20 free PANCE practice questions

Correct answer: B · Acute pericarditis, given the pain pattern and ECG

The MSD Manual describes pericarditis pain as usually aggravated by breathing, coughing, or thoracic motion and often relieved by sitting up and leaning forward, and it calls a pericardial friction rub, which can have three components, the most important physical finding. The ECG fits too: concave ST elevation with PR depression in most leads. Unlike a myocardial infarction, acute pericarditis does not cause reciprocal ST depression (except in aVR and V1) or pathologic Q waves, which argues against an inferior STEMI. A pulmonary embolism can cause pleuritic pain, but it does not explain a friction rub or diffuse PR depression. An aortic dissection can bleed into the pericardium, but nothing here points to it: the pain is positional and pleuritic, and the ECG shows the diffuse pattern of pericarditis.

Look for this next time: Pleuritic chest pain eased by leaning forward, a friction rub, and diffuse concave ST elevation with PR depression point to acute pericarditis (MSD Manual).

Correct answer: D · Prescribe a statin for the primary prevention of CVD

The USPSTF's 2022 recommendation (grade B) is that clinicians prescribe a statin for the primary prevention of cardiovascular disease in adults aged 40 to 75 who have 1 or more risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. She is 58, has hypertension, and her estimated risk is 12%, so she meets every condition. Primary prevention means preventing a first event, so never having had a heart attack or stroke is the reason the recommendation applies, not a reason to skip it. The USPSTF bases the decision on age, risk factors, and estimated risk rather than on an LDL cutoff, and it gives no basis for waiting 5 years. At a risk of 7.5% to under 10%, it recommends offering a statin selectively (grade C).

Look for this next time: Adults aged 40 to 75 with at least one CVD risk factor and a 10-year risk of 10% or more should be prescribed a statin for primary prevention (USPSTF 2022, grade B).

Correct answer: A · Basal cell carcinoma

The MSD Manual describes basal cell carcinoma as a shiny papule that enlarges slowly over months or years and develops a pearly border with prominent surface vessels (telangiectases) and a central depression or ulcer. It notes that these tumors often crust and heal by turns, which can falsely reassure both patient and clinician, and that the diagnosis is confirmed by biopsy. A seborrheic keratosis is a benign growth that does not form a pearly, telangiectatic border or ulcerate again and again. An actinic keratosis is a rough, scaly patch on sun-damaged skin rather than a pearly papule. Molluscum contagiosum causes small umbilicated papules from a viral infection, not one slowly enlarging lesion that bleeds and heals over a year.

Look for this next time: A slowly growing, pearly papule with telangiectases and a central crust or ulcer that bleeds and heals suggests basal cell carcinoma; confirm it by biopsy (MSD Manual).

Correct answer: C · Give IV potassium first and hold insulin until it has risen

The MSD Manual's DKA treatment withholds insulin while serum potassium is below 3.3 mEq/L and gives potassium first; the 2024 consensus report on hyperglycemic crises in adults sets the cutoff higher, postponing insulin until potassium is above 3.5 mmol/L. Although the body's potassium deficit in DKA is large, insulin drives potassium into cells, so levels fall further during treatment and life-threatening hypokalemia can develop. At 2.9 mEq/L, below both cutoffs, starting insulin now and checking again in 4 hours risks exactly that. Fluid resuscitation with IV 0.9% saline is the first step of treatment, so stopping the fluids is wrong. Bicarbonate should not be given routinely, because it can lead to cerebral edema, mainly in children; MSD reserves it for a pH below 7 after an hour of treatment, and nothing in the stem makes it the step before insulin.

Look for this next time: In DKA with low potassium, replace potassium first and hold insulin until the level is above the cutoff (3.3 mEq/L in the MSD Manual, 3.5 mmol/L in the 2024 consensus), because insulin moves potassium into cells.

Correct answer: C · Weber lateralizes to the right; bone conduction is louder on the right

In the Weber test, a one-sided conductive hearing loss makes the tone louder in the affected ear, while a one-sided sensorineural loss makes it louder in the normal ear (MSD Manual). In the Rinne test, air conduction is normally louder than bone conduction; with a conductive loss of more than 25 dB the relationship reverses, so bone conduction is louder on the affected side. Fluid behind her right eardrum impairs sound conduction, so Weber should lateralize to the right and bone conduction should be louder on the right. Lateralization to the left with air conduction still louder on the right is the sensorineural pattern for a right-sided loss. A midline Weber with air conduction louder on both sides is the normal result, and the last option describes a conductive loss in the left ear.

