PANCE Practice Test

Free PANCE Sample Questions & Answers

Question 1

A 68-year-old man with a history of hypertension and hyperlipidemia develops sudden right-sided weakness and difficulty speaking that began 45 minutes ago. His blood pressure is 172/94 mm Hg. A noncontrast CT scan of the head shows no evidence of intracranial hemorrhage.

Which is the most appropriate next step in management?

A. Administer intravenous alteplase after confirming eligibility

B. Begin aspirin immediately before additional evaluation

C. Lower blood pressure to below 120/80 mm Hg before treatment

D. Observe the patient for 24 hours before initiating therapy

Correct Answer: A. Administer intravenous alteplase after confirming eligibility

Explanation

The patient presents with an acute ischemic stroke within the therapeutic treatment window, and the initial CT excludes intracranial hemorrhage. Intravenous thrombolytic therapy should be considered after confirming that no contraindications exist. Blood pressure generally does not need to be normalized completely before treatment, although it may require modest reduction if above recommended thresholds. Aspirin is typically started after thrombolytic decisions have been completed. Delaying treatment significantly reduces the likelihood of neurological recovery because brain tissue is rapidly lost during ischemia.

Question 2

A 29-year-old woman reports progressive fatigue, cold intolerance, constipation, and weight gain over the past several months. Laboratory testing reveals an elevated thyroid-stimulating hormone (TSH) level and a decreased free thyroxine (T4) concentration.

Which diagnosis best explains these findings?

A. Primary hypothyroidism

B. Hyperthyroidism

C. Secondary adrenal insufficiency

D. Graves disease

Correct Answer: A. Primary hypothyroidism

Explanation

Primary hypothyroidism results from inadequate thyroid hormone production by the thyroid gland. As thyroid hormone levels decrease, the pituitary gland compensates by increasing secretion of TSH. Typical symptoms include fatigue, cold intolerance, dry skin, constipation, slowed reflexes, and weight gain. Hashimoto thyroiditis is the most common cause in iodine-sufficient regions. Graves disease generally produces elevated thyroid hormone levels with suppressed TSH. Treatment typically consists of levothyroxine with periodic monitoring of TSH to ensure adequate replacement.

Question 3

A 57-year-old man with long-standing type 2 diabetes mellitus presents for routine follow-up. His urine albumin-to-creatinine ratio is elevated despite well-controlled blood glucose. Blood pressure is 146/88 mm Hg.

Which medication offers both blood pressure control and renal protection?

A. Lisinopril

B. Hydrochlorothiazide

C. Amlodipine

D. Metoprolol

Correct Answer: A. Lisinopril

Explanation

ACE inhibitors are recommended for patients with diabetes who have evidence of albuminuria because they reduce intraglomerular pressure and slow progression of diabetic kidney disease. These medications also improve blood pressure control, reducing cardiovascular risk. Although calcium channel blockers, beta blockers, and thiazide diuretics lower blood pressure, they do not provide the same level of renal protection demonstrated by ACE inhibitors. Monitoring serum creatinine and potassium after initiation is important because transient changes in renal function and electrolyte levels may occur.

Question 4

A previously healthy 24-year-old woman presents with dysuria, urinary frequency, and urgency for two days. She has no fever, flank pain, nausea, or vaginal discharge.

Which diagnosis is most likely?

A. Acute uncomplicated cystitis

B. Acute pyelonephritis

C. Pelvic inflammatory disease

D. Nephrolithiasis

Correct Answer: A. Acute uncomplicated cystitis

Explanation

Acute uncomplicated cystitis commonly presents with dysuria, urinary frequency, urgency, and suprapubic discomfort in otherwise healthy women. Fever, chills, nausea, vomiting, or costovertebral angle tenderness would suggest upper urinary tract involvement such as pyelonephritis. Vaginal discharge or pelvic pain may indicate a gynecologic cause. Most uncomplicated infections are caused by Escherichia coli. Appropriate empiric antibiotic therapy should follow current antimicrobial stewardship recommendations while considering local resistance patterns and patient-specific allergies.

Question 5

A 61-year-old smoker presents with crushing substernal chest pain radiating to the left arm for one hour. Electrocardiography demonstrates ST-segment elevation in the inferior leads.

What is the priority management strategy?

A. Immediate reperfusion therapy

B. Outpatient stress testing

C. Proton pump inhibitor therapy

D. Oral corticosteroid treatment

Correct Answer: A. Immediate reperfusion therapy

Explanation

ST-segment elevation myocardial infarction (STEMI) is a medical emergency requiring rapid restoration of coronary blood flow. Primary percutaneous coronary intervention is preferred when it can be performed promptly; fibrinolytic therapy may be appropriate when PCI is unavailable within recommended time limits and no contraindications exist. Delayed treatment increases infarct size and mortality. Additional evidence-based management includes aspirin, anticoagulation, high-intensity statin therapy, and careful assessment for complications. Early recognition and rapid reperfusion remain the most important determinants of improved patient outcomes.

