PANCE Exam Prep: Study Guide, 6-Week Plan, and Practice Questions
Start your PANCE exam prep with one clinical case right now, then use the priority map and six-week plan to decide what comes next. This free, no-signup guide covers the Physician Assistant National Certifying Examination (PANCE) for initial U.S. PA certification and follows NCCPA's PANCE content blueprint effective January 2025 (PDF).
Castleport Test Prep Editorial Team · Exam facts last verified November 5, 2026
Start your first study session
| Do this now | What you'll have when you're done |
|---|---|
| Answer Question 1 below before opening the explanation. | Your answer, plus one sentence on why you chose it |
| Name the task the question asks for: diagnosis, test, treatment, prevention, or a professional decision. | The decision the question actually wants |
| Compare your reasoning with the explanation and write down one correction. | A specific point to revisit, or a reason your answer was sound |
Question 1: try this case now
A 28-year-old man has had sharp, retrosternal chest pain for 2 days. It gets worse when he lies flat or breathes in, and it eases when he sits up and leans forward. He had a cold last week. Temperature is 37.6 °C (99.7 °F), blood pressure 124/78 mm Hg, and heart rate 96/min. With the patient leaning forward, a scratchy sound is heard at the left sternal border. ECG shows concave-upward ST-segment elevation in leads I, II, aVL, aVF, and V2–V6, with PR-segment depression and no reciprocal ST depression. Which of the following is the most likely diagnosis?
Show answer and explanation
Answer: C. Acute pericarditis
The positional, pleuritic chest pain, pericardial friction rub, and widespread ST elevation with PR depression point to acute pericarditis. The 2025 ACC guidance uses a suggestive presentation plus at least one supporting clinical, ECG, inflammatory-marker, or imaging finding. The cold last week fits a possible viral trigger, but doesn't establish the cause.
Why the other choices are wrong:
- A. Inferior STEMI typically causes regional ST elevation in the inferior leads, often with reciprocal ST depression. This patient's widespread changes, positional pain, and friction rub favor pericarditis; pain position or ECG shape alone doesn't exclude myocardial infarction.
- B. Pulmonary embolism can cause pleuritic pain, but the combined positional pain, pericardial rub, and widespread ST elevation with PR depression favor pericarditis.
- D. Aortic dissection classically causes abrupt, severe pain that radiates to the back. This patient's two-day positional, pleuritic pain with a rub fits pericarditis better.
- E. Early repolarization can cause concave ST elevation, but it doesn't explain the inflammatory chest-pain syndrome and pericardial rub.
Sources: ACC: 2025 pericarditis clinical guidance, diagnostic criteria and evaluation; Snyder MJ, Bepko J, White M. Acute Pericarditis: Diagnosis and Management. Am Fam Physician. 2014;89(7):553-560
Same patient, seven different questions
Question 1 asked for a diagnosis. On the PANCE, every medical question is also coded to a clinical task, and the same disease can show up as any of them. Here's the pericarditis case asked seven ways. Cover the right column and answer each one first.
| Task | How it might be asked | What you need to know |
|---|---|---|
| History and physical exam | Which maneuver best brings out the rub? | Have the patient lean forward (or rest elbows on knees) and listen with firm diaphragm pressure while they hold their breath. A pericardial rub can remain audible while the patient holds their breath. |
| Diagnostic studies | Which study should every patient with suspected acute pericarditis get? | Transthoracic echocardiography, to look for an effusion or tamponade. Baseline workup also includes CBC, a metabolic panel, troponin, ESR/CRP, and a chest radiograph. |
| Most likely diagnosis | (Question 1) | The 2025 ACC guidance uses a suggestive presentation plus at least one supporting finding: a rub, ECG changes, elevated inflammatory markers, or imaging evidence of pericardial inflammation or effusion. |
| Clinical intervention | Who should be admitted instead of treated at home? | Major warning signs: fever above 38 °C (100.4 °F), gradual (subacute) onset, signs of tamponade, a large effusion over 20 mm, or no response to nonsteroidal anti-inflammatory drugs (NSAIDs) after 7 days. Minor ones: immunosuppression, oral anticoagulation, trauma, and associated myocarditis. |
| Pharmaceutical therapeutics | First-line treatment? What should you avoid? | An NSAID plus colchicine (weight-based, for about 3 months), which cuts recurrence. Avoid routine first-line glucocorticoids unless there is a specific indication; they can raise recurrence risk. Be careful with colchicine alongside macrolides or reduced kidney function. |
| Health maintenance and education | What do you tell him about exercise? | Avoid strenuous activity during active disease; return to exercise should follow clinical reassessment and remission, with timing individualized. Gastroprotection with a proton pump inhibitor is recommended with aspirin/NSAID treatment. |
| Foundational science | Why does leaning forward help? Why is troponin sometimes elevated? | Sitting forward reduces pressure on the parietal pericardium. An elevated troponin indicates myocardial injury and should prompt assessment for accompanying myocarditis; it should not be dismissed as inflammation of the pericardium alone. |
Sources: ACC 2025 pericarditis guidance: diagnosis, imaging, and first-line treatment; ESC 2025 guideline slide set, pages 27, 48, 51–52, 61, and 78: risk, treatment, and exercise; ACC 2024 myocarditis guidance: diagnostic evaluation; AFP 2014 review: auscultation, positional pain, and colchicine precautions.
Use this on every topic you review. For each high-yield condition, write one line per task: what you'd hear, what you'd find, what you'd order, what it is, what you'd do, what you'd prescribe (and avoid), what you'd teach, and why it happens. A blank line is a question you'd probably miss.
Your PANCE priority map
The blueprint groups questions by content category. The table shows NCCPA's percentages and how many focused content days each area gets in the six-week plan below.
| Content category | Blueprint weight | Days in the 6-week plan |
|---|---|---|
| Cardiovascular System | 11% | 3 |
| Pulmonary System | 9% | 3 |
| Gastrointestinal System/Nutrition | 8% | 2 |
| Musculoskeletal System | 8% | 2 |
| Infectious Diseases | 7% | 2 |
| Neurologic System | 7% | 2 |
| Psychiatry/Behavioral Science | 7% | 2 |
| Reproductive System | 7% | 2 |
| Endocrine System | 6% | 2 |
| Eyes, Ears, Nose, and Throat | 6% | 2 |
| Professional Practice | 6% | 2 |
| Hematologic System | 5% | 1 |
| Renal System | 5% | 1 |
| Dermatologic System | 4% | 1 |
| Genitourinary System | 4% | 1 |
Weights: NCCPA PANCE Content Blueprint (PDF), page 1. NCCPA notes that allocations can vary slightly from one exam form to another. The 28 focused content days are our editorial allocation; the remaining grid days are for checkpoints, review, rehearsal, and rest.
The four biggest areas add up to 36% of the exam. Endocrine, Hematologic, Renal, Dermatologic, and Genitourinary together still total 24%. Keep lower-weighted systems in your review plan.
Where to start: If you already know your weak spots from end-of-rotation exams, practice questions, or your own notes, start there. If you don't, start with Cardiovascular and Pulmonary, the two biggest single categories. Either way, keep every category in the rotation.
The second half of the map: task categories
Every medical question is also coded to what you have to do with the knowledge. This is the part many study plans skip.
| Task category | Weight | What it sounds like in a question |
|---|---|---|
| Formulating the Most Likely Diagnosis | 18% | "Which of the following is the most likely diagnosis?" |
| History Taking and Performing Physical Examination | 16% | "Which finding is most likely on examination?" |
| Clinical Intervention | 16% | "Which is the most appropriate next step in management?" |
| Pharmaceutical Therapeutics | 15% | Choosing a drug, adverse effects, interactions |
| Health Maintenance, Patient Education, and Preventive Measures | 11% | Screening, vaccines, counseling |
| Using Diagnostic and Laboratory Studies | 10% | "Which study is most appropriate to confirm…?" |
| Applying Foundational Scientific Concepts | 8% | Mechanism, physiology, anatomy |
| Professional Practice | 6% | Consent, capacity, ethics, scope, billing, public health, patient safety |
These two tables describe the same exam content from two angles; the task table isn't extra questions. Professional Practice is the one category NCCPA doesn't also assign a task. Its blueprint section (pages 20–21) covers consent and refusal, advance directives, privacy, billing and coding, communication and social determinants of health, PA scope and mandated reporting, public health and outbreak response, and patient safety.
Pediatrics and surgery run through every system
NCCPA says 12% to 15% of questions focus on pediatric patients and 8% to 10% cover surgical topics. These aren't extra rows; a croup question is still a Pulmonary question. Whenever you review a system, ask two things: what does this look like in a child, and when does it become a surgical problem?
Studying from older notes
Older material is fine if you check it. Compare its headings against the current blueprint (PDF), and check anything that depends on a guideline (screening ages, vaccine rules, first-line drugs) against the organization that issues it. A familiar question or a recent copyright year doesn't prove a resource is current. A quick check: the current weights are 11% for Cardiovascular and 9% for Pulmonary; compare the whole resource against the current blueprint.
Your 6-week PANCE study plan
Assumptions: six study days a week with one rest day, built for the weeks after you finish your program. Content-review days use the study loop below; checkpoint and rehearsal days follow the timed work in the grid. On a full content-review day, run the loop two or three times and, if you have time to review it, add one timed block of 60 questions from a question bank, program questions, or other unfamiliar questions you already have. If you're still on rotations or working, do one loop a day and see the time adjustments below. This is an editorial plan, not an NCCPA requirement or a guarantee that six weeks is enough for everyone.
| Week | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Day 6 |
|---|---|---|---|---|---|---|
| 1 | Baseline: two timed 60-question mixed blocks; log every miss | Cardiovascular | Cardiovascular | Cardiovascular | Pulmonary | Pulmonary |
| 2 | Pulmonary | GI/Nutrition | GI/Nutrition | Musculoskeletal | Musculoskeletal | Professional Practice |
| 3 | Infectious Diseases | Infectious Diseases | Neurologic | Neurologic | Psychiatry/Behavioral | Psychiatry/Behavioral |
| 4 | Reproductive | Reproductive | Endocrine | Endocrine | EENT | EENT |
| 5 | Hematologic | Renal | Dermatologic | Genitourinary | Professional Practice | Checkpoint: two timed 60-question mixed blocks, then fix what they show |
| 6 | Full rehearsal: five timed 60-question blocks with a 45-minute total break budget | Review the full rehearsal | Repair your top three system-plus-task weak spots | Two timed mixed blocks | Light review of your error log only | Rest; confirm your ID, route, and arrival time |
What to aim for each week:
- Week 1: a short list of your recurring mistakes, and at least one corrected principle in each system you covered.
- Week 2: one useful side-by-side comparison of conditions you confuse, and a revisit of Week 1 misses.
- Week 3: your error log sorted into three kinds of miss: didn't know it, missed a clue, or answered the wrong task.
- Week 4: a set of lab patterns you can interpret correctly, with units checked.
- Week 5: a list of old notes you corrected against current guidelines.
- Week 6: a specific remaining-work list and your test-day logistics settled. No "ready or not" label; just what's left.
Every practice question on this page is labeled with its content category, so you can save each one for the matching day in the plan. The 21 questions here are a starter set, not enough material for the timed blocks in the grid. Use unfamiliar program questions or other questions you already have for those blocks; use the seven-task exercise and your program notes for focused review.
The study loop (90 minutes)
| Minutes | What you do | What you'll have at the end |
|---|---|---|
| 10 | Without notes, write what you remember from yesterday's corrections. On a new topic, write what you already know. | Two or three statements to check |
| 25 | Review one focused topic from the blueprint list and settle your biggest uncertainty against a current source. | A short explanation in your own words |
| 20 | Apply it: answer vignettes or practice questions before looking at the key. | Your answer and your reason for each |
| 30 | Check every explanation, including questions you guessed right. Compare the closest wrong answer. Update your error log. | One or more corrected principles |
| 5 | Pick the next session's topic and a date to revisit today's misses. | Your next step, on the calendar |
Trying to recall or apply something before checking it is called retrieval practice. Lab research has found that testing yourself helps you remember material later better than rereading it (Roediger and Karpicke, Psychological Science, 2006). That research wasn't done on the PANCE, and the minute split above is our template, not a tested formula.