Look for this next time: In a one-sided conductive hearing loss, Weber lateralizes to the affected ear and bone conduction beats air conduction on that side (MSD Manual).

Correct answer: A · Transabdominal ultrasound of the right upper quadrant

The MSD Manual describes the pain of acute cholecystitis as similar to biliary colic but longer (more than 6 hours) and more severe, often with vomiting and a Murphy sign, in which deep inspiration during palpation of the right upper quadrant worsens the pain and halts the breath. Transabdominal ultrasound is the best test to detect gallstones, can show tenderness over the gallbladder (a sonographic Murphy sign), and shows the wall thickening or pericholecystic fluid that signal inflammation. MSD keeps cholescintigraphy for equivocal ultrasound results and treats CT or MRI as adjunctive tests when results are inconclusive or complications are suspected, so MRI is not the first study. A plain radiograph is not among the tests it recommends, and ERCP is an invasive bile duct procedure, not a first test for gallbladder inflammation.

Look for this next time: For suspected acute cholecystitis, order a transabdominal right upper quadrant ultrasound first (MSD Manual).

Correct answer: D · Loss of the ileal sites where vitamin B12 is absorbed

Vitamin B12 binds intrinsic factor, secreted by the gastric parietal cells, and the complex is absorbed in the terminal ileum. The MSD Manual notes that absorption may be inadequate when the ileal absorptive sites are destroyed by inflammatory bowel disease or removed surgically, which describes his resection. A macrocytic anemia with numbness in the feet fits vitamin B12 deficiency. Loss of intrinsic factor from autoimmune atrophic gastritis defines pernicious anemia, but his stomach is not the problem here. B12 comes from meat, poultry, eggs, and dairy foods, and nothing suggests a poor diet. Iron is absorbed in the duodenum and upper jejunum, and iron deficiency causes a microcytic, not a macrocytic, anemia.

Look for this next time: Ileal resection or ileal Crohn disease can cause vitamin B12 deficiency, because B12 bound to intrinsic factor is absorbed in the terminal ileum (MSD Manual).

Correct answer: B · Emergency urology consult for immediate scrotal exploration

These are the classic findings of testicular torsion: sudden severe pain with nausea and vomiting, and a tender testis that is elevated and horizontal, with the cremasteric reflex usually absent on that side (MSD Manual). MSD advises treating patients with suggestive clinical findings and reserving imaging for equivocal cases, because exploration within a few hours offers the only hope of saving the testis; salvage falls from 80 to 100% at 6 to 8 hours to near zero at 12 hours. Manual detorsion may be tried during the first examination, but surgery follows. A nuclear scan takes longer and is less useful clinically, so delaying referral for it wastes time. Watchful waiting with an NSAID, or a urine-guided antibiotic plan, treats torsion as if it were a minor or infectious problem.

Look for this next time: With classic signs of testicular torsion, do not wait for imaging: urgent surgical exploration offers the best chance of saving the testis (MSD Manual).

Correct answer: A · Iron deficiency anemia from chronic menstrual blood loss

The MSD Manual calls iron deficiency the most common cause of anemia, usually from blood loss, with microcytic red cells and low iron stores shown by a low serum ferritin and serum iron and a high total iron-binding capacity. It adds that a ferritin below 30 ng/mL is specific for iron deficiency, and that pica, such as chewing ice, raises suspicion. Ferritin is an acute-phase reactant that rises with inflammation, so a ferritin of 6 ng/mL does not fit anemia of chronic inflammation, and she has no inflammatory disease. Beta thalassemia trait causes microcytosis without draining iron stores, so it would not explain this ferritin. Vitamin B12 deficiency causes a macrocytic anemia, and her MCV of 72 fL is microcytic.

Look for this next time: Microcytic anemia with a ferritin below 30 ng/mL, low serum iron, and a high TIBC means iron deficiency; in a menstruating woman, look first at blood loss (MSD Manual).

Correct answer: C · Start oral doxycycline now, without waiting for serologic tests

CDC's erythema migrans guidance says that patients with likely erythema migrans and possible tick exposure in an endemic area should be treated promptly, whether or not acute serologic testing is ordered, because serologic tests may be falsely negative in the first few weeks of infection, when the rash is common. Waiting for a positive result therefore risks leaving early Lyme disease untreated, and simple observation has no support in that guidance. CDC lists oral doxycycline, amoxicillin, and cefuroxime as the treatment options. It says azithromycin may be used for people who cannot take those three but that it is less effective, so it is not the preferred first choice for a man with no drug allergies.

