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PANCE Comprehensive Advanced Practice Examination
180 Multiple-Choice Questions | Advanced Difficulty |
With Detailed Rationales
EXAM TITLE: Comprehensive PANCE Advanced Clinical Competency Assessment — A Systems-
Based, High-Yield Review for Physician Assistant National Certifying Examination (Effective
2025 NCCPA Blueprint)
SECTION 1: CARDIOVASCULAR SYSTEM (11%) — Questions 1–20
1. A 68-year-old male with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and peripheral edema. Echocardiography reveals
an ejection fraction of 32% with global hypokinesis. Which of the following medication classes
has been shown to provide the greatest mortality benefit in this patient population?
A. Loop diuretics
B. Calcium channel blockers
C. ACE inhibitors
D. Digoxin
E. Beta-blockers alone
CorreCt Answer: C
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Rationale: ACE inhibitors (and ARBs) are the cornerstone of heart failure with reduced ejection
fraction (HFrEF) therapy and have demonstrated significant mortality reduction. While beta-
blockers also reduce mortality, ACE inhibitors provide the greatest mortality benefit in HFrEF.
Loop diuretics relieve symptoms but do not improve survival. Digoxin reduces hospitalizations
but not mortality.
2. A 55-year-old male presents with substernal chest pressure that occurs predictably with
exertion and is relieved within 5 minutes of rest. His ECG is normal at rest. Which of the
following is the most appropriate initial diagnostic test?
A. Coronary angiography
B. Exercise stress test
C. CT coronary angiography
D. Resting echocardiogram
E. Holter monitor
CorreCt Answer: B
Rationale: This patient presents with classic stable angina—exertional chest pain relieved by
rest. An exercise stress test is the appropriate initial diagnostic test for stable angina in a patient
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with a normal resting ECG and no contraindications. Coronary angiography is reserved for high-
risk features or failed medical management.
3. A 72-year-old female with a history of hypertension presents with syncope. On
examination, she has a harsh, crescendo-decrescendo systolic murmur heard best at the right
upper sternal border that radiates to the carotids. Her carotid upstrokes are delayed and
diminished. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Aortic regurgitation
E. Pulmonary stenosis
CorreCt Answer: B
Rationale: The classic murmur of aortic stenosis is a harsh crescendo-decrescendo systolic
ejection murmur heard best at the right upper sternal border with radiation to the carotids.
Delayed and diminished carotid upstrokes (parvus et tardus) are characteristic. Syncope is a
classic symptom of severe aortic stenosis.
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4. A 45-year-old male with no significant past medical history presents with acute onset of
severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg in
the right arm and 130/80 mmHg in the left arm. Which of the following is the most
appropriate initial imaging study?
A. Chest X-ray
B. Transthoracic echocardiogram
C. CT angiography of the chest
D. Transesophageal echocardiogram
E. MRI of the chest
CorreCt Answer: C
Rationale: CT angiography of the chest is the gold standard and most appropriate initial test for
suspected aortic dissection. It has high sensitivity and specificity and can be obtained rapidly.
The differential blood pressures between arms and tearing chest pain are classic findings. While
transesophageal echocardiography is also sensitive, CT angiography is more readily available in
most emergency settings.
PANCE Comprehensive Advanced Practice Examination
180 Multiple-Choice Questions | Advanced Difficulty |
With Detailed Rationales
EXAM TITLE: Comprehensive PANCE Advanced Clinical Competency Assessment — A Systems-
Based, High-Yield Review for Physician Assistant National Certifying Examination (Effective
2025 NCCPA Blueprint)
SECTION 1: CARDIOVASCULAR SYSTEM (11%) — Questions 1–20
1. A 68-year-old male with a history of hypertension and type 2 diabetes presents with
progressive dyspnea on exertion, orthopnea, and peripheral edema. Echocardiography reveals
an ejection fraction of 32% with global hypokinesis. Which of the following medication classes
has been shown to provide the greatest mortality benefit in this patient population?
A. Loop diuretics
B. Calcium channel blockers
C. ACE inhibitors
D. Digoxin
E. Beta-blockers alone
CorreCt Answer: C
,2
Rationale: ACE inhibitors (and ARBs) are the cornerstone of heart failure with reduced ejection
fraction (HFrEF) therapy and have demonstrated significant mortality reduction. While beta-
blockers also reduce mortality, ACE inhibitors provide the greatest mortality benefit in HFrEF.
Loop diuretics relieve symptoms but do not improve survival. Digoxin reduces hospitalizations
but not mortality.
2. A 55-year-old male presents with substernal chest pressure that occurs predictably with
exertion and is relieved within 5 minutes of rest. His ECG is normal at rest. Which of the
following is the most appropriate initial diagnostic test?
A. Coronary angiography
B. Exercise stress test
C. CT coronary angiography
D. Resting echocardiogram
E. Holter monitor
CorreCt Answer: B
Rationale: This patient presents with classic stable angina—exertional chest pain relieved by
rest. An exercise stress test is the appropriate initial diagnostic test for stable angina in a patient
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with a normal resting ECG and no contraindications. Coronary angiography is reserved for high-
risk features or failed medical management.
3. A 72-year-old female with a history of hypertension presents with syncope. On
examination, she has a harsh, crescendo-decrescendo systolic murmur heard best at the right
upper sternal border that radiates to the carotids. Her carotid upstrokes are delayed and
diminished. What is the most likely diagnosis?
A. Mitral regurgitation
B. Aortic stenosis
C. Hypertrophic cardiomyopathy
D. Aortic regurgitation
E. Pulmonary stenosis
CorreCt Answer: B
Rationale: The classic murmur of aortic stenosis is a harsh crescendo-decrescendo systolic
ejection murmur heard best at the right upper sternal border with radiation to the carotids.
Delayed and diminished carotid upstrokes (parvus et tardus) are characteristic. Syncope is a
classic symptom of severe aortic stenosis.
, 4
4. A 45-year-old male with no significant past medical history presents with acute onset of
severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg in
the right arm and 130/80 mmHg in the left arm. Which of the following is the most
appropriate initial imaging study?
A. Chest X-ray
B. Transthoracic echocardiogram
C. CT angiography of the chest
D. Transesophageal echocardiogram
E. MRI of the chest
CorreCt Answer: C
Rationale: CT angiography of the chest is the gold standard and most appropriate initial test for
suspected aortic dissection. It has high sensitivity and specificity and can be obtained rapidly.
The differential blood pressures between arms and tearing chest pain are classic findings. While
transesophageal echocardiography is also sensitive, CT angiography is more readily available in
most emergency settings.