How many questions a day? As many as you can still review properly. If explaining your answers keeps spilling past your study time, do fewer questions next time rather than skimming the explanations.
Adjust the plan to your time
- Studying part-time (rotations or work): One 90-minute session six days a week totals 54 hours over six weeks. That is a study-time budget, not the total time required by this grid: the two-block checkpoints, five-block rehearsal, and their reviews need longer sessions. With 45 minutes a day, split each ordinary study loop across two days and extend the timetable. Keep the review step and reserve longer windows for timed rehearsals.
- Three to four weeks: Keep the Week 1 baseline and the full five-block rehearsal. Pair content days, so two days of the same system become one, and keep at least one checkpoint.
- More time: Add a focused session on a documented weak spot, and a second full rehearsal about two weeks before your exam.
- Retaking after a failed attempt: Start from the content-area feedback on your NCCPA score report, but treat the small categories carefully; NCCPA notes that subscores for small areas are less precise. Give extra days to areas that show up across your score report, practice results, and error log. Your next attempt can't be within 90 days of the last one; the annual and overall attempt limits below also apply. (NCCPA score-report guidance, PANCE Subscores; retake rules (PDF), page 1.)
- Testing accommodations: Practice with your approved timing and arrangements, not the standard pace.
Your error log
Keep one row per missed question. Look at it at the start of each week and before every checkpoint.
| Question / topic | Task | Why I missed it | The rule I'll use next time | Source | Revisit on |
|---|---|---|---|---|---|
| Q3 / croup | Clinical intervention | Didn't notice "stridor at rest" | For this child's stridor at rest and retractions: dexamethasone and nebulized epinephrine, then observation | Canadian Paediatric Society croup guidance, 2026 | Next Monday |
| Q4 / cholecystitis | Diagnostic studies | Knew the diagnosis, picked HIDA | Suspected acute cholecystitis: ultrasound first; choose further imaging if ultrasound is unclear | ACR Right Upper Quadrant Pain, 2022 | Next Monday |
| Blank | Blank | Blank | Blank | Blank | Blank |
Common reasons for a miss: didn't know it, missed a clue, answered the wrong task, assumed something the question didn't say, made a calculation error, or ran out of time. When three or more rows share the same task, make that task your repair target for the week, whatever the system.
More PANCE practice questions
These 20 questions, plus Question 1 above, make a 21-question original set. Castleport Test Prep wrote them; they aren't NCCPA questions or recalled exam content. Together they include at least one question from each of the 15 content categories, including pediatric and surgical cases. Like NCCPA's published samples, each is a single-best-answer clinical vignette; ours all use five options.
Twenty-one questions is a starting signal, not a score. Your percentage describes these questions only. It isn't an NCCPA scaled score, and it doesn't predict whether you'll pass.
Question 2
A 34-year-old woman has 3 days of fever and productive cough. She has no chronic medical conditions, hasn't taken antibiotics or been hospitalized in the past year, and rarely drinks alcohol. Temperature is 38.4 °C (101.1 °F), respiratory rate 18/min, and oxygen saturation 97% on room air. Chest radiograph shows a right lower lobe infiltrate. No respiratory virus has been identified. She will be treated as an outpatient. Which of the following is the most appropriate empiric antibiotic?
Show answer and explanation
Answer: A. Amoxicillin 1 g three times daily
When empiric antibacterial treatment is indicated for a healthy outpatient adult with community-acquired pneumonia and no comorbidities or risk factors for resistant organisms, the ATS/IDSA guideline strongly recommends amoxicillin. Doxycycline is an alternative, and a macrolide is acceptable only where pneumococcal macrolide resistance is under 25%.
Why the other choices are wrong:
- B. Levofloxacin alone is an option for outpatients who have comorbidities, such as chronic heart, lung, liver, or kidney disease, diabetes, alcohol use disorder, cancer, or asplenia. She has none.
- C. Amoxicillin-clavulanate plus a macrolide is the other regimen for outpatients with those comorbidities.
- D. Vancomycin plus piperacillin-tazobactam covers MRSA and Pseudomonas. The guideline reserves that coverage for patients with locally validated risk factors.
- E. Ceftriaxone plus azithromycin is an inpatient regimen. This case specifies outpatient treatment; her normal oxygenation and respiratory rate do not establish a need for hospital admission.
Sources: ATS/IDSA 2019 CAP Guideline, Executive Summary (PDF)
Question 3
A 2-year-old boy has had a runny nose and low-grade fever for 2 days. Tonight he developed a harsh, barking cough and a hoarse voice. He is alert and isn't drooling. He has inspiratory stridor at rest and mild suprasternal retractions; air entry is normal. Oxygen saturation is 96% on room air. Which of the following is the most appropriate management?
Show answer and explanation
Answer: D. A single dose of dexamethasone plus nebulized epinephrine, then observation
This is croup, a clinical diagnosis: barking cough, stridor, and hoarseness after a viral prodrome. Stridor at rest with retractions makes it moderate. Corticosteroids are recommended for croup of any severity, and nebulized epinephrine is added for moderate to severe croup. Epinephrine's clinical effect wears off after about 2 hours. Observe for 2 to 4 hours after treatment and confirm that symptoms do not recur before discharge.
Why the other choices are wrong:
- A. Humidified air hasn't been shown to improve moderate croup, and stridor at rest needs treatment.
- B. Albuterol treats lower-airway bronchospasm. Croup is swelling below the vocal cords, and bronchodilators aren't part of recommended croup treatment.
- C. Typical croup is viral, most commonly from parainfluenza viruses, so amoxicillin does not treat its cause.
- E. Radiographs aren't routinely needed. The steeple sign is neither sensitive nor specific, and imaging shouldn't delay treatment.