Look for this next time: Treat likely erythema migrans in an endemic area promptly with an oral antibiotic such as doxycycline; early serology may be falsely negative (CDC).

Correct answer: D · Get a chest radiograph and evaluate her for TB disease

CDC's testing guidance says a positive TB blood test or skin test usually means TB infection, and that more tests, such as a chest radiograph, are needed to rule out TB disease; the test result alone cannot exclude or confirm disease. CDC's complete evaluation includes a medical history, a physical examination, the infection test, a chest radiograph, and a bacteriologic examination, and latent TB infection is diagnosed only when that evaluation does not indicate TB disease. Starting latent TB treatment today skips the step that excludes disease. Treatment for active TB is not started on an infection test alone, before any evidence of disease. Having no symptoms does not cancel a positive result, which usually means she is infected.

Look for this next time: A positive IGRA or TB skin test usually means TB infection; get a chest radiograph and evaluation to rule out TB disease before diagnosing latent infection (CDC).

Correct answer: B · Lachman test with the knee flexed about 20 degrees

The MSD Manual calls the Lachman test the most sensitive physical test for acute anterior cruciate ligament tears. With the patient supine and the knee flexed about 20 degrees, the examiner supports the thigh and moves the lower leg forward; excessive anterior motion suggests a tear. The anterior drawer test, done with the knee at 90 degrees, is less sensitive and less specific for the same injury. The McMurray test evaluates the menisci rather than the cruciate ligaments, and a valgus stress test checks the medial collateral ligament. A pivoting injury with a pop and swelling within hours is the history that makes the ACL test the one to choose.

Look for this next time: The Lachman test, at about 20 degrees of knee flexion, is the most sensitive physical test for an acute ACL tear (MSD Manual).

Correct answer: D · Continue it at the same dose and treat the flare as well

The MSD Manual says that if a patient is taking a urate-lowering drug when a flare begins, it should be continued at the same dose, with dose adjustments deferred until the flare has subsided, and that urate-lowering therapy should not be stopped because of a flare. The flare itself is treated promptly with anti-inflammatory therapy; MSD lists colchicine, NSAIDs, and glucocorticoids as first-line options, chosen by comorbidities and contraindications. Stopping allopurinol interrupts long-term urate control, and raising the dose during the flare is the adjustment MSD says to defer. Switching to probenecid in the middle of a flare has no support in this guidance.

Look for this next time: Keep urate-lowering therapy at the same dose during a gout flare, and treat the flare with colchicine, an NSAID, or a glucocorticoid (MSD Manual).

Correct answer: A · A central lesion, such as a stroke, needing prompt evaluation

The MSD Manual explains that the forehead muscles often receive central input from both cerebral hemispheres, while the lower face receives it from one side. A central lesion, such as a hemispheric stroke or a tumor, therefore weakens mainly the lower face and spares the forehead, so the patient can still wrinkle the forehead, furrow the brow, and close the eyes tightly. A peripheral facial nerve palsy such as Bell palsy weakens the upper and lower face on the same side, which is not what he shows. The trigeminal nerve's motor fibers serve the muscles of chewing, not facial expression. Facial weakness that began this morning is not explained by aging.

Look for this next time: Lower facial weakness that spares the forehead suggests a central lesion such as a stroke; Bell palsy weakens the whole side of the face (MSD Manual).

Correct answer: C · Hold lithium and check her serum lithium concentration now

FDA labeling for lithium warns that diuretics, NSAIDs, renin-angiotensin system antagonists, and metronidazole may increase serum lithium concentrations, and it calls for checking serum levels after any change in concurrent medication. Toxicity is closely related to the serum concentration, and the neurological signs the labeling lists include tremor, lack of coordination, drowsiness, ataxia, and slurred speech. It also tells patients to stop lithium and contact their provider when signs of toxicity appear. Her symptoms began after a thiazide was added, so holding lithium and measuring the level is the step that fits. A beta-blocker would mask one symptom and leave the cause, raising the dose gets the interaction backward, and the labeling warns of neurological toxicity when lithium is combined with antipsychotics.

Look for this next time: A thiazide, an NSAID, or a renin-angiotensin system antagonist can raise lithium levels; new tremor, ataxia, or slurred speech calls for holding lithium and checking the level (FDA lithium labeling).

