÷ 12 ≈ 33%), a common trap. B and E don't follow from either calculation.
Review takeaway: NNT = 1 ÷ absolute risk reduction, never the relative reduction.
Professional Practice · Source: Cochrane Handbook, Chapter 15: Interpreting Results and Drawing Conclusions
Question 21 of 60
A 12-year-old boy with obesity has had 3 weeks of left knee pain and a limp. He recalls no injury and can still bear weight on the leg. The left knee has no swelling, tenderness, or instability. Which additional finding is most expected?
Answer and explanation
Answer: E. Obligatory external rotation of the hip with flexion
Knee pain with a normal knee exam in an early adolescent with obesity should send you to the hip: slipped capital femoral epiphysis (SCFE) often refers pain to the knee. Loss of internal rotation and obligatory external rotation as the hip is flexed are typical. For a stable slip like this, get AP and frog-leg lateral X-rays of both hips; an unstable slip requires a cross-table lateral view instead. Keep him off the leg and arrange urgent orthopedic care for fixation. A suggests Osgood-Schlatter disease. B, C, and D point to knee problems this exam doesn't support.
Review takeaway: Adolescent knee pain with a normal knee exam: examine the hip and think SCFE.
Musculoskeletal System · History Taking and Performing Physical Examination · Pediatric · Surgical topic · Sources: Peck DM, et al. Slipped Capital Femoral Epiphysis: Diagnosis and Management. Am Fam Physician. 2017; AAOS OrthoInfo: Slipped Capital Femoral Epiphysis (SCFE)
Question 22 of 60
A 52-year-old woman had knee arthroscopy under general anesthesia 10 days ago and returned yesterday from a 14-hour flight. Her right calf is 4 cm larger around than the left, with pitting edema and tenderness along the deep veins. Her Wells score for deep venous thrombosis is 4. Which of the following is the most appropriate next step?
Answer and explanation
Answer: B. Compression duplex ultrasonography
With a high pretest probability, the guideline recommends going straight to compression ultrasound rather than starting with a D-dimer. A fits low pretest probability, where a normal D-dimer can rule out DVT; at high probability, a normal D-dimer can't safely do that. C is invasive and rarely needed. D looks for pulmonary embolism rather than evaluating the symptomatic leg. E neither diagnoses nor appropriately treats DVT.
Review takeaway: High pretest probability for DVT means ultrasound first; a negative D-dimer alone is not enough here.
Cardiovascular System · Using Diagnostic and Laboratory Studies · Source: Lim W, et al. ASH 2018 guidelines: diagnosis of venous thromboembolism
Question 23 of 60
A 68-year-old man developed right-sided weakness and trouble speaking 70 minutes ago. His NIH Stroke Scale score is 12, glucose 132 mg/dL, and a noncontrast head CT shows no bleeding. Blood pressure is 198/112 mm Hg on two readings. He meets every other criterion for intravenous thrombolysis. Which of the following is the most appropriate next step?
Answer and explanation
Answer: A. Lower blood pressure below 185/110, then give thrombolysis
For a patient who is otherwise eligible, blood pressure should be brought below 185/110 mm Hg before IV thrombolysis to reduce bleeding risk, then kept below 180/105 mm Hg for at least 24 hours. B raises the risk of bleeding in the brain. C is wrong because a pressure that can be lowered doesn't permanently rule out treatment. D passes up a time-sensitive treatment he qualifies for. E overshoots; lowering pressure too far can worsen the stroke.
Review takeaway: Before IV thrombolysis, get blood pressure under 185/110 — not normal, just under the line.
Neurologic System · Clinical Intervention · Sources: AHA/ASA: Early Management of Acute Ischemic Stroke 2026, pocket guideline; AHA/ASA 2019 Acute Ischemic Stroke Guideline slide set (PDF)
Question 24 of 60
A healthy 31-year-old man was bitten on the hand by a raccoon that ran into the woods and cannot be located for testing. He has never received rabies vaccine. The wound has been thoroughly washed with soap and water, and public health officials recommend post-exposure prophylaxis. Which of the following is the most appropriate prophylaxis?
Answer and explanation
Answer: D. Rabies immune globulin plus four vaccine doses
Raccoons can carry rabies, and this one can't be captured for testing. A previously unvaccinated person with a healthy immune system needs human rabies immune globulin (infiltrated around the wound when anatomically possible) plus vaccine on days 0, 3, 7, and 14. A and B each leave out a required component of prophylaxis. C applies to healthy dogs, cats, and ferrets that can be watched. E — check his tetanus status, but that doesn't replace rabies prophylaxis.
Review takeaway: Unvaccinated plus a high-risk bite: immune globulin plus vaccine days 0, 3, 7, 14.
Infectious Diseases · Health Maintenance, Patient Education, and Preventive Measures · Sources: CDC: Rabies Post-exposure Prophylaxis Guidance; CDC: Information for Veterinarians—Rabies
Question 25 of 60
A 60-year-old man in septic shock has a serum lactate of 7.8 mmol/L. Labs: sodium 138 mEq/L, chloride 102 mEq/L, bicarbonate 12 mEq/L. Arterial blood gas: pH 7.29, PaCO₂ 26 mm Hg. Which of the following best describes his acid–base status?
Answer and explanation
Answer: A. High anion gap metabolic acidosis, appropriately compensated
Anion gap = Na − (Cl + HCO₃) = 138 − (102 + 12) = 24, which is high (lactic acidosis). Winter's formula predicts PaCO₂ = 1.5 × HCO₃ + 8, ± 2 = 1.5 × 12 + 8 = 26 ± 2. His measured PaCO₂ of 26 matches, so compensation is appropriate. B would need a PaCO₂ above 28. C would need a PaCO₂ below 24. D is wrong because the gap is high. E is wrong because the pH is acidic, so the main process is acidosis.
Review takeaway: For metabolic acidosis, compute the anion gap, then check PaCO₂ with Winter's formula.
Renal System · Applying Foundational Scientific Concepts · Sources: Berend K, et al. Physiological Approach to Assessment of Acid–Base Disturbances. N Engl J Med. 2014 (PDF); Merck Manual Professional: Acid-Base Disorders
Question 26 of 60
A 44-year-old man has a duodenal ulcer, and gastric biopsies are positive for Helicobacter pylori. He has never been treated for H. pylori. He developed hives after taking amoxicillin as a child. Antibiotic susceptibility testing is unavailable. Which of the following is the most appropriate treatment?
Answer and explanation
Answer: E. Bismuth quadruple therapy for 14 days
The 2024 ACG guideline recommends optimized bismuth quadruple therapy for 14 days as first-line treatment for patients never treated before when antibiotic susceptibility is unknown — and it contains no penicillin, which matters here. Confirm cure with a breath test, stool antigen, or biopsy at least 4 weeks after treatment; hold proton pump inhibitors for 2 weeks and antibiotics and bismuth for 4 weeks before testing. A, C, and D each contain amoxicillin; A also relies on clarithromycin without known susceptibility, which the guideline advises against because resistance is common. B may heal the ulcer but does not eradicate the infection.
