PANCE Practice Questions (2026) — Free Sample Questions with Answers

Answer: B

McMurray test with rotation: McMurray tests for meniscal tears (a painful click with flexion-extension and rotation). It does not assess anterior translation of the tibia.

Lachman test: Correct. A pivoting injury with a pop and rapid hemarthrosis suggests an ACL tear. The Lachman test (anterior tibial translation at 20–30° of flexion) is the most sensitive exam maneuver for ACL tears.

Posterior drawer test: The posterior drawer tests the posterior cruciate ligament, which is usually injured by a direct blow to the proximal tibia (for example a dashboard injury).

Valgus stress test at 30°: Valgus stress tests the medial collateral ligament, typically injured by a blow to the lateral knee. MCL injuries are extra-articular and rarely cause a large hemarthrosis.

Pivot, pop and rapid effusion suggest an ACL tear, and the Lachman test is the most sensitive maneuver. The pivot-shift test is the most specific.

Answer: A

Order a quantitative high-sensitivity D-dimer assay: Correct. When PE is unlikely by Wells score and PERC cannot be applied, a negative high-sensitivity D-dimer (age-adjusted in patients over 50) safely excludes PE. A positive result leads to CT pulmonary angiography.

Proceed directly to CT pulmonary angiography today: CTPA without D-dimer testing exposes a low-probability patient to unnecessary contrast and radiation. It is reserved for a positive D-dimer or a 'PE likely' pretest probability.

Order a ventilation-perfusion scan as the first test: V/Q scanning is mainly used when CTPA is contraindicated (for example severe contrast allergy or renal failure). It is not the first test in low-probability patients.

Obtain bilateral lower-extremity venous duplex scans: Compression ultrasound may support a PE diagnosis in selected patients, but a negative study cannot exclude PE, and she has no leg symptoms.

Suspected PE workup: estimate pretest probability (Wells), apply PERC if probability is low, use D-dimer if PE is unlikely, and go to CTPA if D-dimer is positive or PE is likely.

Answer: C

Acute calculous cholecystitis: Cholecystitis causes RUQ pain, fever and a positive Murphy sign, but it usually does not cause marked jaundice or a dilated common bile duct, because the obstruction is at the cystic duct.

Acute viral hepatitis: Viral hepatitis causes a hepatocellular pattern (transaminases often in the thousands) rather than a cholestatic pattern with a dilated bile duct and high fever.

Acute ascending cholangitis: Correct. Fever, RUQ pain and jaundice (Charcot triad) with cholestatic labs and a dilated common bile duct indicate infection behind an obstructing common duct stone. Treatment is antibiotics plus urgent biliary drainage (ERCP).

Acute gallstone pancreatitis: Gallstone pancreatitis causes epigastric pain radiating to the back with lipase more than 3 times the upper limit of normal. Lipase is normal here.

Charcot triad (fever, jaundice, RUQ pain) means cholangitis. Reynolds pentad adds hypotension and confusion. Treat with antibiotics and urgent ERCP decompression.

Answer: D

No screening, because she has already quit smoking: Former smokers remain eligible if they quit within the past 15 years. She quit 10 years ago, so she qualifies.

Annual posteroanterior and lateral chest radiographs: Screening chest x-rays (with or without sputum cytology) have not been shown to reduce lung cancer mortality and are not recommended.

Sputum cytology every 6 months for early detection: Sputum cytology is insensitive and has no proven mortality benefit as a screening tool.

Annual low-dose computed tomography of the chest: Correct. USPSTF (2021) recommends annual LDCT for adults aged 50–80 with at least 20 pack-years who currently smoke or quit within the past 15 years. She meets all three criteria.

Lung cancer screening (USPSTF 2021) is annual LDCT for ages 50–80 with at least 20 pack-years who smoke now or quit within 15 years. Stop once 15 years have passed since quitting.

Answer: B

Intravenous diltiazem bolus to slow the rate: Calcium channel blockers can be used for rate control in stable AF, but they worsen hypotension in a patient who is already in shock.

Synchronized electrical cardioversion: Correct. A tachyarrhythmia causing hypotension and altered mental status is unstable and needs immediate synchronized cardioversion (with sedation if possible), regardless of how long it has lasted.

Unsynchronized defibrillation at maximum energy: Unsynchronized shocks are for pulseless VT or VF. Delivering an unsynchronized shock in an organized rhythm with a pulse can trigger VF (R-on-T).

Intravenous adenosine 6 mg by rapid push: Adenosine is for stable regular narrow-complex SVT. It will not convert atrial fibrillation and does not address instability.

For tachycardia with a pulse, first check stability (hypotension, altered mental status, shock, ischemic chest pain, acute heart failure). If unstable, perform synchronized cardioversion. If stable, use rate or rhythm drugs.

Answer: C

Switch to apixaban 5 mg twice daily: DOACs are not approved for, and should not be used in, patients with mechanical heart valves. Apixaban has not shown noninferiority in this population.

Switch to dabigatran 150 mg twice daily: In the RE-ALIGN trial, dabigatran caused more thromboembolic and bleeding events than warfarin in patients with mechanical valves. It is contraindicated.

Continue warfarin with an INR goal of 2.5–3.5 (target 3.0): Correct. Warfarin is the only appropriate oral anticoagulant for mechanical valves. A mechanical mitral valve carries higher thrombotic risk and needs an INR goal of 3.0 (range 2.5–3.5). Low-dose aspirin may be added when bleeding risk is low.

Stop warfarin and use aspirin 325 mg daily alone for prophylaxis: Antiplatelet therapy alone does not adequately prevent valve thrombosis or embolism with a mechanical prosthesis.

Mechanical valves require warfarin, never a DOAC. INR targets are 2.5 for a bileaflet aortic valve without risk factors and 3.0 for a mitral valve or an aortic valve with risk factors.