Correct answer: B · Annual low-dose CT of the chest while he remains eligible

The USPSTF's 2021 recommendation (grade B) is annual screening with low-dose computed tomography for adults aged 50 to 80 who have a 20 pack-year smoking history and currently smoke or quit within the past 15 years. A pack a day for 30 years is 30 pack-years, and he quit 8 years ago, so he qualifies. Screening stops once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery, so for him it would end about 7 years from now. Quitting more than 5 years ago does not disqualify him. The recommended test is low-dose CT, not a yearly chest radiograph or sputum cytology.

Look for this next time: Adults aged 50 to 80 with a 20 pack-year history who smoke or quit within the past 15 years should have annual low-dose CT screening (USPSTF 2021, grade B).

Correct answer: A · Needle decompression of the left chest without waiting for imaging

This is a tension pneumothorax: rising pressure in the pleural space collapses the lung, shifts the mediastinum, and impairs venous return, which can cause hypotension and cardiorespiratory arrest (MSD Manual). The findings fit: absent breath sounds and hyperresonance on the left, with the trachea pushed to the opposite side. MSD calls tension pneumothorax a medical emergency to be diagnosed clinically, without spending time on a confirming chest radiograph, and treated immediately by needle thoracostomy. A radiograph or CT scan before treatment delays the one step that restores circulation. Pericardial tamponade can also cause shock, but it does not explain one-sided absent breath sounds, hyperresonance, and a shifted trachea.

Look for this next time: Suspected tension pneumothorax with hypotension is treated immediately with needle decompression, without waiting for a chest radiograph (MSD Manual).

Correct answer: D · Kidneys retaining bicarbonate because of volume and chloride loss

Vomiting removes gastric acid and chloride, which raises serum bicarbonate and starts a metabolic alkalosis. The MSD Manual explains that the alkalosis persists only if the kidneys fail to excrete the extra bicarbonate, which is normally filtered freely, and that volume depletion and hypokalemia are the most common stimuli for increased bicarbonate reabsorption. Her dizziness on standing, low chloride, and low potassium all point to that mechanism, and MSD treats chloride-responsive alkalosis with IV 0.9% saline. Vomitus carries acid, not bicarbonate. The expected respiratory response to a metabolic alkalosis is a rise in PCO2, not hyperventilation, which would cause a respiratory alkalosis. Ketoacids consume bicarbonate and cause acidosis, the opposite of her pH.

Look for this next time: Vomiting starts a metabolic alkalosis by removing gastric acid; volume and chloride depletion, with hypokalemia, keep it going by making the kidneys reabsorb bicarbonate (MSD Manual).

Correct answer: C · An ectopic pregnancy, most likely in the right adnexa

Above a beta-hCG level called the discriminatory zone, ultrasonography should detect a gestational sac with a yolk sac in a uterine pregnancy; the MSD Manual notes that the recommended threshold has been raised to 3,500 mIU/mL to avoid overdiagnosing ectopic pregnancy. Her level of 4,800 mIU/mL is above it, yet no sac is seen. MSD also lists a complex adnexal mass and echogenic free fluid in the cul-de-sac as ultrasound findings that, with no intrauterine pregnancy, suggest an ectopic pregnancy. An early uterine pregnancy too small to see explains an empty uterus below the discriminatory zone, not above it. A threatened miscarriage requires a pregnancy inside the uterus, and none is seen. A corpus luteum cyst does not explain the empty uterus at this hCG level.

Look for this next time: An empty uterus with a beta-hCG above the discriminatory zone, plus a complex adnexal mass or echogenic free fluid, suggests ectopic pregnancy (MSD Manual).

Correct answer: B · Explore his fears, respect his choice, and document the discussion

The MSD Manual's informed consent guidance says patients have the right to refuse treatment, and that a refusal is not by itself evidence of diminished capacity. A puzzling refusal should prompt further discussion; capacity should be assessed if it seems questionable, but not solely because the patient refuses. He states the risk in his own words, so exploring the fear behind his choice, answering his questions, and noting the discussion in the record respects his decision while leaving room for him to reconsider. A psychiatric evaluation ordered only because he declined is what that guidance warns against. Because he can decide for himself, no one else consents for him, and threatening to end his care pressures him rather than informing him.

Look for this next time: An adult with decision-making capacity may refuse recommended care; explore the reasons, respect the choice, and document the discussion (MSD Manual).