Sources: Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018;97(9):575-580; Canadian Paediatric Society: Acute management of croup in the emergency department
Question 4
A 46-year-old woman has had constant right upper quadrant pain for 9 hours that began after a fatty meal, with nausea. Temperature is 38.3 °C (100.9 °F). She stops breathing in during deep palpation of the right upper quadrant. Leukocyte count is 14,000/mm³. Which of the following is the most appropriate initial imaging study?
Show answer and explanation
Answer: B. Right upper quadrant ultrasonography
Pain lasting more than 6 hours, fever, leukocytosis, and a Murphy sign (catching the breath during right upper quadrant palpation) point to acute cholecystitis. Ultrasonography is the recommended first imaging study: it's quick, uses no radiation, and is highly sensitive for gallstones.
Why the other choices are wrong:
- A. CT can assess alternative diagnoses or complications, but ultrasound is preferred first in this presentation of suspected biliary disease.
- C. A HIDA scan is one possible follow-up study when ultrasound is equivocal; it is not the initial test here.
- D. MRCP is a secondary study, mainly for bile duct stones or an unclear ultrasound.
- E. Plain radiographs miss most gallstones.
Sources: Abraham S, et al. Surgical and Nonsurgical Management of Gallstones. Am Fam Physician. 2014;89(10):795; Cartwright SL, Knudson MP. Diagnostic Imaging of Acute Abdominal Pain in Adults. Am Fam Physician. 2015;91(7):452 (PDF); ACR Appropriateness Criteria: Right Upper Quadrant Pain (PDF)
Question 5
A 4-week-old firstborn boy has had forceful, nonbilious vomiting after every feed for 5 days. He seems hungry right after vomiting and has lost weight. Serum sodium is 136 mEq/L, potassium 3.1 mEq/L, chloride 89 mEq/L, and bicarbonate 32 mEq/L. Which of the following is the most appropriate study to confirm the most likely diagnosis?
Show answer and explanation
Answer: E. Abdominal ultrasonography of the pylorus
Projectile nonbilious vomiting in a hungry young infant with low chloride, low potassium, and high bicarbonate (a metabolic alkalosis from losing stomach acid) is classic hypertrophic pyloric stenosis. Ultrasound is the test of choice, with about 95% sensitivity. The alkalosis is corrected before pyloromyotomy because uncorrected alkalosis raises the risk of apnea after surgery.
Why the other choices are wrong:
- A. An upper GI series is a backup when ultrasound is nondiagnostic and suspicion stays high.
- B. An air-contrast enema can diagnose and reduce intussusception, which more typically causes intermittent pain or distress and vomiting. The feeding-related vomiting and metabolic alkalosis here favor pyloric stenosis.
- C. CT adds radiation without adding anything ultrasound doesn't already give here.
- D. pH monitoring evaluates reflux. Reflux doesn't explain this metabolic picture, and having reflux doesn't rule out pyloric stenosis.
Sources: Len KA. Hypertrophic Pyloric Stenosis. Case Based Pediatrics, University of Hawaii John A. Burns School of Medicine, 2022; Case in Point: Infantile Hypertrophic Pyloric Stenosis. Consultant360; Royal Children’s Hospital Melbourne: Pyloric stenosis; Royal Children’s Hospital Melbourne: Intussusception
Question 6
A 67-year-old man with stage 4 chronic kidney disease started lisinopril and spironolactone 2 weeks ago. He now has generalized weakness. Serum potassium is 7.1 mEq/L (reference 3.5–5.0). ECG shows peaked T waves and a QRS duration of 0.14 seconds. Which of the following is the most appropriate first treatment?
Show answer and explanation
Answer: A. Intravenous calcium gluconate
Hyperkalemia with ECG changes is an emergency. IV calcium stabilizes cardiac cell membranes and can rapidly improve the ECG abnormalities. It does not lower potassium. Give potassium-lowering treatment promptly, including insulin with glucose and blood-glucose monitoring, while arranging potassium removal and repeat potassium measurements as needed. Hold and review contributing lisinopril and spironolactone during acute management; their combination increases hyperkalemia risk, especially with reduced kidney function.
Why the other choices are wrong:
- B. Insulin with dextrose shifts potassium into cells and should follow promptly, but it doesn't protect the heart as fast as calcium.
- C. Nebulized albuterol also shifts potassium into cells; like insulin, it's a next step, not the first.
- D. Sodium polystyrene sulfonate lowers total-body potassium, but far too slowly for a widened QRS.
- E. Furosemide also removes potassium slowly and doesn't protect the heart now.
Sources: UK Kidney Association: Management of Hyperkalaemia in Adults (PDF)
Question 7
A 22-year-old man fell onto his outstretched right hand while snowboarding. He has pain on the thumb side of the wrist and tenderness in the anatomic snuffbox. Posteroanterior, lateral, oblique, and scaphoid-view radiographs show no fracture. Which of the following is the most appropriate management?
Show answer and explanation
Answer: C. Thumb spica immobilization with repeat radiographs in 10 to 14 days or advanced imaging
Scaphoid fractures may not show on the first radiographs. Snuffbox tenderness after a fall on an outstretched hand warrants treatment as a possible fracture: immobilize the wrist and arrange reassessment with repeat radiographs in 10 to 14 days or advanced imaging such as MRI. A thumb spica is an appropriate immobilization option; thumb immobilization is not mandatory in every case.
Why the other choices are wrong:
- A. An elastic wrap under-treats a possible fracture.
- B. A fixed one-week course without reassessment or follow-up imaging leaves a possible occult fracture unresolved. The problem is not simply that the splint leaves the thumb free.
- D. Surgery is for displaced or unstable fractures, and none has been shown.
- E. A steroid injection has no role in a suspected acute fracture.
Question 8
A 56-year-old man has had recurrent episodes of sudden pain, redness, and swelling at the base of his big toe (the first metatarsophalangeal joint). During a current flare, fluid is aspirated from the joint. Which of the following findings most directly supports gout?
