Test-taking is a skill in itself. One that’s crucial throughout your PA education, and essential to master before taking the PANCE. Just like any other skill, this requires practice! You may know the material from lectures, but can you recognize it in a clinical vignette? Are you able to identify distractors in your PANCE practice questions? Can you think one step beyond the diagnosis? All these things are useful to know, and they can help you get a better score on the PANCE.
To help you get ready for the exam, let’s do some PANCE practice questions together from Blueprint’s PANCE Qbank (formerly Rosh Review). I’ll give you some tips and tricks for doing them, so when exam day comes, you feel ready. Let’s get to it!
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PANCE Practice Question #1:
A 48-year-old right-handed woman presents to your office with a 6-week history of left shoulder pain and stiffness. She recalls shoveling snow prior to the pain starting but did not have any injury. She has difficulty putting on a bra or jacket, and sometimes the pain interferes with sleep. Her medical history is significant for type 2 diabetes mellitus, hypothyroidism, osteoporosis, and a 20 pack-year smoking history. On physical examination, she has no swelling over the shoulder or upper arm and no tenderness to palpation. Active range of motion of the shoulder is 100° of forward flexion, 45° of abduction, 30° of external rotation, and little internal rotation past neutral. Passive range of motion is identical to active and all motions have firm endpoints. She has good strength with resisted abduction, internal rotation, and external rotation with the arm at the side. Findings on neurovascular examination and X-rays of the shoulder are normal. Which of the following is the greatest risk factor for this patient’s condition?
A) Cigarette smoking
B) Diabetes mellitus
C) Hypothyroidism
D) Osteoporosis
E) Rotator cuff pathology
Question Breakdown
Before we dive in, just a brief note: as a general rule, it’s good practice to approach questions the same way every time you take practice exams. This will help you review questions efficiently, reducing your risk of missing important points and reducing the time it takes to get through a question.
Start with the Lead-In
With that in mind, when reviewing this example, start with the lead-in (last sentence): “Which of the following is the greatest risk factor for this patient’s condition?”
This is an example of a second-order question. Not only do you need to determine what the diagnosis is, you’re taking it one step further and identifying the biggest risk factor for that condition.
💡 While you may see some straightforward, first-order questions on your PANCE, most will be second- or third-order questions!
Identify Key Points
Now that you know the question prompt from reading the last line, you know you’re looking first for a diagnosis. As we read through this vignette, think about the most important points:
- 6 weeks of left shoulder pain and stiffness
- No known injury
- Pain interfering with sleep
- Decreased active and passive range of motion
- Normal neurovascular exam
Review Patient Characteristics
Once you’ve identified the key points, all you can do at this point is rely on your clinical knowledge to determine the diagnosis. If you’re drawing a blank, review the patient characteristics:
- 48 year old woman
- Medical history: type 2 diabetes mellitus, hypothyroidism, osteoporosis, tobacco use disorder
Establish a Differential
While the epidemiology is just the most common population for this to occur in, a lot of PANCE questions will adhere to this. Therefore, think of conditions that can cause shoulder pain/stiffness in individuals such as the patient in this vignette.
And the Answer Is…
Once you establish a differential, see what best fits your other important points. In this case, the patient has adhesive capsulitis (nicknamed frozen shoulder).
However, you’re not done yet! Now you have to remember what is the greatest risk factor for adhesive capsulitis, which is diabetes mellitus. Therefore, the correct answer is B.
PANCE Practice Question #2:
A 44-year-old man presents to the clinic after hospitalization for an acute myocardial infarction 1 week ago. He states he is sore in his right groin from the cardiac catheterization and has increasing fatigue and dyspnea on exertion, but he reports no chest pain. His history includes hypertension and dyslipidemia. He is now taking lisinopril 10 mg once daily, carvedilol 6.25 mg twice daily, aspirin 81 mg once daily, clopidogrel 75 mg once daily, and atorvastatin 40 mg once daily. His vital signs are a blood pressure of 100/60 mm Hg, heart rate of 62 bpm, respirations 24/minute, oxygen saturation of 95% on room air, and a temperature of 98.7°F. Physical exam reveals a small bruise on the right groin, trace pedal edema, diminished breath sounds in his bilateral lung bases, and a new systolic, blowing, high-pitched apical murmur that radiates to the left axilla. Which of the following is the most likely pathophysiologic cause of this patient’s physical exam findings?