Review takeaway: Untreated H. pylori with unknown susceptibility: bismuth quadruple therapy, then confirm cure.
Gastrointestinal System/Nutrition · Pharmaceutical Therapeutics · Sources: American College of Gastroenterology: H. pylori Guidelines Highlights 2024 (PDF); ACG: ACG Guideline on Treatment of Helicobacter pylori: New Recommendations… Will Practice Change?
Question 27 of 60
A 26-year-old woman whose last menstrual period was 7 weeks ago has left lower quadrant pain and lightheadedness. Blood pressure is 82/50 mm Hg and pulse 128/min. Her abdomen is distended with rebound tenderness. Urine hCG is positive. Bedside transvaginal ultrasound shows no pregnancy in the uterus and a large amount of free fluid in the pelvis and around the liver. Which of the following is the most appropriate management?
Answer and explanation
Answer: B. Emergency surgery with resuscitation
A positive pregnancy test, no pregnancy in the uterus, blood in the abdomen, and shock mean a ruptured ectopic pregnancy, which needs immediate surgery (laparoscopy or laparotomy) while she's resuscitated. A and D are options only for stable, unruptured ectopic pregnancies that meet specific criteria. C delays treatment of active bleeding. E samples the uterus and doesn't address a ruptured tube.
Review takeaway: Ectopic pregnancy plus hemodynamic instability means surgery, not methotrexate.
Reproductive System · Clinical Intervention · Surgical topic · Source: ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018
Question 28 of 60
A 52-year-old man with bipolar I disorder has been stable on lithium for years. Ten days ago he started hydrochlorothiazide for high blood pressure. He now has a coarse tremor, nausea, diarrhea, an unsteady gait, and confusion. Which of the following is the most likely explanation?
Answer and explanation
Answer: A. Thiazide-reduced lithium clearance causing toxicity
Thiazides cause sodium loss, so the kidney holds on to more sodium — and lithium along with it — raising lithium levels. Coarse tremor, GI upset, unsteady gait, and confusion are typical of toxicity. Withhold lithium and obtain urgent medical assessment, including a lithium level, kidney function, and electrolytes; stop the interacting thiazide. ACE inhibitors and NSAIDs can also raise lithium levels. B can cause neurologic symptoms through low sodium, but the new thiazide–lithium interaction better explains this combination of gastrointestinal and neurologic findings. C is less supported by the medication change: hydrochlorothiazide reduces lithium clearance rather than adding a serotonergic drug. D does not explain the abrupt toxicity pattern after this medication change. E causes episodic weakness rather than this pattern of gastrointestinal symptoms and ataxia.
Review takeaway: Thiazides, ACE inhibitors, and NSAIDs can raise lithium levels.
Psychiatry/Behavioral Science · Pharmaceutical Therapeutics · Source: DailyMed: Lithium carbonate tablets/capsules—prescribing information
Question 29 of 60
A 58-year-old man with poorly controlled hypertension has sudden, severe, tearing chest pain that radiates between his shoulder blades. Blood pressure is 178/96 mm Hg in the right arm and 132/80 mm Hg in the left. CT angiography shows an intimal flap extending from the ascending aorta into the descending aorta. Which of the following is the most appropriate management?
Answer and explanation
Answer: D. Emergency surgery with IV beta-blockade
A dissection involving the ascending aorta is type A (Stanford), which needs emergency open surgery because of the risk of rupture, tamponade, aortic regurgitation, and coronary involvement. Meanwhile, an IV beta-blocker lowers heart rate and the stress on the aortic wall. A and B are dangerous — thrombolysis or anticoagulation can cause fatal bleeding and do not treat this dissection. C undertreats a surgical emergency. E describes an approach for selected type B dissections, not type A.
Review takeaway: Ascending aorta involved means type A dissection and emergency surgery.
Cardiovascular System · Clinical Intervention · Surgical topic · Source: Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease
Question 30 of 60
An 18-month-old has had fever and has been tugging at her right ear for 2 days. Which otoscopic finding most strongly supports a diagnosis of acute otitis media?
Answer and explanation
Answer: C. Moderate to severe bulging of the eardrum
The AAP guideline requires fluid in the middle ear plus signs of acute inflammation; moderate to severe bulging of the tympanic membrane is the most specific sign. When an antibiotic is chosen, high-dose amoxicillin is first-line for most children. A can come from crying or fever alone. B suggests otitis media with effusion, which isn't treated with antibiotics. D is normal. E prevents diagnosis until the canal is cleared.
Review takeaway: Bulging eardrum is the sign that makes the diagnosis of acute otitis media.
Eyes, Ears, Nose, and Throat · History Taking and Performing Physical Examination · Pediatric · Sources: American Academy of Pediatrics EQIPP: Acute Otitis Media flowchart (PDF); CDC: Outpatient Clinical Care for Pediatric Populations
Question 31 of 60
A 66-year-old man receiving unfractionated heparin after coronary artery bypass surgery had a platelet count of 240,000/µL before surgery. On postoperative day 7, the count is 95,000/µL, and duplex ultrasonography shows a new left femoral deep venous thrombosis. Which of the following is the most appropriate next step?
Answer and explanation
Answer: A. Stop heparin; start a non-heparin anticoagulant
A platelet drop of more than 50% 5–10 days after starting heparin, plus a new clot, gives a high clinical probability of heparin-induced thrombocytopenia (HIT). Stop all heparin and start a non-heparin anticoagulant while obtaining a PF4/heparin immunoassay and, when indicated, a functional assay. B is wrong because low-molecular-weight heparin cross-reacts. C is not routine treatment; platelet transfusion may be considered for active bleeding or high bleeding risk. D started on its own during acute HIT can cause limb gangrene; warfarin waits until platelets recover. E keeps giving the trigger.
Review takeaway: High-probability HIT: stop every form of heparin and start a non-heparin anticoagulant.
Hematologic System · Clinical Intervention · Source: American Society of Hematology: Diagnosis and Management of Heparin-Induced Thrombocytopenia pocket guide (PDF)
Question 32 of 60
A 34-year-old woman has had a dry cough for 2 months. She now has painful red nodules on both shins and swollen, painful ankles. Chest radiograph shows enlarged lymph nodes at both lung hila without lung infiltrates. A transbronchial lymph node biopsy shows noncaseating granulomas, and stains and cultures for mycobacteria and fungi are negative. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: E. Sarcoidosis
Erythema nodosum, ankle arthritis, and bilateral hilar lymph node enlargement form Löfgren syndrome, an acute presentation of sarcoidosis; noncaseating granulomas with a negative infection workup support the diagnosis. A and C are infectious causes of granulomas, but the characteristic clinical triad and negative studies favor sarcoidosis here; negative studies alone do not exclude every infection. B can enlarge hilar nodes, but this biopsy has not shown a malignant cell population. D usually has an exposure-related pattern and parenchymal lung findings, rather than this triad.