Show answer and explanation
Answer: A. Urate crystals in the synovial fluid
Gout is inflammation caused by urate crystals forming in and around a joint. Seeing those crystals under a special microscope in fluid from the affected joint is direct evidence of the disease mechanism.
Why the other choices are wrong:
- B. A high serum urate is a risk marker, not proof. Many people with high urate never develop gout.
- C. An elevated ESR shows inflammation but doesn't say what's causing it.
- D. An elevated white count also points to inflammation or infection without identifying urate crystals.
- E. Swelling describes the joint's response without identifying its cause.
Sources: NIAMS: Gout (overview); NIAMS: Gout, Diagnosis, Treatment, and Steps to Take
Question 9
A 52-year-old woman reports 6 months of fatigue, weight gain, constipation, cold intolerance, and dry skin. Examination shows delayed relaxation of the ankle reflexes. She takes no thyroid medication. Which of the following is the most appropriate initial laboratory test?
Show answer and explanation
Answer: B. Thyroid-stimulating hormone (TSH)
TSH is the best first test for suspected primary hypothyroidism. If TSH is high, add FT4: a low FT4 means overt hypothyroidism, and a normal FT4 means subclinical hypothyroidism. Read the two together, because TSH rises when the thyroid isn't making enough hormone.
Why the other choices are wrong:
- A. FT4 is the second step. On its own it can't identify subclinical disease, which is defined by a high TSH with a normal FT4.
- C. Total T3 isn't routinely useful for diagnosing hypothyroidism.
- D. TPO antibodies suggest an autoimmune cause (Hashimoto thyroiditis) but don't make the diagnosis.
- E. Ultrasound evaluates palpable nodules and isn't part of the routine workup.
Question 10
A 38-year-old man woke 18 hours ago with drooping on the right side of his face. He can't wrinkle his right forehead or fully close his right eye, and the right nasolabial fold is flattened. Strength, sensation, speech, coordination, and the other cranial nerves are normal. Which of the following is the most appropriate management?
Show answer and explanation
Answer: D. Oral corticosteroids now, plus eye protection
Sudden weakness of one whole side of the face, forehead included, with an otherwise normal neurologic exam fits Bell palsy. The AAO-HNSF guideline strongly recommends oral steroids within 72 hours of onset for patients 16 and older, plus eye protection when the eye doesn't close fully.
Why the other choices are wrong:
- A. The guideline recommends against an antiviral alone. An antiviral may be added to steroids, not used instead of them.
- B. The isolated facial palsy and otherwise normal neurologic examination favor Bell palsy. Forehead involvement alone does not rule out stroke; new limb weakness, speech changes, or other neurologic findings require urgent evaluation.
- C. Routine imaging and labs aren't recommended for new Bell palsy.
- E. Observing alone misses the window in which steroids help.
Sources: Baugh RF, et al. Clinical Practice Guideline: Bell's Palsy. AAO-HNS Foundation, November 2013 (fact sheet); Agarwal R, et al. Pontine stroke presenting as isolated facial nerve palsy mimicking Bell’s palsy: a case report
Question 11
A 69-year-old woman comes to an outpatient clinic because of sudden right-arm weakness and trouble finding words that began 30 minutes ago. The symptoms lasted about 15 minutes and have fully resolved; her exam is now normal. Point-of-care glucose is 96 mg/dL. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: D. Arrange immediate emergency evaluation through emergency medical services
Sudden focal weakness and speech difficulty are stroke symptoms. When they resolve, the episode may have been a transient ischemic attack (TIA), which signals a high short-term stroke risk and still needs emergency evaluation. The glucose is normal now; that does not exclude an earlier hypoglycemic episode or remove the need for emergency evaluation.
Why the other choices are wrong:
- A. A routine test weeks later delays evaluation of a possibly serious vascular event.
- B. Resolution of symptoms does not remove the risk; a normal examination after the episode can occur with TIA.
- C. Assuming migraine shouldn't delay evaluation of sudden focal deficits in a 69-year-old.
- E. An outpatient EEG doesn't replace the immediate evaluation this needs.
Sources: CDC: Signs and Symptoms of Stroke (May 19, 2026); American Heart Association: Stroke symptoms, even if they disappear within an hour, need emergency assessment (Jan 19, 2023)
Question 12
A 45-year-old woman who takes sertraline for depression started tramadol 2 days ago for back pain. She is now agitated and sweating. Temperature is 38.6 °C (101.5 °F), heart rate 118/min, and blood pressure 158/94 mm Hg. Her pupils are dilated, reflexes are brisk, and dorsiflexing her ankle produces sustained rhythmic beating. She has had diarrhea since this morning. Which of the following is the most likely diagnosis?
Show answer and explanation
Answer: E. Serotonin syndrome
She added a second serotonergic drug (tramadol) to an SSRI and developed inducible clonus with agitation and sweating, which meets the Hunter criteria. Management starts with stopping the serotonergic drugs and urgent supportive care; benzodiazepines can treat agitation. Cyproheptadine may be considered when symptoms persist despite supportive care, but evidence for benefit is limited.
Why the other choices are wrong:
- A. Neuroleptic malignant syndrome typically follows antipsychotic exposure, develops more slowly, and features rigidity with diminished reflexes. Rapid onset and hyperreflexia favor serotonin syndrome.
- B. Anticholinergic toxicity typically dries the skin and slows the gut; she's sweating and has diarrhea.
- C. Malignant hyperthermia follows anesthetic exposure, which she hasn't had.
- D. The history gives no opioid reduction or discontinuation. The new serotonergic drug and clonus favor serotonin syndrome.
Sources: DailyMed: Tramadol hydrochloride tablets, prescribing information; MSD Manual Professional: Serotonin Syndrome
Question 13
A 31-year-old woman in Connecticut who is not pregnant or breastfeeding went hiking 10 days ago. She now has a 7-cm expanding red oval patch on her thigh with partial central clearing, plus mild fatigue. She has no facial weakness, heart symptoms, or joint swelling. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: B. Doxycycline for 10 days without laboratory testing
A rash typical of erythema migrans after possible tick exposure in an area where Lyme disease is common is diagnosed clinically. The IDSA/AAN/ACR guideline recommends no laboratory testing in that situation and treatment with 10 days of doxycycline (or 14 days of amoxicillin or cefuroxime).
Why the other choices are wrong:
- A. Serology is often negative this early, before antibodies develop, and isn't needed for a typical rash.
- C. A single dose of doxycycline is prophylaxis within 72 hours after removing a high-risk tick, not treatment of an established infection.
- D. IV ceftriaxone is for certain disseminated manifestations, not uncomplicated erythema migrans.
- E. A topical antifungal treats tinea, which this lesion, setting, and exposure don't fit.
Sources: AAN/ACR/IDSA 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease
Question 14
A healthy 40-year-old man without HIV steps on a rusty nail in his garden, causing a soil-contaminated puncture wound. The wound is being cleaned. His records show a completed tetanus primary series, and his last tetanus-containing vaccine was 6 years ago. Which of the following is the appropriate tetanus prophylaxis?
Show answer and explanation
Answer: E. A tetanus-containing vaccine without TIG
A puncture wound counts as a dirty or major wound. For dirty wounds, CDC recommends a tetanus-containing vaccine when a person with a completed primary series had the last dose 5 or more years ago. Six years meets that rule. TIG is reserved for dirty wounds in people with an unknown, incomplete, or absent vaccine history, or with HIV or severe immunodeficiency; he has none of those.
Why the other choices are wrong:
- A. TIG isn't indicated for him, and giving it alone would skip the vaccine he does need.
- B. The 10-year interval applies to clean, minor wounds. For a dirty wound, the cutoff is 5 years.
- C. Adding TIG isn't indicated for a fully vaccinated adult with a normal immune system.
- D. CDC doesn't recommend antibiotics to prevent tetanus. Watch the wound and treat infection if it develops.
Source: CDC: Clinical Guidance for Wound Management to Prevent Tetanus (updated Sept 8, 2026)
Question 15
A 27-year-old woman whose last menstrual period was 7 weeks ago has sudden, severe left lower abdominal pain and feels lightheaded. Blood pressure is 82/50 mm Hg and heart rate 128/min. Urine hCG is positive. Bedside ultrasound shows free fluid in the abdomen; transvaginal ultrasound shows no intrauterine pregnancy and a complex left adnexal mass. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: A. Resuscitation and emergent surgical management
A positive pregnancy test, no pregnancy in the uterus, an adnexal mass, free fluid, and shock point to a ruptured ectopic pregnancy. When rupture is suspected and the patient is hemodynamically unstable, treatment is surgical.
Why the other choices are wrong:
- B. Methotrexate is for stable patients with an unruptured ectopic pregnancy.
- C. Serial hCG belongs to the workup of a stable patient whose pregnancy location is unclear.
- D. Expectant management is only for stable patients with low, falling hCG and minimal symptoms.
- E. Curettage is an occasional diagnostic step in stable patients, not in someone in shock.
Sources: Lozeau AM, Potter B. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. 2005;72(9):1707-1714; RCOG: Ectopic pregnancy; Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Am Fam Physician. 2020;101(10):599–606
Question 16
A 64-year-old woman walks out of a dark movie theater and develops severe right eye pain, a frontal headache, blurred vision with halos around lights, and vomiting. The right eye shows conjunctival redness, a hazy cornea, and a mid-dilated pupil that barely reacts to light. The eye feels firm. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: C. Measure intraocular pressure, start pressure-lowering treatment, and arrange emergent ophthalmology care
A painful red eye, halos, a hazy cornea, a mid-dilated poorly reactive pupil, and a hard eye after time in dim light are classic for acute angle-closure glaucoma. It's an emergency: without treatment, vision can be lost within hours. Pressure-lowering treatment can start before the ophthalmologist arrives.
Why the other choices are wrong:
- A. Topical steroids treat inflammation such as iritis and don't open the blocked drainage angle.
- B. Antibiotic drops treat conjunctivitis, which doesn't cause halos, a hazy cornea, or a fixed pupil.
- D. Dilating the pupil can worsen the pupil-block mechanism that causes angle closure.
- E. Treating this as migraine misses a sight-threatening diagnosis; headache and vomiting are common in angle closure.
Sources: Moran CORE, University of Utah: Acute Angle Closure Glaucoma; MSD Manual Professional: Angle-Closure Glaucoma
Question 17
A 34-year-old woman with heavy menstrual periods reports fatigue. Hemoglobin is 9.8 g/dL and mean corpuscular volume is 74 fL. Which of the following is the most appropriate initial test to evaluate the most likely cause of her anemia?
Show answer and explanation
Answer: D. Serum ferritin
Small red cells with ongoing menstrual blood loss make iron deficiency the most likely cause here. Ferritin reflects iron stores and is the most accurate blood test for iron deficiency. One catch: ferritin also rises with inflammation, so inflammation can push it into the normal range.
Why the other choices are wrong:
- A. Serum iron fluctuates and can be misleading when used alone.
- B. Hemoglobin electrophoresis evaluates thalassemia and other hemoglobin disorders; it's a later step if small red cells persist with normal iron stores.
- C. Bone marrow iron is the historical reference standard but is invasive and unnecessary here.
- E. Vitamin B12 deficiency classically causes large red cells; this microcytic, blood-loss pattern favors iron deficiency.
Sources: AFP: Evaluation of Microcytosis (2010); Iron Deficiency Anemia: Evaluation and Management. Am Fam Physician. 2013;87(2):98-104; NIH Office of Dietary Supplements: Iron, health-professional fact sheet; Cochrane CD011817: Ferritin for diagnosing iron deficiency
Question 18
A 19-year-old college student noticed a single 4-cm oval, salmon-colored patch with a fine rim of scale on her trunk 10 days ago. Over the past few days, many smaller oval, scaly spots have appeared on her back, lined up along the skin's cleavage lines in a fir-tree pattern. Itching is mild. Her palms, soles, and mouth are clear. Which of the following is the most likely diagnosis?
Show answer and explanation
Answer: B. Pityriasis rosea
A herald patch followed by smaller oval lesions along cleavage lines, which make a Christmas-tree pattern on the back, is pityriasis rosea. It's a self-limited rash that's most common in children and young adults.
Why the other choices are wrong:
- A. Tinea corporis can look like the herald patch, but it doesn't produce a widespread eruption along cleavage lines.
- C. Guttate psoriasis causes small drop-like plaques, often after strep throat, with no herald patch.
- D. Secondary syphilis is the key mimic. Check syphilis serology when the diagnosis is uncertain, especially if the palms or soles are involved and the patient is sexually active.
- E. Nummular eczema causes coin-shaped, very itchy plaques without a herald patch or cleavage-line pattern.
Sources: American Academy of Dermatology: Pityriasis rosea signs and symptoms; AFP: Pityriasis Rosea: Diagnosis and Treatment (2018); CDC STI Treatment Guidelines: Syphilis
Question 19
A 66-year-old man with severe symptomatic aortic stenosis declines recommended valve replacement. He is alert and oriented. He accurately explains the proposed operation's benefits, risks, and alternatives. In his own words, he explains that without surgery he could die suddenly, and he weighs that against what he saw during his late wife's difficult surgical recovery. His choice has been the same at three visits. His daughter asks the PA to "do whatever it takes" to get him to surgery. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: E. Accept his refusal, document the capacity assessment and informed refusal, and keep offering care
He shows all four elements of decision-making capacity: he understands the information, appreciates how it applies to him, reasons with it, and communicates a consistent choice. Refusing a clearly beneficial treatment is a reason to assess capacity, not proof that it's missing. With capacity established, his informed refusal stands, and the door to surgery stays open if he changes his mind.
Why the other choices are wrong:
- A. Nothing in this case establishes incapacity or a reason to seek a guardian.
- B. A psychiatry consult isn't required simply because a patient refuses treatment. Consultation can help if capacity remains uncertain.
- C. His daughter cannot override his informed refusal while he has decision-making capacity.
- D. Ending care punishes a patient for using his right to refuse and leaves his ongoing needs unmet.
Sources: Barstow C, Shahan B, Roberts M. Evaluating Medical Decision-Making Capacity in Practice. Am Fam Physician. 2018;98(1):40 (PDF); AMA Code Opinion 1.1.3: Patient Rights; AMA Code Opinion 2.1.2: Decisions for Adult Patients Who Lack Capacity
Question 20
A 46-year-old man asks about colorectal cancer screening. He has no symptoms; no personal history of colorectal cancer, polyps, or inflammatory bowel disease; and no family history of colorectal cancer. Which of the following is the most appropriate recommendation?
Show answer and explanation
Answer: C. Begin screening now with a test recommended by the USPSTF
The USPSTF recommends screening average-risk adults aged 45 to 49 (grade B) and 50 to 75 (grade A), using stool-based tests or direct visualization such as colonoscopy, with the patient helping choose the test.
Why the other choices are wrong:
- A. Age 50 was the old starting age; the 2021 recommendation lowered it to 45.
- B. The USPSTF recommendation doesn't include serum tests for screening.
- D. Capsule endoscopy isn't included in the USPSTF screening strategies.
- E. Screening is for people without symptoms; symptoms call for diagnostic testing instead.
Question 21
A 15-year-old boy woke 3 hours ago with sudden, severe left scrotal pain and has vomited twice. The left testis sits high in the scrotum with a horizontal lie and is tender all over. The left cremasteric reflex is absent. Which of the following is the most appropriate next step?
Show answer and explanation
Answer: A. Immediate urology consultation for surgical exploration
Sudden severe scrotal pain with vomiting, a high-riding horizontal testis, and an absent cremasteric reflex is testicular torsion until proven otherwise. Torsion is a clinical diagnosis; when history and exam suggest it, surgical exploration shouldn't wait for imaging. Testes are saved in about 90% to 100% of cases explored within 6 hours of symptom onset, and that falls to around 50% after 12 hours.
Why the other choices are wrong:
- B. Doppler ultrasound helps when the picture is unclear, but it shouldn't delay surgery when the clinical picture is this strong.
- C. Antibiotics treat epididymitis, which usually comes on gradually with urinary symptoms and an intact cremasteric reflex.
- D. Conservative care risks losing the testis.
- E. Urine testing delays definitive care and doesn't rule torsion in or out.
Sources: Sharp VJ, Kieran K. Testicular Torsion: Diagnosis, Evaluation, and Management. Am Fam Physician. 2013;88(12):835; EAU Guidelines on Paediatric Urology: Acute Scrotum
Answer key
| Question | Answer | Content category | Task |
|---|---|---|---|
| 1 | C | Cardiovascular System | Most likely diagnosis |
| 2 | A | Pulmonary System | Pharmaceutical therapeutics |
| 3 | D | Pulmonary System | Clinical intervention |
| 4 | B | Gastrointestinal System/Nutrition | Diagnostic studies |
| 5 | E | Gastrointestinal System/Nutrition | Diagnostic studies |
| 6 | A | Renal System | Clinical intervention |
| 7 | C | Musculoskeletal System | Clinical intervention |
| 8 | A | Musculoskeletal System | Diagnostic studies |
| 9 | B | Endocrine System | Diagnostic studies |
| 10 | D | Neurologic System | Pharmaceutical therapeutics |
| 11 | D | Neurologic System | Clinical intervention |
| 12 | E | Psychiatry/Behavioral Science | Most likely diagnosis |
| 13 | B | Infectious Diseases | Pharmaceutical therapeutics |
| 14 | E | Infectious Diseases | Health maintenance |
| 15 | A | Reproductive System | Clinical intervention |
| 16 | C | Eyes, Ears, Nose, and Throat | Clinical intervention |
| 17 | D | Hematologic System | Diagnostic studies |
| 18 | B | Dermatologic System | Most likely diagnosis |
| 19 | E | Professional Practice | — |
| 20 | C | Gastrointestinal System/Nutrition | Health maintenance |
| 21 | A | Genitourinary System | Clinical intervention |
Copy each miss into your error log with its category and its task. If two or three misses share a task, such as knowing the diagnosis but choosing the wrong test, that's your first repair target.
