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PANCE 2026 Comprehensive Exam Bank:
Multiple-Choice Questions Across All Blueprint
Domains with Expert Rationales
SECTION I: CARDIOVASCULAR SYSTEM (Questions 1–39)
Ischemic Heart Disease (Questions 1–10)
Question 1
A 62-year-old male with a history of hypertension and hyperlipidemia presents to the
emergency department with substernal chest pressure that radiates to his left arm. The pain
began 45 minutes ago while he was walking. He is diaphoretic and nauseated. His ECG shows ST-
segment elevation in leads V1–V4. Which of the following is the most appropriate immediate
management?
A) Aspirin 324 mg PO, nitroglycerin SL, and primary percutaneous coronary intervention (PCI)
B) Aspirin 81 mg PO, sublingual nitroglycerin, and admission for medical management
C) Aspirin 324 mg PO, sublingual nitroglycerin, and thrombolytic therapy
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D) Aspirin 324 mg PO, oral beta-blocker, and echocardiogram
E) Aspirin 324 mg PO, sublingual nitroglycerin, and referral for stress testing
CorreCt Answer: A
Rationale: This patient presents with an acute anterior STEMI (ST elevation in V1–V4). The most
appropriate immediate management is aspirin, nitroglycerin, and primary PCI (if available
within 90 minutes of first medical contact). Thrombolytic therapy (C) is an alternative if PCI is
not available. Medical management alone (B) is inadequate. Stress testing (E) is contraindicated
in acute STEMI.
Question 2
A 58-year-old female with a history of diabetes presents with intermittent chest discomfort that
occurs with exertion and improves with rest. She reports that the pain is a dull pressure
sensation in her chest that sometimes radiates to her jaw. Her ECG is normal, and troponin
levels are negative. Which of the following is the most appropriate next step in management?
A) Exercise stress testing
B) Coronary angiography
C) Aspirin and statin therapy with lifestyle modification
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D) Beta-blocker therapy
E) Echocardiogram
CorreCt Answer: C
Rationale: This patient has stable angina based on the history of exertional chest pain relieved
by rest with negative troponin. The most appropriate management is aspirin, statin therapy,
and lifestyle modification (risk factor reduction). Exercise stress testing (A) would be
appropriate to confirm the diagnosis but is not the initial management step. Coronary
angiography (B) is reserved for patients with unstable angina or high-risk features.
Question 3
A 65-year-old male with a history of myocardial infarction presents with worsening shortness of
breath, orthopnea, and peripheral edema. Physical examination reveals jugular venous
distention, crackles in the lung bases, and an S3 gallop. Which of the following is the most likely
diagnosis?
A) Acute decompensated heart failure
B) Pulmonary embolism
C) Chronic obstructive pulmonary disease
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D) Myocardial infarction
E) Pericarditis
CorreCt Answer: A
Rationale: This patient presents with classic signs of acute decompensated heart failure:
dyspnea, orthopnea, peripheral edema, JVD, crackles, and an S3 gallop. The history of prior MI
and the physical findings strongly support this diagnosis. Pulmonary embolism (B) would more
likely present with acute dyspnea, pleuritic chest pain, and hypoxia.
Question 4
A 55-year-old female presents with chest pain that is sharp and pleuritic in nature. The pain
worsens when she lies flat and improves when she sits up and leans forward. She reports a
recent upper respiratory infection. An ECG shows diffuse ST-segment elevation and PR
depression. Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
PANCE 2026 Comprehensive Exam Bank:
Multiple-Choice Questions Across All Blueprint
Domains with Expert Rationales
SECTION I: CARDIOVASCULAR SYSTEM (Questions 1–39)
Ischemic Heart Disease (Questions 1–10)
Question 1
A 62-year-old male with a history of hypertension and hyperlipidemia presents to the
emergency department with substernal chest pressure that radiates to his left arm. The pain
began 45 minutes ago while he was walking. He is diaphoretic and nauseated. His ECG shows ST-
segment elevation in leads V1–V4. Which of the following is the most appropriate immediate
management?
A) Aspirin 324 mg PO, nitroglycerin SL, and primary percutaneous coronary intervention (PCI)
B) Aspirin 81 mg PO, sublingual nitroglycerin, and admission for medical management
C) Aspirin 324 mg PO, sublingual nitroglycerin, and thrombolytic therapy
,2
D) Aspirin 324 mg PO, oral beta-blocker, and echocardiogram
E) Aspirin 324 mg PO, sublingual nitroglycerin, and referral for stress testing
CorreCt Answer: A
Rationale: This patient presents with an acute anterior STEMI (ST elevation in V1–V4). The most
appropriate immediate management is aspirin, nitroglycerin, and primary PCI (if available
within 90 minutes of first medical contact). Thrombolytic therapy (C) is an alternative if PCI is
not available. Medical management alone (B) is inadequate. Stress testing (E) is contraindicated
in acute STEMI.
Question 2
A 58-year-old female with a history of diabetes presents with intermittent chest discomfort that
occurs with exertion and improves with rest. She reports that the pain is a dull pressure
sensation in her chest that sometimes radiates to her jaw. Her ECG is normal, and troponin
levels are negative. Which of the following is the most appropriate next step in management?
A) Exercise stress testing
B) Coronary angiography
C) Aspirin and statin therapy with lifestyle modification
,3
D) Beta-blocker therapy
E) Echocardiogram
CorreCt Answer: C
Rationale: This patient has stable angina based on the history of exertional chest pain relieved
by rest with negative troponin. The most appropriate management is aspirin, statin therapy,
and lifestyle modification (risk factor reduction). Exercise stress testing (A) would be
appropriate to confirm the diagnosis but is not the initial management step. Coronary
angiography (B) is reserved for patients with unstable angina or high-risk features.
Question 3
A 65-year-old male with a history of myocardial infarction presents with worsening shortness of
breath, orthopnea, and peripheral edema. Physical examination reveals jugular venous
distention, crackles in the lung bases, and an S3 gallop. Which of the following is the most likely
diagnosis?
A) Acute decompensated heart failure
B) Pulmonary embolism
C) Chronic obstructive pulmonary disease
, 4
D) Myocardial infarction
E) Pericarditis
CorreCt Answer: A
Rationale: This patient presents with classic signs of acute decompensated heart failure:
dyspnea, orthopnea, peripheral edema, JVD, crackles, and an S3 gallop. The history of prior MI
and the physical findings strongly support this diagnosis. Pulmonary embolism (B) would more
likely present with acute dyspnea, pleuritic chest pain, and hypoxia.
Question 4
A 55-year-old female presents with chest pain that is sharp and pleuritic in nature. The pain
worsens when she lies flat and improves when she sits up and leans forward. She reports a
recent upper respiratory infection. An ECG shows diffuse ST-segment elevation and PR
depression. Which of the following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pericarditis
C) Pulmonary embolism