Review takeaway: Erythema nodosum plus bilateral hilar nodes plus arthritis means Löfgren syndrome (sarcoidosis).
Pulmonary System · Formulating the Most Likely Diagnosis · Source: Crouser ED, et al. Diagnosis and Detection of Sarcoidosis: An Official ATS Clinical Practice Guideline (PDF)
Question 33 of 60
A 38-year-old woman has fatigue, weight gain, constipation, and cold intolerance. Her thyroid is diffusely enlarged, firm, and painless. TSH is 14.2 mIU/L (reference 0.4–4.0), free T4 is 0.6 ng/dL (reference 0.8–1.8), and anti-thyroid peroxidase antibodies are markedly elevated. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: C. Hashimoto thyroiditis
High TSH with low free T4 is overt primary hypothyroidism, and a painless, firm goiter with high anti-TPO antibodies points to Hashimoto thyroiditis, the most common cause in the United States. Treatment is levothyroxine. A causes hyperthyroidism (low TSH, high T4). B usually causes a painful, tender thyroid, sometimes after a viral illness, with a temporary hyperthyroid phase. D usually produces a low or inappropriately normal TSH. E requires a normal free T4.
Review takeaway: High TSH, low free T4, positive anti-TPO, painless goiter means Hashimoto.
Endocrine System · Formulating the Most Likely Diagnosis · Sources: American Thyroid Association: Hashimoto’s Thyroiditis; American Thyroid Association: Thyroid Function Tests; American Thyroid Association: Thyroiditis
Question 34 of 60
A 61-year-old man woke with a hot, red, extremely painful, swollen right big toe after a night of heavy beer drinking. He has no fever. Fluid is drawn from the first metatarsophalangeal joint. Which finding confirms the most likely diagnosis?
Answer and explanation
Answer: D. Needle-shaped, negatively birefringent crystals
Finding monosodium urate crystals — needle-shaped and negatively birefringent under polarized light — in joint fluid is the gold standard for diagnosing gout. A describes calcium pyrophosphate crystals (pseudogout). B points to septic arthritis, which can occur alongside gout and must be ruled out when suspected. C supports gout but doesn't confirm it, and urate can be normal during a flare. E raises concern for infection rather than confirming crystal disease.
Review takeaway: Gout is confirmed by urate crystals in joint fluid, not by a serum uric acid level.
Musculoskeletal System · Using Diagnostic and Laboratory Studies · Sources: Neogi T, et al. 2015 Gout Classification Criteria: An ACR/EULAR Collaborative Initiative; Cohen-Rosenblum AR, et al. Orthopaedic Management of Gout. JAAOS Global Research & Reviews. 2022
Question 35 of 60
A 45-year-old man with an upper gastrointestinal bleed has a hemoglobin of 6.2 g/dL. He is alert and oriented, explains his condition, understands that he could die without a transfusion, and consistently refuses blood products for religious reasons. His wife, who doesn't share his beliefs, asks the team to transfuse him. Which of the following is the most appropriate action?
Answer and explanation
Answer: B. Respect the informed refusal
An adult who understands his condition, grasps the consequences of each option, and decides voluntarily can decline treatment, including life-saving treatment. Document his capacity and the discussion, and keep providing every acceptable form of care, such as endoscopic control of the bleeding and volume support. A and C override a capable patient's informed decision. D is wrong because a surrogate decides only when the patient can't. E doesn't respect his decision and delays care.
Review takeaway: A capable adult's informed refusal stands; surrogates step in only when capacity is missing.
Professional Practice · Sources: AMA Code of Medical Ethics, Opinion 2.1.1: Informed Consent; AMA Code of Medical Ethics, Opinion 5.3: Withholding or Withdrawing Life-Sustaining Treatment
Question 36 of 60
A 68-year-old man with no symptoms smoked 20 pack-years and quit 10 years ago. He asks which screening tests he needs. Which of the following is recommended for abdominal aortic aneurysm?
Answer and explanation
Answer: E. One-time abdominal ultrasonography
USPSTF recommends one-time ultrasound screening for abdominal aortic aneurysm in men 65 to 75 who have ever smoked, defined as 100 or more cigarettes in a lifetime. A is wrong because past smoking counts. B isn't recommended after a normal screen. C can detect an aneurysm but is not recommended for routine screening because of radiation exposure. D misses many aneurysms.
Review takeaway: Men 65–75 who ever smoked: one abdominal aortic ultrasound.
Cardiovascular System · Health Maintenance, Patient Education, and Preventive Measures · Source: USPSTF, Abdominal Aortic Aneurysm: Screening (December 10, 2019)
Question 37 of 60
A 29-year-old woman went hiking in Connecticut in July. Eight days later she noticed fatigue, a low-grade fever, and an expanding red patch on the back of her thigh, now 9 cm across with partial clearing in the center. It isn't painful. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: B. Erythema migrans
An expanding red rash appearing days to weeks after time outdoors in an area where Lyme disease is common is erythema migrans. Treat promptly based on the clinical picture — blood tests are often negative this early — with doxycycline as one recommended option. A is typically warm and tender rather than a painless expanding ring. C has a scaly, raised border and grows slowly. D produces many target-shaped lesions, usually after a herpes infection or a drug. E classically causes fever and a spotty rash that starts at the wrists and ankles.
Review takeaway: Erythema migrans is a clinical diagnosis; don't wait for serology to treat.
Infectious Diseases · Formulating the Most Likely Diagnosis · Sources: CDC: Clinical Treatment of Erythema Migrans Rash; CDC: Lyme Disease Rashes; CDC: Clinical Signs and Symptoms of Rocky Mountain Spotted Fever
Question 38 of 60
A 20-month-old had a 2-minute generalized tonic-clonic seizure at the start of a fever of 39.4 °C (103 °F) from a viral upper respiratory infection. One hour later she is alert, playful, and back to normal, with a normal neurologic exam and no signs of meningitis. Her immunizations are up to date. She has no prior afebrile seizures, no other seizures in the past 24 hours, and has not received antibiotics. Which of the following is the most appropriate next step?
Answer and explanation
Answer: E. Reassure and educate
This is a simple febrile seizure: generalized, under 15 minutes, not repeated within 24 hours, in a neurologically normal child 6–60 months old. Routine lumbar puncture, EEG, and brain imaging aren't indicated, and daily seizure medication isn't recommended. A is indicated when meningitis is suspected; incomplete Hib or pneumococcal immunization is an additional reason to consider it in infants 6–12 months old, and recent antibiotic treatment may also affect the decision. B and C don't change management after a simple febrile seizure. D carries side effects that outweigh its benefits. Fever medicine helps comfort but doesn't prevent another febrile seizure — worth telling the parents.