Question 6

A 64-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea, productive cough, and increased sputum purulence for the past three days. His oxygen saturation is 89% on room air. Chest radiography shows no focal infiltrate.

Which treatment is most appropriate for this patient?

A. Oral corticosteroids, bronchodilators, supplemental oxygen, and appropriate antibiotics

B. Immediate intubation without additional therapy

C. High-dose diuretics as first-line treatment

D. Oral antihistamines and observation only

Correct Answer: A. Oral corticosteroids, bronchodilators, supplemental oxygen, and appropriate antibiotics

Explanation

This patient is experiencing an acute COPD exacerbation characterized by increased dyspnea, sputum volume, and sputum purulence. Management includes short-acting bronchodilators, systemic corticosteroids to shorten recovery time, and supplemental oxygen titrated to maintain oxygen saturation between 88% and 92%. Antibiotics are recommended when increased sputum purulence accompanies worsening respiratory symptoms because bacterial infection is a common trigger. Intubation is reserved for patients with impending respiratory failure or severe hypoxemia despite optimal therapy. Early treatment reduces hospitalization length and improves pulmonary function.

Question 7

A 45-year-old woman presents with sudden onset of severe right upper quadrant abdominal pain that began after eating a fatty meal. Physical examination reveals tenderness in the right upper quadrant and a positive Murphy sign. She is afebrile.

Which diagnosis is most likely?

A. Acute calculous cholecystitis

B. Acute pancreatitis

C. Peptic ulcer disease

D. Acute appendicitis

Correct Answer: A. Acute calculous cholecystitis

Explanation

Acute calculous cholecystitis usually results from obstruction of the cystic duct by gallstones, leading to gallbladder inflammation. Patients commonly report persistent right upper quadrant pain that often follows consumption of fatty foods and may radiate to the right shoulder. A positive Murphy sign is highly suggestive of this condition. Ultrasonography is the preferred initial imaging study because it effectively identifies gallstones and gallbladder wall thickening. Initial treatment includes intravenous fluids, analgesics, antibiotics when indicated, and surgical consultation for early laparoscopic cholecystectomy.

Question 8

A 72-year-old woman presents with sudden pain, deformity, and inability to bear weight after falling on her left side. Her left leg appears shortened and externally rotated.

Which injury is most likely?

A. Femoral neck fracture

B. Anterior cruciate ligament tear

C. Ankle sprain

D. Tibial plateau fracture

Correct Answer: A. Femoral neck fracture

Explanation

A shortened, externally rotated leg following a fall strongly suggests a proximal femoral fracture, particularly a femoral neck fracture. Older adults with osteoporosis are at increased risk after low-energy trauma. Prompt diagnosis with hip radiographs is essential because delayed treatment increases complications such as avascular necrosis, prolonged immobility, venous thromboembolism, and mortality. Surgical repair is generally recommended to restore mobility as soon as medically feasible. Pain management, fall prevention, and evaluation for osteoporosis should be included in the overall treatment plan.

Question 9

A 31-year-old woman reports symmetrical pain and swelling involving both wrists and metacarpophalangeal joints. Morning stiffness lasts approximately two hours and improves with activity.

Which diagnosis best fits this presentation?

A. Rheumatoid arthritis

B. Osteoarthritis

C. Gout

D. Fibromyalgia

Correct Answer: A. Rheumatoid arthritis

Explanation

Rheumatoid arthritis is a chronic autoimmune disease characterized by persistent, symmetrical inflammatory arthritis involving the small joints of the hands and wrists. Morning stiffness lasting longer than one hour is a classic feature and distinguishes inflammatory arthritis from osteoarthritis. Early diagnosis is important because prompt initiation of disease-modifying antirheumatic drugs (DMARDs) reduces joint destruction and improves long-term functional outcomes. Laboratory evaluation may reveal rheumatoid factor and anti-cyclic citrullinated peptide antibodies, although diagnosis relies on the overall clinical presentation rather than laboratory findings alone.

Question 10

A 67-year-old man with hypertension develops sudden inability to speak fluently while maintaining good comprehension. He becomes frustrated because he knows what he wants to say but cannot produce words effectively.

Which area of the brain is most likely affected?

A. Broca area of the dominant frontal lobe

B. Wernicke area of the temporal lobe

C. Occipital cortex

D. Cerebellar hemisphere

Correct Answer: A. Broca area of the dominant frontal lobe

Explanation

Broca aphasia is characterized by impaired speech production with relatively preserved language comprehension. Patients typically speak in short, effortful phrases while remaining aware of their communication difficulty. The lesion usually involves the dominant inferior frontal gyrus supplied by the superior division of the middle cerebral artery. Wernicke aphasia produces fluent but nonsensical speech with impaired comprehension. Prompt neuroimaging is required to differentiate ischemic from hemorrhagic stroke because early treatment decisions depend on accurate diagnosis and symptom onset.

Question 11

A 22-year-old college student presents with fever, neck stiffness, severe headache, and photophobia. Physical examination demonstrates nuchal rigidity.

Which is the most appropriate initial management?

A. Obtain blood cultures and begin empiric intravenous antibiotics immediately

B. Observe the patient for 24 hours

C. Prescribe oral analgesics only

D. Schedule outpatient follow-up in one week

Correct Answer: A. Obtain blood cultures and begin empiric intravenous antibiotics immediately

Explanation

Acute bacterial meningitis is a medical emergency requiring immediate treatment. Blood cultures should be obtained promptly, but empiric intravenous antibiotics should not be delayed while awaiting lumbar puncture or imaging when bacterial meningitis is strongly suspected. Early administration significantly reduces mortality and neurological complications. Corticosteroids may also be administered in selected patients before or with the first antibiotic dose. Delaying therapy increases the risk of permanent hearing loss, seizures, cognitive impairment, and death. Rapid recognition remains essential in all healthcare settings.

Question 12

A 58-year-old woman reports progressive fatigue, polyuria, constipation, and recurrent kidney stones. Laboratory testing reveals elevated serum calcium and elevated parathyroid hormone levels.

Which diagnosis is most likely?

A. Primary hyperparathyroidism

B. Vitamin D deficiency

C. Addison disease

D. Hypoparathyroidism

Correct Answer: A. Primary hyperparathyroidism

Explanation

Primary hyperparathyroidism is characterized by excessive secretion of parathyroid hormone, resulting in hypercalcemia. Common manifestations include kidney stones, constipation, fatigue, depression, bone pain, and excessive urination. Elevated calcium together with an inappropriately elevated parathyroid hormone level confirms the diagnosis in most cases. Surgical removal of the affected parathyroid gland is recommended for many symptomatic patients or those meeting guideline criteria. Untreated disease increases the risk of osteoporosis, nephrolithiasis, and declining renal function over time.

Question 13

A 7-year-old boy develops fever, sore throat, and a fine sandpaper-like rash over his trunk. Examination reveals enlarged anterior cervical lymph nodes and a “strawberry tongue.”

Which organism is the most likely cause?

A. Group A Streptococcus

B. Epstein-Barr virus

C. Staphylococcus aureus

D. Coxsackievirus

Correct Answer: A. Group A Streptococcus

Explanation

Scarlet fever is caused by toxin-producing strains of Group A Streptococcus following streptococcal pharyngitis. Characteristic findings include a diffuse sandpaper rash, strawberry tongue, fever, and tender anterior cervical lymphadenopathy. Diagnosis is confirmed using a rapid antigen detection test or throat culture when appropriate. Treatment with penicillin or amoxicillin shortens symptom duration, reduces transmission, and prevents complications such as acute rheumatic fever. Patients should also receive supportive care including hydration, antipyretics, and adequate rest during recovery.

Question 14

A 26-year-old woman presents with lower abdominal pain, fever, cervical motion tenderness, and purulent cervical discharge.

Which diagnosis is most likely?

A. Pelvic inflammatory disease

B. Ectopic pregnancy

C. Ovarian torsion

D. Endometriosis

Correct Answer: A. Pelvic inflammatory disease

Explanation

Pelvic inflammatory disease (PID) is an ascending infection of the female reproductive tract, most commonly associated with Chlamydia trachomatis and Neisseria gonorrhoeae. Cervical motion tenderness, uterine tenderness, and adnexal tenderness are classic clinical findings. Because delayed treatment increases the risk of infertility, chronic pelvic pain, and ectopic pregnancy, empiric broad-spectrum antibiotics should be started when PID is suspected. Pregnancy testing should be performed to exclude ectopic pregnancy, and patients should be counseled regarding partner evaluation and treatment to prevent reinfection.

Question 15

A 58-year-old man presents with a pearly papule on the bridge of his nose that has slowly enlarged over the past year. Examination reveals rolled borders with visible surface blood vessels.

Which diagnosis is most likely?

A. Basal cell carcinoma

B. Melanoma

C. Squamous cell carcinoma

D. Seborrheic keratosis

Correct Answer: A. Basal cell carcinoma

Explanation

Basal cell carcinoma is the most common form of skin cancer and typically develops on chronically sun-exposed areas of the face. It often appears as a pearly papule with rolled borders and telangiectasias and may ulcerate if untreated. Although metastasis is rare, local tissue destruction can become significant. Diagnosis is confirmed with skin biopsy. Standard treatment includes surgical excision or Mohs micrographic surgery for cosmetically sensitive areas. Patients should also receive counseling regarding sun protection and regular skin examinations to detect future lesions early.

Question 16

A 70-year-old man presents with urinary hesitancy, weak urinary stream, nocturia, and incomplete bladder emptying. Digital rectal examination reveals a smooth, enlarged prostate.

Which diagnosis is most likely?

A. Benign prostatic hyperplasia

B. Acute bacterial prostatitis

C. Prostate cancer

D. Urethral stricture

Correct Answer: A. Benign prostatic hyperplasia

Explanation

Benign prostatic hyperplasia (BPH) is a common age-related condition caused by nonmalignant enlargement of the prostate gland. Typical lower urinary tract symptoms include hesitancy, decreased urinary stream, nocturia, frequency, and incomplete bladder emptying. Digital rectal examination usually demonstrates a smooth, symmetrically enlarged prostate. Initial management depends on symptom severity and may include alpha-adrenergic blockers or 5-alpha-reductase inhibitors. Evaluation should also exclude urinary tract infection, neurologic disease, and prostate malignancy. Untreated severe obstruction can eventually lead to urinary retention and renal impairment.

Question 17

A 38-year-old woman presents with sudden pleuritic chest pain and shortness of breath one week after knee surgery. Her heart rate is 118 beats/min, and oxygen saturation is 91% on room air.

Which diagnosis should be considered first?

A. Pulmonary embolism

B. Community-acquired pneumonia

C. Stable angina

D. Acute pericarditis

Correct Answer: A. Pulmonary embolism

Explanation

Recent surgery is a significant risk factor for venous thromboembolism. The combination of acute dyspnea, pleuritic chest pain, tachycardia, and hypoxemia should immediately raise suspicion for pulmonary embolism. Clinical probability should be assessed using validated tools, followed by appropriate imaging such as CT pulmonary angiography when indicated. Anticoagulation should be initiated promptly in eligible patients once the diagnosis is confirmed or when clinical suspicion is high and bleeding risk is acceptable. Delayed recognition substantially increases morbidity and mortality.

Question 18

A 48-year-old woman complains of persistent sadness, fatigue, poor concentration, reduced appetite, and loss of interest in activities she previously enjoyed. Symptoms have been present nearly every day for seven weeks and interfere with work performance.

Which diagnosis is most appropriate?

A. Major depressive disorder

B. Generalized anxiety disorder

C. Bipolar I disorder

D. Adjustment disorder

Correct Answer: A. Major depressive disorder

Explanation

Major depressive disorder requires at least two weeks of depressed mood or loss of interest accompanied by additional symptoms such as sleep disturbance, appetite changes, fatigue, impaired concentration, feelings of worthlessness, or suicidal ideation. Symptoms must cause clinically significant functional impairment and not be attributable to another medical condition or substance use. Treatment typically combines psychotherapy with antidepressant medication depending on severity and patient preference. All patients should be screened for suicide risk and assessed for a history of manic or hypomanic episodes before initiating antidepressant therapy.

Question 19

A 62-year-old man presents with severe epigastric pain radiating to the back, nausea, and vomiting. Laboratory testing reveals a markedly elevated serum lipase level.

Which diagnosis is most likely?

A. Acute pancreatitis

B. Acute cholecystitis

C. Perforated peptic ulcer

D. Mesenteric ischemia

Correct Answer: A. Acute pancreatitis

Explanation

Acute pancreatitis commonly presents with severe epigastric pain radiating to the back, accompanied by nausea and vomiting. Diagnosis requires at least two of the following: characteristic abdominal pain, serum lipase or amylase levels at least three times the upper limit of normal, or imaging findings consistent with pancreatitis. Gallstones and excessive alcohol use remain the leading causes. Initial treatment emphasizes aggressive intravenous fluid resuscitation, pain management, nutritional support, and identification of the underlying cause. Routine prophylactic antibiotics are not recommended in uncomplicated pancreatitis.

Question 20

A 55-year-old woman with long-standing hypertension presents with fatigue and lower-extremity edema. Laboratory testing reveals an estimated glomerular filtration rate (eGFR) of 42 mL/min/1.73 m² that has remained reduced for more than three months.

Which diagnosis is most appropriate?

A. Chronic kidney disease

B. Acute kidney injury

C. Nephrotic syndrome

D. Acute glomerulonephritis

Correct Answer: A. Chronic kidney disease

Explanation

Chronic kidney disease (CKD) is defined by abnormalities of kidney structure or function that persist for at least three months. An eGFR below 60 mL/min/1.73 m² for more than three months meets the diagnostic criteria, even if symptoms are mild. Hypertension and diabetes are the most common underlying causes. Management focuses on controlling blood pressure, reducing cardiovascular risk, avoiding nephrotoxic medications, and slowing disease progression with appropriate renoprotective therapies when indicated. Regular monitoring of kidney function, electrolytes, and urinary albumin is essential for long-term care.