A) Free wall rupture
B) Left septal fascicular block
C) Papillary muscle rupture
D) Peri-infarction pericarditis
E) Sinoatrial node dysfunction
Question Breakdown
Following the same pattern as the last question, we review the last line first, “Which of the following is the most likely pathophysiologic cause of this patient’s physical exam findings?”
Again, this question is asking you to not only identify the diagnosis, but take it one step further and discuss the pathophysiologic cause.
Let’s again start with the key points:
- 1 week following myocardial infarction (MI)
- Increasing fatigue and dyspnea on exertion, no chest pain
- New systolic, blowing, high-pitched apical murmur that radiates to the left axilla
Review Vital Signs
One thing to become comfortable with is looking at the vital signs given and identifying anything noteworthy. This includes a quick review noting that the vital signs are normal, or highlighting areas that stand out.
In the above vignette, the key thing to notice is that the patient is slightly hypotensive, a bit tachypneic, and slightly hypoxic. From here, you can decide if the patient is stable or unstable. I would classify this patient as unstable, which aids establishing your differential diagnosis and appropriate management.
Avoid Distractors
Another important step in answering questions like this is to avoid distractors. The largest distractor in the above question is the right groin soreness. They further discuss this in the physical exam findings with the small bruise. Hyperfixating on this will just waste time when answering this question.
A good way to identify this as a distractor is that they already tell you what that soreness is from, when the lead-in question (the last sentence) is asking about pathophysiology. In addition, a new onset murmur is never normal! That is the area they want you to focus on in this question.
So, this patient has a new onset murmur one week following his myocardial infarction, pointing to a valvular disorder. This is described as systolic, blowing/high-pitched, and apical. They even give you the further clue of radiation to the axilla. No matter how you do it, the valvular disorders do need to be committed to memory prior to the PANCE.
Narrow Your Options
Which valves are open and closed?
One thing that can be helpful is understanding which valves are open and closed during systole and diastole. For example, this question is asking about a systolic murmur. During systole, the aortic and pulmonary valves are open, while the mitral and tricuspid valves are closed.
Valves that are open would have a stenosis, while closed valves could have a regurgitation. This narrows down your valvular disorder options to: aortic/pulmonic stenosis or mitral/tricuspid regurgitation.
What is the location of the murmurs?
The next way to break down the murmurs is by location. This murmur is best heard at the apex, which is a characteristic of mitral valve disorders. Since we have an apical, systolic murmur, the valvular disorder we are dealing with here is mitral regurgitation.
What about mitral valve prolapse?
Now, you may wonder, “What about mitral valve prolapse?” And that would be a great question because technically that would be a mitral valve disorder heard during systole.
This is when we circle back to those key characteristics about the patient and the murmur:
- 44 year old man, 1 week post MI
- Blowing, high-pitched
- Physical exam findings: trace pedal edema, decreased breath sounds in bilateral bases
- Acute onset, unstable vital signs
And the Answer Is…
As you know, the above are characteristics more likely seen in acute mitral regurgitation than mitral prolapse. Of course, the question does not end there. We now need to remember the most likely pathophysiologic cause of acute mitral regurgitation following a myocardial infarction, and that is papillary muscle rupture, option C.
PANCE Practice Question #3:
An 80-year-old man with a history of dementia, benign prostatic hyperplasia, diverticulitis, and hypertension presents to the emergency department via ambulance from a nursing home. His medications include donepezil, memantine, tamsulosin, and lisinopril. The paramedics tell you that the nursing home staff were concerned that the patient was having severe abdominal pain. He has not had a bowel movement in 5 days and has had 2 days of nausea and vomiting. He underwent surgery for diverticulitis 1 month ago. The patient is nonverbal due to severe dementia and is unable to answer any questions about his symptoms. Vitals include temperature 38.3°C, BP 100/75 mm Hg, pulse 105 bpm, and SpO2 97% on room air. Physical exam reveals an ill-appearing older man in significant distress who is alert but not oriented to person, place, or time. His abdomen is distended and diffusely tender to palpation without guarding or rigidity. There are well-healing incisions from the prior surgery without erythema, edema, or drainage. The remainder of the physical exam is unremarkable. Part of the abdominal series X-ray is shown above. Which of the following is the best next step for the management of this patient’s condition?