Review takeaway: Simple febrile seizure in a well, fully immunized child: no routine LP, EEG, imaging, or daily medication.
Neurologic System · Health Maintenance, Patient Education, and Preventive Measures · Pediatric · Sources: AAP Subcommittee on Febrile Seizures. Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure (PDF); American Academy of Pediatrics HealthyChildren: Febrile Seizures in Children
Question 39 of 60
A 31-year-old woman, pregnant for the second time, is at 11 weeks' gestation. Her previous pregnancy was complicated by preeclampsia. Blood pressure today is 116/72 mm Hg, and she has no contraindication to aspirin. Which of the following is the most appropriate recommendation?
Answer and explanation
Answer: C. Low-dose aspirin after 12 weeks
USPSTF recommends low-dose aspirin (81 mg/day) after 12 weeks of gestation for people at high risk of preeclampsia, and a history of preeclampsia puts her in that group. A treats high blood pressure she doesn't have. B has no established preventive benefit here and carries risks. D prevents seizures in established severe preeclampsia; it isn't early prevention. E unnecessarily delays preventive treatment; aspirin should be planned now to start after 12 weeks.
Review takeaway: High preeclampsia risk: aspirin 81 mg daily starting after 12 weeks.
Reproductive System · Health Maintenance, Patient Education, and Preventive Measures · Sources: USPSTF, Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality (September 28, 2021); SMFM Consult Series #50: The role of activity restriction in obstetric management
Question 40 of 60
A 72-year-old man had 3 days of burning pain over his right forehead, followed by a band of grouped blisters on a red base running from the right forehead into the scalp. Which additional finding most strongly predicts eye involvement and calls for urgent ophthalmology evaluation?
Answer and explanation
Answer: A. Blisters on the tip or side of the nose (Hutchinson sign)
Blisters on the tip or side of the nose mean the nasociliary branch of the ophthalmic nerve is involved — the same branch that supplies the eye — so eye complications are much more likely. Eye involvement can also occur without Hutchinson sign. B is the usual shingles prodrome and doesn't localize. C raises the overall risk of shingles complications but doesn't specifically predict eye involvement. D is expected, because shingles follows one dermatome. E is nonspecific.
Review takeaway: Hutchinson sign (nose-tip lesions) in forehead shingles means get ophthalmology involved.
Dermatologic System · History Taking and Performing Physical Examination · Sources: Shaikh S, Ta CN. Evaluation and Management of Herpes Zoster Ophthalmicus. Am Fam Physician. 2002; Mihalache A, et al. Hutchinson’s Sign in Herpes Zoster Ophthalmicus: A Systematic Review and Meta-Analysis. Ophthalmology. 2026
Question 41 of 60
A 27-year-old woman has 8 months of bloating, loose stools, and fatigue. She has iron deficiency anemia and eats a regular diet that includes wheat. Which of the following is the most appropriate first test for the condition you suspect?
Answer and explanation
Answer: D. tTG-IgA plus total IgA
For suspected celiac disease in someone eating gluten, tTG-IgA is the preferred first test. Total IgA is checked because IgA deficiency, which is more common in celiac disease, can cause a false-negative result. A positive test leads to duodenal biopsy. A is good at ruling celiac out but can't confirm it. B looks for infection, not long-term malabsorption with anemia. C doesn't provide the serologic or biopsy evidence needed for diagnosis. E before testing can make blood tests and biopsy falsely negative.
Review takeaway: Test for celiac with tTG-IgA plus total IgA while the patient is still eating gluten.
Gastrointestinal System/Nutrition · Using Diagnostic and Laboratory Studies · Source: NIDDK, Celiac Disease Tests
Question 42 of 60
During a clinic visit, a 34-year-old man with major depressive disorder says he plans to shoot himself tonight. He has a handgun at home. He stands up and says he wants to leave. Which of the following is the most appropriate action?
Answer and explanation
Answer: C. Keep him safe and arrange emergency evaluation
A specific plan, intent with a timeline, and access to a lethal method mean imminent risk. He needs continuous observation and an emergency psychiatric evaluation now; safety planning and counseling about access to the gun follow. A, B, and E are outpatient steps that leave him unprotected tonight. D isn't an effective safety measure and doesn't replace assessment.
Review takeaway: Plan plus intent plus means is imminent risk: stay with the patient and get emergency evaluation.
Psychiatry/Behavioral Science · Clinical Intervention · Source: NIMH, Adult Outpatient Brief Suicide Safety Assessment Guide
Question 43 of 60
A 2-year-old has had a runny nose for 2 days and tonight developed a barking cough and a hoarse voice. She has a high-pitched noise on breathing in only when crying, none at rest, and no retractions. Oxygen saturation is 98% on room air. Which of the following is the most appropriate treatment?
Answer and explanation
Answer: B. A single oral dose of dexamethasone
A barking cough and stridor after a few days of cold symptoms is croup. Even mild croup benefits from one dose of a corticosteroid such as oral dexamethasone, which eases symptoms and reduces return visits. A treats wheezing from narrowed lower airways, not upper-airway swelling. C isn't indicated for this viral illness. D adds treatment this mild presentation doesn't need. Nebulized epinephrine is used for moderate to severe croup, followed by observation; admission depends on the response. E isn't needed when the diagnosis is clear clinically.
Review takeaway: Croup of any severity: a single dose of a corticosteroid.
Pulmonary System · Pharmaceutical Therapeutics · Pediatric · Source: Canadian Paediatric Society, Acute management of croup in the emergency department
Question 44 of 60
A 17-year-old basketball player has had chest discomfort and near-fainting during sprints. His father died suddenly at age 38. A harsh crescendo–decrescendo systolic murmur is heard at the left lower sternal border without spread to the carotids. Which bedside finding would most support the suspected diagnosis?
Answer and explanation
Answer: E. Louder on standing from a squat
Exertional symptoms and a family history of sudden death suggest hypertrophic cardiomyopathy (HCM) with outflow obstruction. Maneuvers that reduce the blood returning to the heart — standing up, the strain phase of Valsalva — narrow the outflow tract and make the murmur louder, unlike most other murmurs. A and B describe the opposite of HCM's behavior (squatting increases filling and softens the murmur). C suggests mitral stenosis. D suggests an atrial septal defect. Next steps include an ECG and echocardiogram, with competitive play on hold until he's evaluated.
Review takeaway: HCM murmur gets louder with less preload (standing, Valsalva) and softer with squatting.
Cardiovascular System · History Taking and Performing Physical Examination · Pediatric · Sources: Lembo NJ, et al. Bedside diagnosis of systolic murmurs. N Engl J Med. 1988; American College of Cardiology, 2024 HCM guideline key points; AHA/ACC, Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities. 2025
Question 45 of 60
A 64-year-old man has a weak urinary stream, hesitancy, and gets up three times a night to urinate; his symptoms are moderately bothersome. Digital rectal exam shows a smooth, symmetric, enlarged prostate without nodules. Urinalysis is normal, and his PSA is in the expected range for his age. Post-void residual is 60 mL. He wants the fastest relief possible. Which of the following is the most appropriate initial therapy?
Answer and explanation
Answer: A. Tamsulosin
Alpha-1 blockers relax smooth muscle in the prostate and bladder neck and improve symptoms within days to weeks, so they're first-line for bothersome urinary symptoms from benign prostatic hyperplasia (BPH). Counsel him about dizziness on standing and a complication during cataract surgery (intraoperative floppy iris syndrome). B shrinks the prostate but takes months to help. C treats an overactive bladder and isn't first-line alone for obstructive symptoms. D is not required before trying medication in this uncomplicated presentation. E treats bacterial prostatitis, which his normal urinalysis doesn't support.
Review takeaway: BPH needing quick relief: an alpha-1 blocker; 5-alpha reductase inhibitors work slowly.
Genitourinary System · Pharmaceutical Therapeutics · Sources: NIDDK, Enlarged Prostate (Benign Prostatic Hyperplasia); Tamsulosin hydrochloride prescribing information, DailyMed; Finasteride tablets prescribing information, DailyMed
Question 46 of 60
A 4-month-old with sickle cell anemia (HbSS) found on newborn screening is well today. Her routine immunizations are up to date. Which of the following is the most important preventive measure to start now?
Answer and explanation
Answer: D. Oral penicillin prophylaxis
Children with HbSS lose spleen function early and are at high risk of overwhelming pneumococcal infection. Twice-daily oral penicillin from diagnosis until at least age 5, together with pneumococcal vaccines, sharply lowers that risk. A is reserved for specific situations such as stroke prevention. B risks iron overload without iron deficiency. C isn't routine prevention. E doesn't prevent infection.
Review takeaway: Infants with sickle cell anemia: penicillin prophylaxis until at least 5, plus vaccines.
Hematologic System · Health Maintenance, Patient Education, and Preventive Measures · Pediatric · Sources: NHLBI, Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014—Guide to Recommendations (PDF); NHLBI, Sickle Cell Disease: Treatment
Question 47 of 60
A 22-year-old has had a sore throat for 5 days that keeps getting worse. He now has a fever, a muffled "hot potato" voice, trouble opening his mouth, and is drooling. The right tonsil area bulges, and the uvula is pushed to the left. He's breathing comfortably. Which of the following is the most appropriate management?
Answer and explanation
Answer: C. Drainage plus antibiotics
Trouble opening the mouth, a muffled voice, bulging beside one tonsil, and a pushed-over uvula indicate a peritonsillar abscess. Drainage (needle aspiration or incision and drainage) plus antibiotics against streptococci and mouth anaerobes is standard. A doesn't drain the abscess. B misses a collection that needs drainage, although mono can occur alongside it. D is reserved for selected cases, such as repeated abscesses. E delays treatment; CT is used if a deeper neck infection is suspected.
Review takeaway: Peritonsillar abscess with trismus, drooling, or a muffled voice needs drainage plus antibiotics.
Eyes, Ears, Nose, and Throat · Clinical Intervention · Surgical topic · Sources: University of Iowa, Peritonsillar Abscess (PTA) Management; Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2017
Question 48 of 60
A 7-year-old boy has puffy eyes in the morning and cola-colored urine. About 10 days ago he had a sore throat. Blood pressure is 138/88 mm Hg. Urinalysis shows red cell casts and 1+ protein. C3 is low, and anti-streptococcal antibody levels are elevated. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: B. Poststreptococcal glomerulonephritis
Swelling around the eyes, dark urine with red cell casts, and high blood pressure about 10 days after strep throat, with low C3 and evidence of strep infection, fit poststreptococcal glomerulonephritis. Treatment addresses hypertension and edema; antibiotics eradicate any remaining group A strep. A usually causes heavy protein loss and low serum albumin, rather than this nephritic pattern with red cell casts. C typically causes blood in the urine during or soon after a respiratory infection, with serum C3 usually normal. D classically follows a diarrheal illness and includes hemolytic anemia and low platelets. E is inherited, often with hearing loss.
Review takeaway: Nephritis about 10 days after strep throat with low C3 suggests PSGN; blood in the urine during or soon after infection with normal C3 suggests IgA nephropathy.
Renal System · Formulating the Most Likely Diagnosis · Pediatric · Sources: CDC, Clinical Guidelines for Post-Streptococcal Glomerulonephritis; NIDDK, Nephrotic Syndrome in Children; National Kidney Foundation, IgA Nephropathy; MedlinePlus Genetics, Alport syndrome; KDIGO 2025 Clinical Practice Guideline for IgA Nephropathy and IgA Vasculitis (PDF); CDC, E. coli Infection: Information for Clinicians
Question 49 of 60
A 41-year-old woman has fatigue, weight loss, salt craving, and darkening of her palm creases and inner cheeks. Sodium is 128 mEq/L and potassium 5.9 mEq/L. Morning cortisol is low and ACTH is markedly elevated. What is the mechanism of her darkened skin?
Answer and explanation
Answer: A. High ACTH acting on melanocortin receptors
In primary adrenal insufficiency, low cortisol removes the brake on the pituitary, which overproduces proopiomelanocortin (POMC). Its products, ACTH and melanocyte-stimulating hormone, activate melanocortin-1 receptors and increase melanin. Low aldosterone explains the low sodium and high potassium. B is wrong because aldosterone is low. C is wrong because cortisol is low. D describes hemochromatosis. E plays no role here.
Review takeaway: Primary adrenal insufficiency darkens skin because ACTH is high; central causes don't.
Endocrine System · Applying Foundational Scientific Concepts · Sources: Bornstein SR, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: Endocrine Society Clinical Practice Guideline; Wakamatsu K, et al. Characterisation of ACTH peptides in human skin and their activation of the melanocortin-1 receptor. Pigment Cell Res. 1997
Question 50 of 60
A 24-year-old fell on an outstretched hand while snowboarding and has pain on the thumb side of the wrist. The first wrist X-rays are read as normal. Which exam finding most suggests a fracture that early X-rays can miss?
Answer and explanation
Answer: E. Anatomic snuffbox tenderness
Snuffbox tenderness after a fall on an outstretched hand suggests a scaphoid fracture, which often doesn't show on the first X-rays and can fail to heal because of its fragile blood supply. Immobilize in a thumb spica splint and get follow-up imaging, such as MRI. A points to the end of the ulna. B tests de Quervain tenosynovitis. C (Tinel sign) suggests median nerve compression. D suggests a hamate fracture, usually from gripping a club or bat.
Review takeaway: Snuffbox tenderness with normal X-rays: treat as a scaphoid fracture until imaging says otherwise.
Musculoskeletal System · History Taking and Performing Physical Examination · Sources: American Academy of Orthopaedic Surgeons, Scaphoid Fracture of the Wrist; British Society for Surgery of the Hand, Scaphoid fractures: standards of care (PDF)
Question 51 of 60
A 70-year-old woman developed six watery stools a day 4 days after finishing amoxicillin–clavulanate. Her white cell count is 11,000/µL and creatinine is at her baseline of 1.0 mg/dL. Stool testing confirms toxin-producing Clostridioides difficile. This is her first episode, and she has no low blood pressure or ileus. Which of the following is the preferred treatment?
Answer and explanation
Answer: C. Oral fidaxomicin
For a first, non-fulminant episode, the 2021 IDSA/SHEA update prefers oral fidaxomicin, with oral vancomycin as an acceptable alternative, because of lower recurrence. A doesn't deliver adequate vancomycin to the colonic lumen; this patient needs an oral drug. B is an alternative only for non-severe disease when neither preferred drug is available. D doesn't treat the infection and should not replace antibiotic therapy. E doesn't treat the infection.
Review takeaway: First non-fulminant C. difficile episode: oral fidaxomicin preferred; oral vancomycin is an acceptable alternative.
Infectious Diseases · Pharmaceutical Therapeutics · Sources: IDSA/SHEA, 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults; IDSA/SHEA, 2017 Clinical Practice Guidelines for Clostridium difficile Infection
Question 52 of 60
A 34-year-old man has had attacks of severe pain around his left eye nearly every night for 3 weeks. Each attack lasts about 45 minutes, and he paces the room during them. He had a similar 6-week stretch last year. Which accompanying finding is most expected during an attack?
Answer and explanation
Answer: B. Same-side tearing, nasal symptoms, droopy eyelid, small pupil
One-sided pain around the eye lasting 15–180 minutes, restlessness, nightly timing, and attacks in clusters define cluster headache, which comes with autonomic signs on the same side (tearing, nasal congestion or runny nose, eyelid droop, small pupil). Acute treatment is high-flow 100% oxygen or injectable sumatriptan. A describes tension-type headache. C fits migraine, where people prefer to lie still. D suggests giant cell arteritis in an older adult. E describes trigeminal neuralgia.
Review takeaway: One-sided eye pain with same-side tearing and restlessness means cluster headache.
Neurologic System · History Taking and Performing Physical Examination · Sources: International Classification of Headache Disorders, 3rd edition, 3.1 Cluster headache; May A, et al. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol. 2023
Question 53 of 60
A premature infant born at 28 weeks has bounding pulses, a wide pulse pressure, and a continuous "machinery" murmur below the left collarbone. Echocardiography confirms a hemodynamically significant patent ductus arteriosus, and the team chooses medical closure with indomethacin. How does this drug promote closure?
Answer and explanation
Answer: D. Cyclooxygenase inhibition
Circulating prostaglandin E₂ keeps the ductus open. Indomethacin and ibuprofen block cyclooxygenase, lowering prostaglandin levels so the ductus can constrict. A describes alprostadil (a PGE₁ drug), used to keep the ductus open when a newborn's circulation depends on it. B has no role in closing the ductus. C and E do not describe the prostaglandin-synthesis inhibition used here.
Review takeaway: Prostaglandins keep the ductus open; COX inhibitors help close it.
Cardiovascular System · Applying Foundational Scientific Concepts · Pediatric · Sources: Indomethacin for injection prescribing information, DailyMed; Indomethacin capsules prescribing information, DailyMed
Question 54 of 60
A PA realizes that a medication was prescribed at 10 times the intended dose. The patient took one dose, was monitored, and is now stable with no lasting effects. Which of the following is the most appropriate action?
Answer and explanation
Answer: B. Disclose promptly and report
Ethical standards call for telling patients promptly and honestly that an error occurred, explaining what it means and what's being done to prevent another one, and reporting through safety systems so others can learn — and concern about liability shouldn't change that honesty. A and C withhold information the patient has a right to. D shifts responsibility away from the prescriber. E delays disclosure; risk management can support the conversation but shouldn't replace it.
Review takeaway: Errors get disclosed to the patient and reported, even when no lasting harm occurred.
Professional Practice · Source: AMA Code of Medical Ethics, Opinion 8.6: Promoting Patient Safety
Question 55 of 60
A 46-year-old woman who is not pregnant has had right upper quadrant pain for 8 hours after a fatty meal. Temperature is 38.4 °C (101.1 °F), she stops breathing in when you press under the right ribs, and her white cell count is 14,200/µL. Bilirubin is normal. Which imaging study should be ordered first?
Answer and explanation
Answer: A. Right upper quadrant ultrasonography
For suspected acute cholecystitis, ultrasound is the recommended first imaging test: it's fast, uses no radiation, and shows gallstones, a thickened gallbladder wall, fluid around the gallbladder, and tenderness under the probe. B can help when initial imaging is nondiagnostic, but it is not the first test. C can help evaluate complications or alternative diagnoses when ultrasound is inconclusive. D looks at the bile ducts when a duct stone is suspected. E treats bile duct stones; it isn't a first diagnostic test when bilirubin is normal.
Review takeaway: Suspected cholecystitis: ultrasound first; further imaging depends on the findings and clinical suspicion.
Gastrointestinal System/Nutrition · Using Diagnostic and Laboratory Studies · Surgical topic · Sources: IDSA, 2024 Clinical Practice Guideline Update on Intra-abdominal Infections; World Society of Emergency Surgery, 2020 updated guidelines for acute calculus cholecystitis
Question 56 of 60
A 23-year-old woman has had about six menstrual periods a year since her periods began. She has coarse hair on her upper lip and chin and persistent acne. BMI is 31. Urine pregnancy test is negative; TSH, prolactin, and morning 17-hydroxyprogesterone are normal. Her symptoms began gradually in her teens. Which of the following is the most likely diagnosis?
Answer and explanation
Answer: C. Polycystic ovary syndrome
She has two of the diagnostic features — irregular ovulation and clinical signs of excess androgens — and the listed screening tests make common mimics less likely. Once other causes are excluded, these two features are enough to diagnose PCOS without an ultrasound. Screen her for glucose intolerance and abnormal lipids. A is less likely with a normal morning 17-hydroxyprogesterone. B would bring features such as purple stretch marks, weak upper arms and thighs, and easy bruising. D is ruled out by a normal prolactin. E usually causes rapid virilization (deepening voice, clitoral enlargement), not gradual symptoms since adolescence.
Review takeaway: PCOS is two of three features after excluding mimics; sudden virilization points elsewhere.
Reproductive System · Formulating the Most Likely Diagnosis · Sources: Teede HJ, et al. 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome; Endocrine Society, Hirsutism Guideline Resources
Question 57 of 60
A 66-year-old woman with osteoporosis (lumbar spine T-score −2.8) is starting alendronate 70 mg once a week. Which instruction is correct?
Answer and explanation
Answer: E. Empty stomach, plain water, upright at least 30 minutes and until after eating
Alendronate is poorly absorbed, and food, other drinks, and calcium cut absorption further; it can also irritate the esophagus if it lingers there. The label says to swallow it with 6–8 ounces of plain water at least 30 minutes before the first food, drink, or medicine of the day, and not to lie down for at least 30 minutes and until after eating. A, B, and D reduce absorption. C raises the risk of esophageal injury.
Review takeaway: Oral alendronate: plain water, empty stomach, upright for at least 30 minutes and until after the first food of the day.
Musculoskeletal System · Health Maintenance, Patient Education, and Preventive Measures · Source: FOSAMAX (alendronate sodium) prescribing information, FDA label, revised 2/2026 (PDF) — section 2.6
Question 58 of 60
A 29-year-old adult with attention-deficit/hyperactivity disorder is starting methylphenidate. Which of the following best describes how it works?
Answer and explanation
Answer: A. Blocks dopamine and norepinephrine reuptake
Methylphenidate blocks the dopamine and norepinephrine transporters, leaving more of these neurotransmitters in the synapse. B describes SSRIs. C describes guanfacine and clonidine, nonstimulant ADHD options. D describes MAO inhibitors, which are dangerous with stimulants. E describes benzodiazepines.
Review takeaway: Methylphenidate blocks dopamine and norepinephrine reuptake; guanfacine is an alpha-2A agonist.
Psychiatry/Behavioral Science · Applying Foundational Scientific Concepts · Source: RITALIN (methylphenidate hydrochloride) prescribing information, DailyMed
Question 59 of 60
A 26-year-old with asthma uses only an albuterol inhaler. She has symptoms about 3 days a week and wakes at night coughing twice a month. Her FEV₁ is 85% of predicted. According to GINA's preferred treatment track for adults and adolescents, which change is most appropriate?
Answer and explanation
Answer: B. As-needed low-dose budesonide–formoterol
GINA recommends against treating adults and teens with a short-acting reliever alone because of exacerbation risk. Its preferred approach for mild asthma is low-dose inhaled corticosteroid–formoterol taken as needed, which cuts severe flare-ups compared with albuterol alone. A leaves her without anti-inflammatory treatment. C is less effective than inhaled corticosteroid–containing treatment. D is unsafe — a long-acting beta-agonist without an inhaled corticosteroid raises the risk of severe asthma events. E exposes her to repeated steroid side effects. This as-needed reliever use is off-label in the United States; U.S. budesonide–formoterol labeling specifies maintenance treatment, not relief of acute bronchospasm.
Review takeaway: No albuterol-only asthma treatment; as-needed ICS–formoterol is GINA's preferred mild-asthma reliever.
Pulmonary System · Pharmaceutical Therapeutics · Sources: Global Initiative for Asthma, 2026 Summary Guide for Asthma Management and Prevention (PDF); SYMBICORT (budesonide and formoterol fumarate dihydrate) prescribing information, DailyMed
Question 60 of 60
A 50-year-old says his left ear has felt "plugged" with muffled hearing for 2 weeks. On tuning-fork testing, the Weber test sound is louder in the left ear. On the left, bone conduction is louder than air conduction (negative Rinne); on the right, air conduction is louder than bone conduction. Which of the following is the most likely interpretation?
Answer and explanation
Answer: C. Left conductive hearing loss
In conductive hearing loss, the Weber test lateralizes toward the affected ear and the Rinne test is negative on that side (bone louder than air). Both point to the left. Look for earwax, middle-ear fluid, or another cause of conductive loss. A would send the Weber sound to the right, with a positive Rinne on the left. B and D don't match the left-sided findings. E would give a midline Weber and positive Rinne in both ears.
Review takeaway: Weber toward the bad ear plus negative Rinne there means conductive loss.
Eyes, Ears, Nose, and Throat · History Taking and Performing Physical Examination · Source: University of Iowa, Physical Examination of the Head and Neck
Score your practice block
Check each answer against the key below and count your correct answers out of 60. Count a question you skipped, or whose explanation you read before answering, as not correct. Your percentage is correct ÷ 60 × 100 — for example, 42 correct is 70% on this set.
That number describes your work on these 60 questions. It isn't a PANCE scaled score, and no conversion turns it into one. Several organ systems have only two to five questions here, so treat a low system score as a reason to review that system, not a measure of your ability in it.
Answer key
| Question | Answer | Content category | Task |
|---|---|---|---|
| 1 | B | Cardiovascular | Most likely diagnosis |
| 2 | E | Pulmonary | Clinical intervention |
| 3 | C | Endocrine | Pharmaceutical therapeutics |
| 4 | D | GI/Nutrition | Most likely diagnosis |
| 5 | A | Professional Practice | Professional practice |
| 6 | E | Musculoskeletal | History and physical |
| 7 | C | Infectious Diseases | Pharmaceutical therapeutics |
| 8 | D | Neurologic | Most likely diagnosis |
| 9 | E | Hematologic | Diagnostic and lab studies |
| 10 | D | Reproductive | Pharmaceutical therapeutics |
| 11 | B | Psychiatry/Behavioral | Most likely diagnosis |
| 12 | A | Renal | Clinical intervention |
| 13 | E | Cardiovascular | Pharmaceutical therapeutics |
| 14 | A | EENT | Most likely diagnosis |
| 15 | D | GI/Nutrition | Health maintenance |
| 16 | D | Dermatologic | Most likely diagnosis |
| 17 | C | Endocrine | Clinical intervention |
| 18 | D | Genitourinary | Clinical intervention |
| 19 | B | Pulmonary | Diagnostic and lab studies |
| 20 | C | Professional Practice | Professional practice |
| 21 | E | Musculoskeletal | History and physical |
| 22 | B | Cardiovascular | Diagnostic and lab studies |
| 23 | A | Neurologic | Clinical intervention |
| 24 | D | Infectious Diseases | Health maintenance |
| 25 | A | Renal | Scientific concepts |
| 26 | E | GI/Nutrition | Pharmaceutical therapeutics |
| 27 | B | Reproductive | Clinical intervention |
| 28 | A | Psychiatry/Behavioral | Pharmaceutical therapeutics |
| 29 | D | Cardiovascular | Clinical intervention |
| 30 | C | EENT | History and physical |
| 31 | A | Hematologic | Clinical intervention |
| 32 | E | Pulmonary | Most likely diagnosis |
| 33 | C | Endocrine | Most likely diagnosis |
| 34 | D | Musculoskeletal | Diagnostic and lab studies |
| 35 | B | Professional Practice | Professional practice |
| 36 | E | Cardiovascular | Health maintenance |
| 37 | B | Infectious Diseases | Most likely diagnosis |
| 38 | E | Neurologic | Health maintenance |
| 39 | C | Reproductive | Health maintenance |
| 40 | A | Dermatologic | History and physical |
| 41 | D | GI/Nutrition | Diagnostic and lab studies |
| 42 | C | Psychiatry/Behavioral | Clinical intervention |
| 43 | B | Pulmonary | Pharmaceutical therapeutics |
| 44 | E | Cardiovascular | History and physical |
| 45 | A | Genitourinary | Pharmaceutical therapeutics |
| 46 | D | Hematologic | Health maintenance |
| 47 | C | EENT | Clinical intervention |
| 48 | B | Renal | Most likely diagnosis |
| 49 | A | Endocrine | Scientific concepts |
| 50 | E | Musculoskeletal | History and physical |
| 51 | C | Infectious Diseases | Pharmaceutical therapeutics |
| 52 | B | Neurologic | History and physical |
| 53 | D | Cardiovascular | Scientific concepts |
| 54 | B | Professional Practice | Professional practice |
| 55 | A | GI/Nutrition | Diagnostic and lab studies |
| 56 | C | Reproductive | Most likely diagnosis |
| 57 | E | Musculoskeletal | Health maintenance |
| 58 | A | Psychiatry/Behavioral | Scientific concepts |
| 59 | B | Pulmonary | Pharmaceutical therapeutics |
| 60 | C | EENT | History and physical |
Turn a missed question into a study target
A miss is most useful when you can say exactly which clue you overlooked. For each one:
- Find the deciding clue. Reread the stem and name the one fact that settles the answer.
- Name why your choice lost. Say in a sentence why the option you picked doesn't fit this patient.
- Write the rule. Copy the review takeaway, then check it against the linked source.
Worked example — Question 22. Say you picked D-dimer. The deciding clue was the Wells score of 4, which makes DVT likely. A normal D-dimer can't safely end the workup at that probability, so ultrasound is the first test. The rule: high pretest probability for DVT means ultrasound first. That's one sentence you can test yourself on tomorrow.
What this practice test covers
We spread the 60 questions across content categories in proportion to NCCPA's PANCE Content Blueprint, effective January 2025 for all PANCE administrations. To do that, we multiplied each official percentage by 60 and rounded so the total stays at 60. These counts are our allocation for one practice block, not an NCCPA rule for any exam form.
| NCCPA content category | Official blueprint weight | Questions in this set |
|---|---|---|
| Cardiovascular System | 11% | 7 |
| Pulmonary System | 9% | 5 |
| Gastrointestinal System/Nutrition | 8% | 5 |
| Musculoskeletal System | 8% | 5 |
| Infectious Diseases | 7% | 4 |
| Neurologic System | 7% | 4 |
| Psychiatry/Behavioral Science | 7% | 4 |
| Reproductive System | 7% | 4 |
| Endocrine System | 6% | 4 |
| Eyes, Ears, Nose, and Throat | 6% | 4 |
| Professional Practice | 6% | 4 |
| Hematologic System | 5% | 3 |
| Renal System | 5% | 3 |
| Dermatologic System | 4% | 2 |
| Genitourinary System | 4% | 2 |
| Total | 100% | 60 |
Every question except the four Professional Practice items also tests one blueprint task. In this set: Formulating the Most Likely Diagnosis 11, History Taking and Performing Physical Examination 8, Using Diagnostic and Laboratory Studies 6, Health Maintenance, Patient Education, and Preventive Measures 7, Clinical Intervention 10, Pharmaceutical Therapeutics 10, and Applying Foundational Scientific Concepts 4. Ten questions involve children or adolescents, and eight are tagged for surgical topics. These task and topic counts are our editorial mix for this practice block; they do not reproduce every official percentage. NCCPA lists 12–15% pediatric and 8–10% surgical content for the exam and notes that its percentages may vary slightly from exam to exam.
Sixty questions can't touch every disease on the blueprint, which runs 21 pages. Read the official PANCE Content Blueprint (PDF) to see the full topic list for each system.
How this compares with the real PANCE
| Feature | Official PANCE |
|---|---|
| Questions | 300 multiple-choice questions |
| Structure | Five blocks of 60 questions, 60 minutes per block |
| Breaks and tutorial | 45 minutes of total break time; 15-minute tutorial |
| Inside a block | Answer in any order and change answers until you leave the block or time runs out |
| Question style | No true/false, "all of the above," or "none of the above" questions |
| Scoring | Scaled from 200 to 800; the passing standard is 350 |
| Results | About two weeks after the exam |
These 60 questions match one block's length and pace, not the full five hours of question time. NCCPA scales scores so that small differences in difficulty between exam forms don't advantage anyone, which means the number of correct answers needed to pass varies from one form to another. There's no fixed raw passing percentage — and no reliable way to turn this set's practice percentage into a predicted PANCE score.
Format, blueprint, scoring, and result timing last verified November 5, 2026, against NCCPA's test-day instructions, Exam Development & Scoring page, PANCE Content Blueprint (PDF), Becoming Certified FAQs, and PANCE at a Glance presentation (PDF). For application steps and fees, see NCCPA's Become Certified page.
Official practice resources from NCCPA and Pearson VUE
- Sample questions (free). NCCPA's PANCE sample questions (PDF) are a 13-question PDF; most use five answer choices.
- Exam software tutorial (free). Pearson VUE's NCCPA page links a tutorial that lets you practice moving through the exam, changing answers, flagging questions, and opening the lab values table.
Sources and independence
Each question lists the guideline or reference behind its answer. Official exam facts come from these NCCPA sources:
- PANCE Content Blueprint, effective January 2025 (PDF) — p. 1 weights and notes; pp. 2–21 topic and task lists
- What to Expect on Test Day — exam blocks and exam length
- Exam Development & Scoring — scale and passing standard
- PANCE at a Glance presentation (2025) (PDF) — exam tips
- Becoming Certified FAQs — “When will I receive my score?”
Clinical and professional-practice sources last checked November 5, 2026.
By the Castleport Test Prep Editorial Team. These questions were developed with AI assistance. We wrote every question for this page and checked each answer against the cited guideline or reference; the questions have not been reviewed by a practicing PA or physician. How we check questions and sources. Spot an error? Report it.
Castleport Test Prep is an independent exam prep publisher. It is not affiliated with, endorsed by, or approved by the National Commission on Certification of Physician Assistants (NCCPA). PANCE and other exam and credential names identify the subjects discussed; trademarks belong to their respective owners. These are original, unofficial practice questions, not NCCPA exam items, and practice results don't predict exam scores or guarantee passing, certification, or licensure.