PANCE format, scoring, and test day
| Question | Answer |
|---|---|
| How many questions, and how long? | 300 multiple-choice questions in five blocks of 60, with 60 minutes per block: five hours of question time. That's an average of one minute per question, not a timer on each one. (NCCPA test day) |
| How do breaks work? | You get 45 minutes of break time in total, taken between blocks, and you manage it yourself. There's also a 15-minute tutorial. Going over your break budget comes out of exam time, and leaving during a block is an unscheduled break that uses that block's time. (NCCPA test day) |
| Can I go back to earlier questions? | Yes, within the block you're working in. Once you leave a block or its time runs out, it's locked. (NCCPA test day) |
| What score passes? | 350 on a scale from 200 to 800. Because exam forms differ slightly in difficulty, the number of questions you need to get right isn't fixed. (NCCPA exam development and scoring) |
| What's the pass rate? | In 2025, 91.5% of 13,145 first-time test takers passed. Across all 14,669 exams given (including repeat attempts), 88.4% were passing. (NCCPA pass rates (PDF)) |
| When do results come? | NCCPA emails you when results are posted to your online record, about two weeks after your exam. (NCCPA FAQs) |
| What's on screen? | A Lab Values screen provides normal adult reference ranges; when a laboratory test is absent from that screen, its normal reference range appears in parentheses in the question. Temperatures appear in both Celsius and Fahrenheit, generic drug names are always given, and highlight and strikethrough tools are available. (NCCPA FAQs) |
Before test day:
- Take the official NCCPA exam tutorial on Pearson VUE's site. It covers navigating, changing and marking answers, and the lab values table.
- Bring two original forms of identification that meet NCCPA's current ID and name-matching rules. Check the accepted documents and permitted name differences before test day. (NCCPA ID rules)
- Plan to arrive at least 30 minutes early. Arriving late can mean forfeiting your fee and reapplying.
- If you need to reschedule or cancel, do it through Pearson VUE at least one business day before your appointment. (NCCPA PANCE policies (PDF))
- Decide in advance how you'll spend your 45 minutes of break time across the four gaps between blocks.
Official steps that affect your study calendar
- Eligibility and application: You need to graduate from an entry-level PA program accredited by ARC-PA at the time you entered it. The application fee is $550. NCCPA starts accepting applications 180 days before your expected program completion date, and the earliest you can test is 7 days after your program-completion date, provided your program director has confirmed that date. Your acknowledgement email gives your authorized testing dates; the timeframe is generally 180 days but can be shorter near the end of your six-year eligibility period. Check NCCPA eligibility and application steps · Authorization-window policy, page 1 (PDF)
- Testing dates: PANCE is offered January 2 through December 18 in both 2026 and 2027. Your own acknowledgement sets the dates you can actually book. Check NCCPA's current testing window
- Accommodations: Request them as part of your application, with documentation from a qualified professional. If NCCPA approves them, you sign and return an accommodation agreement before you can schedule. Approval from your PA program doesn't carry over on its own. Follow NCCPA's accommodations process
- Retakes and attempt limits: You can take the PANCE once in any 90-day period and no more than three times in a calendar year, whichever is fewer. If you graduated on or after January 1, 2003 and have never been certified, you have six attempts within six years of completing your program; whichever runs out first ends your eligibility. Read NCCPA's PANCE policies (PDF)
- Already certified? The PANRE and PANRE-LA are recertification exams, not the PANCE. See NCCPA recertification options Passing the PANCE leads to NCCPA certification; your license to practice comes from your state's licensing board.
PANCE prep questions, answered
How long should I study for the PANCE?
NCCPA doesn't set a study length. Use the Week 1 baseline to choose your first review targets, then revise the schedule at each checkpoint. If you're missing questions across many systems or running out of time, give yourself the full six weeks or longer. Completing a small practice set comfortably doesn't establish readiness.
Where can I see free official sample questions?
NCCPA publishes Sample PANCE Questions with critiques (PDF). Use them to see the published question format, including four- and five-option examples. The PDF is dated 2022, so use current clinical guidance when reviewing treatment or screening recommendations.
Does the 2019 blueprint still apply?
No. The blueprint that took effect in January 2025 applies to every PANCE given since then. Use the current blueprint (PDF) to check both content weights and task categories.
Sources and how we made this page
Exam facts (last verified November 5, 2026):
- NCCPA PANCE Content Blueprint (PDF), effective January 2025: page 1 (weights), pages 2–16 (topics), pages 17–19 (tasks), pages 20–21 (Professional Practice)
- NCCPA: Become Certified: eligibility, fee, application timing
- NCCPA: What to Expect on Test Day: blocks, breaks, arrival; Name Changes/ID Information: accepted IDs and name differences
- NCCPA: PANCE Policies, Procedures, and Authorization (PDF): retakes, attempt limits, rescheduling, score release
- NCCPA: Exam Development and Scoring and PANCE Performance Guide: score scale and subscores
- NCCPA: Five-Year PANCE Pass Rates (PDF): 2021–2025
- NCCPA: Key Dates, Testing Accommodations, Sample PANCE Questions (PDF), and FAQs
- Pearson VUE: NCCPA: tutorial and scheduling
Clinical sources are linked under each practice question and the seven-task table.
The Castleport Test Prep Editorial Team wrote the practice questions, the seven-task table, the priority map, and the study plan, with AI assistance. We checked every exam fact against NCCPA's own pages and each clinical answer against the guideline or review cited with it. This page is study material, not clinical advice, and it hasn't been reviewed by NCCPA or a practicing clinician. How we check exam facts and practice explanations · Educational scope and practice-score limits · Corrections
Castleport Test Prep is an independent exam prep publisher and is not affiliated with, endorsed by, or approved by the National Commission on Certification of Physician Assistants (NCCPA). The practice questions are original and unofficial. Exam and credential names identify the subjects discussed; trademarks belong to their respective owners.