A) CT abdomen and pelvis
B) Empiric antibiotics and serial abdominal exams
C) Hospital admission for intravenous antibiotics
D) Nasogastric tube and serial abdominal exams
E) Urgent surgical consultation for exploratory laparotomy
Question Breakdown
A question I always get asked when talking about PANCE questions is if they’ll be required to interpret diagnostic imaging during the PANCE. Radiographs, electrocardiograms, and high yield neuroimaging are fair game. Regardless, while you may not need to use the diagnostic test alone to answer the question, understanding what you’re seeing can be helpful to confirm your answer.
As usual, start with the lead-in question (last sentence) first. This again requires you to not only diagnose the condition, but also determine what to do next for management.
Key points here include:
- Severe abdominal pain
- No bowel movement in 5 days
- Associated nausea and vomiting
- Prior abdominal surgery
- Unstable vitals: mild fever, hypotension, tachycardia; patient in distress
- Distended, tender abdomen
In this case, you need the abdominal radiograph to reach the proper diagnosis, and therefore appropriate next step. While you can infer based on the clinical vignette that this patient has a bowel obstruction, the abdominal radiograph is showing you free air under the diaphragm. This is a sign of intestinal perforation, which is a complication of a bowel obstruction that’s an emergency and therefore treated differently.
And the Answer Is…
While a normal bowel obstruction would be treated with option D (nasogastric tube and serial abdominal exams to start) a perforated bowel requires E: urgent surgical consultation for exploratory laparotomy.
PANCE Practice Question #4:
A 3-year-old girl presents to the clinic with her mother due to concerns of a sudden-onset cough that began yesterday evening. Her mother reports no prodromal symptoms and states the child was previously in good health. On observation, the child appears to have mild respiratory distress with a harsh cough and stridor with inspiration. Chest wall auscultation reveals focal monophonic wheezing and diminished breath sounds in the upper right lung field. Vital signs include HR of 121 bpm, RR of 28/minute, T of 100.7°F, and SpO2 of 96% on room air. Blood pressure is within normal limits based on age. Which of the following is the most likely diagnosis?
A) Asthma
B) Bronchiolitis
C) Foreign body aspiration
D) Gastroesophageal reflux
E) Tracheomalacia
Question Breakdown
If you use the same technique of reading the lead-in (last sentence) first, you’ll quickly realize you’re just looking for a diagnosis here. This question is more straightforward than the others we’ve reviewed so far.
Let’s focus on the key points:
- 3-year-old
- Sudden onset cough, no prodrome
- No past medical history
- Focal, monophonic wheezing and diminished breath sounds in right upper lung field
- Vitals: tachycardiac, tachypneic, low-grade fever
Despite the question being more straightforward, it still requires you to know the answer choices well. Pediatrics presents a whole new range of possibilities we don’t see in adult medicine. At the same time, things we see in adults are very uncommon in children. When looking at the above answer choices, right away I would get rid of GERD. It doesn’t fit the clinical vignette, and it’s uncommon in children.
With no past medical history, diagnoses like asthma and tracheomalacia are also unlikely. The lung auscultation showed a focal area of wheezing and decreased breath sounds in the right upper lung field.
And the Answer Is…
This fits the clinical presentation of a foreign body aspiration, option C. Foreign body aspiration is very common in children and often happens without the parent being aware, just like in this clinical scenario.
Practice Makes Perfect!
If you feel confident in your understanding of the material but still struggled with answering the questions, I recommend that you continue practicing. There are many great question banks available, including Blueprint’s PANCE Qbank (formerly Rosh Review)! It includes 3,800 NCCPA-formatted questions with detailed explanations, powerful analytics, and more. This not only helps you practice your test-taking skills, it also ensures you really understand the reasoning behind your incorrect answers.
Be sure to check it out, and keep doing PANCE practice questions! ⭐
Looking for more (free!) articles to help you prep for the PANCE? Check out these other posts on the Blueprint PA blog:
