PANCE Examination 2.0 Advanced Clinical
Vignettes and Evidence-Based Decision
Making a well detailed one
written and graded A+ upgraded
A comprehensive 150-question multiple-choice examination
for Physician Assistant candidates, featuring advanced clinical
scenarios across all 15 NCCPA 2025 PANCE blueprint content
categories, emphasizing diagnostic reasoning, therapeutic
decision-making, and evidence-based practice in complex
patient presentations across the lifespan and healthcare
settings.
Instructions
This examination consists of 150 multiple-choice questions. Each question has four
answer options (A, B, C, D). Select the single best answer for each question. Questions
are designed at an advanced level to assess clinical reasoning, diagnostic interpretation,
and therapeutic decision-making consistent with the Physician Assistant National
Certifying Examination (PANCE) standards. Time allocation: 3 hours for completion.
Questions
Cardiovascular System (11%)
,1. A 72-year-old male with a history of ischemic cardiomyopathy (LVEF 28%)
presents with worsening dyspnea, orthopnea, and 3+ pitting edema. His current
medications include carvedilol 25 mg BID, lisinopril 20 mg daily, and furosemide
80 mg BID. Blood pressure is 98/62 mmHg, heart rate 68 bpm, and JVP is 14 cm
H₂O. Which of the following is the most appropriate next step in management?
A) Add digoxin 0.125 mg daily
B) Increase carvedilol to 50 mg BID
C) Add spironolactone 25 mg daily
D) Initiate dobutamine infusion
Correct Answer: C
Rationale: This patient has NYHA class III-IV heart failure with reduced ejection fraction
(HFrEF) despite optimal medical therapy. Spironolactone is indicated for patients with
NYHA class III-IV HFrEF who are already on ACE inhibitors and beta-blockers, as it
reduces mortality and hospitalizations (RALES trial). Digoxin is for symptom control but
does not reduce mortality. Increasing carvedilol may be appropriate but is not the
priority given the patient's already optimized dose. Dobutamine is for acute
decompensation or as bridge to transplant.
2. A 58-year-old female presents with acute onset of substernal chest pain that
began 2 hours ago while at rest. She has a history of hypertension and
hyperlipidemia. ECG shows 1 mm ST-segment depression in leads V3-V6 with T-
wave inversion. Initial high-sensitivity troponin is 15 ng/L (normal <14 ng/L).
Which of the following is the most appropriate management strategy?
A) Immediate coronary angiography
B) Aspirin 324 mg chewed, sublingual nitroglycerin, and observe
C) Aspirin, clopidogrel, heparin, and transfer for angiography within 24-48 hours
D) Thrombolytic therapy
Correct Answer: C
Rationale: This patient has a non-ST-segment elevation myocardial infarction (NSTEMI)
given the presentation, ECG changes, and elevated troponin. The American College of
Cardiology/American Heart Association guidelines recommend an early invasive
strategy (angiography within 24-48 hours) for high-risk NSTEMI patients. Immediate
angiography (<2 hours) is for refractory angina or hemodynamic instability.
Thrombolytics are contraindicated in NSTEMI.
,3. A 45-year-old male with no significant medical history presents with
palpitations, lightheadedness, and near-syncope. ECG demonstrates a regular,
wide-complex tachycardia at 190 bpm with a QRS duration of 140 ms. His blood
pressure is 110/70 mmHg. Which of the following is the most appropriate next
step?
A) Administration of intravenous adenosine 6 mg rapid push
B) Synchronized cardioversion at 100 J
C) Administration of intravenous amiodarone 150 mg over 10 minutes
D) Immediate 12-lead ECG and evaluation for signs of hemodynamic instability
Correct Answer: D
Rationale: Wide-complex tachycardia is either ventricular tachycardia (VT) or
supraventricular tachycardia with aberrancy. The most appropriate next step is a 12-lead
ECG (already performed) and assessment for hemodynamic instability. Since the patient
is hemodynamically stable, a diagnostic approach is warranted. Adenosine may be used
if VT is unlikely or for diagnostic purposes, but it can be dangerous if the rhythm is VT.
Amiodarone is for stable VT. Synchronized cardioversion is for unstable patients.
4. A 68-year-old male with atrial fibrillation and CHA₂DS₂-VASc score of 4 is
started on warfarin. His INR is 1.2 after 5 days of therapy. Which of the following
is the most appropriate management?
A) Continue warfarin at current dose and recheck INR in 7 days
B) Increase warfarin dose by 50%
C) Administer a loading dose of warfarin 10 mg
D) Continue warfarin and initiate enoxaparin bridge therapy
Correct Answer: D
Rationale: This patient has a high CHA₂DS₂-VASc score and requires anticoagulation.
Warfarin has not achieved therapeutic INR. Bridging with enoxaparin until INR reaches
2.0-3.0 is appropriate to prevent thromboembolic events. The warfarin dose should be
titrated based on INR response.
, 5. A 52-year-old female presents with dyspnea on exertion, fatigue, and lower
extremity edema. Echocardiography reveals severe aortic stenosis (valve area 0.8
cm², mean gradient 50 mmHg). She is symptomatic with NYHA class III symptoms.
Which of the following is the most appropriate management?
A) Medical management with diuretics and afterload reduction
B) Aortic valve replacement (surgical or transcatheter)
C) Balloon aortic valvuloplasty
D) Observation with serial echocardiograms
Correct Answer: B
Rationale: Symptomatic severe aortic stenosis has a poor prognosis without
intervention. Aortic valve replacement (surgical or transcatheter) is indicated for
symptomatic patients with severe AS. Balloon valvuloplasty is a palliative procedure for
patients who are not surgical candidates. Medical management alone does not improve
survival.
6. A 65-year-old male with a history of hypertension presents with a blood
pressure of 168/102 mmHg despite adherence to lisinopril 20 mg daily and
hydrochlorothiazide 25 mg daily. His serum creatinine is 1.2 mg/dL, and potassium
is 4.0 mEq/L. Which of the following is the most appropriate next step in
management?
A) Increase lisinopril to 40 mg daily
B) Add amlodipine 5 mg daily
C) Add spironolactone 25 mg daily
D) Refer for renal artery stenosis evaluation
Correct Answer: B
Rationale: This patient has uncontrolled hypertension on two agents (ACE inhibitor and
thiazide diuretic). The American College of Cardiology/American Heart Association
guidelines recommend adding a third agent from a different class, typically a calcium
channel blocker (amlodipine), before escalating existing agents. Spironolactone is an
option but is typically used as fourth-line therapy. Renal artery stenosis evaluation is not
indicated without suggestive features.
Vignettes and Evidence-Based Decision
Making a well detailed one
written and graded A+ upgraded
A comprehensive 150-question multiple-choice examination
for Physician Assistant candidates, featuring advanced clinical
scenarios across all 15 NCCPA 2025 PANCE blueprint content
categories, emphasizing diagnostic reasoning, therapeutic
decision-making, and evidence-based practice in complex
patient presentations across the lifespan and healthcare
settings.
Instructions
This examination consists of 150 multiple-choice questions. Each question has four
answer options (A, B, C, D). Select the single best answer for each question. Questions
are designed at an advanced level to assess clinical reasoning, diagnostic interpretation,
and therapeutic decision-making consistent with the Physician Assistant National
Certifying Examination (PANCE) standards. Time allocation: 3 hours for completion.
Questions
Cardiovascular System (11%)
,1. A 72-year-old male with a history of ischemic cardiomyopathy (LVEF 28%)
presents with worsening dyspnea, orthopnea, and 3+ pitting edema. His current
medications include carvedilol 25 mg BID, lisinopril 20 mg daily, and furosemide
80 mg BID. Blood pressure is 98/62 mmHg, heart rate 68 bpm, and JVP is 14 cm
H₂O. Which of the following is the most appropriate next step in management?
A) Add digoxin 0.125 mg daily
B) Increase carvedilol to 50 mg BID
C) Add spironolactone 25 mg daily
D) Initiate dobutamine infusion
Correct Answer: C
Rationale: This patient has NYHA class III-IV heart failure with reduced ejection fraction
(HFrEF) despite optimal medical therapy. Spironolactone is indicated for patients with
NYHA class III-IV HFrEF who are already on ACE inhibitors and beta-blockers, as it
reduces mortality and hospitalizations (RALES trial). Digoxin is for symptom control but
does not reduce mortality. Increasing carvedilol may be appropriate but is not the
priority given the patient's already optimized dose. Dobutamine is for acute
decompensation or as bridge to transplant.
2. A 58-year-old female presents with acute onset of substernal chest pain that
began 2 hours ago while at rest. She has a history of hypertension and
hyperlipidemia. ECG shows 1 mm ST-segment depression in leads V3-V6 with T-
wave inversion. Initial high-sensitivity troponin is 15 ng/L (normal <14 ng/L).
Which of the following is the most appropriate management strategy?
A) Immediate coronary angiography
B) Aspirin 324 mg chewed, sublingual nitroglycerin, and observe
C) Aspirin, clopidogrel, heparin, and transfer for angiography within 24-48 hours
D) Thrombolytic therapy
Correct Answer: C
Rationale: This patient has a non-ST-segment elevation myocardial infarction (NSTEMI)
given the presentation, ECG changes, and elevated troponin. The American College of
Cardiology/American Heart Association guidelines recommend an early invasive
strategy (angiography within 24-48 hours) for high-risk NSTEMI patients. Immediate
angiography (<2 hours) is for refractory angina or hemodynamic instability.
Thrombolytics are contraindicated in NSTEMI.
,3. A 45-year-old male with no significant medical history presents with
palpitations, lightheadedness, and near-syncope. ECG demonstrates a regular,
wide-complex tachycardia at 190 bpm with a QRS duration of 140 ms. His blood
pressure is 110/70 mmHg. Which of the following is the most appropriate next
step?
A) Administration of intravenous adenosine 6 mg rapid push
B) Synchronized cardioversion at 100 J
C) Administration of intravenous amiodarone 150 mg over 10 minutes
D) Immediate 12-lead ECG and evaluation for signs of hemodynamic instability
Correct Answer: D
Rationale: Wide-complex tachycardia is either ventricular tachycardia (VT) or
supraventricular tachycardia with aberrancy. The most appropriate next step is a 12-lead
ECG (already performed) and assessment for hemodynamic instability. Since the patient
is hemodynamically stable, a diagnostic approach is warranted. Adenosine may be used
if VT is unlikely or for diagnostic purposes, but it can be dangerous if the rhythm is VT.
Amiodarone is for stable VT. Synchronized cardioversion is for unstable patients.
4. A 68-year-old male with atrial fibrillation and CHA₂DS₂-VASc score of 4 is
started on warfarin. His INR is 1.2 after 5 days of therapy. Which of the following
is the most appropriate management?
A) Continue warfarin at current dose and recheck INR in 7 days
B) Increase warfarin dose by 50%
C) Administer a loading dose of warfarin 10 mg
D) Continue warfarin and initiate enoxaparin bridge therapy
Correct Answer: D
Rationale: This patient has a high CHA₂DS₂-VASc score and requires anticoagulation.
Warfarin has not achieved therapeutic INR. Bridging with enoxaparin until INR reaches
2.0-3.0 is appropriate to prevent thromboembolic events. The warfarin dose should be
titrated based on INR response.
, 5. A 52-year-old female presents with dyspnea on exertion, fatigue, and lower
extremity edema. Echocardiography reveals severe aortic stenosis (valve area 0.8
cm², mean gradient 50 mmHg). She is symptomatic with NYHA class III symptoms.
Which of the following is the most appropriate management?
A) Medical management with diuretics and afterload reduction
B) Aortic valve replacement (surgical or transcatheter)
C) Balloon aortic valvuloplasty
D) Observation with serial echocardiograms
Correct Answer: B
Rationale: Symptomatic severe aortic stenosis has a poor prognosis without
intervention. Aortic valve replacement (surgical or transcatheter) is indicated for
symptomatic patients with severe AS. Balloon valvuloplasty is a palliative procedure for
patients who are not surgical candidates. Medical management alone does not improve
survival.
6. A 65-year-old male with a history of hypertension presents with a blood
pressure of 168/102 mmHg despite adherence to lisinopril 20 mg daily and
hydrochlorothiazide 25 mg daily. His serum creatinine is 1.2 mg/dL, and potassium
is 4.0 mEq/L. Which of the following is the most appropriate next step in
management?
A) Increase lisinopril to 40 mg daily
B) Add amlodipine 5 mg daily
C) Add spironolactone 25 mg daily
D) Refer for renal artery stenosis evaluation
Correct Answer: B
Rationale: This patient has uncontrolled hypertension on two agents (ACE inhibitor and
thiazide diuretic). The American College of Cardiology/American Heart Association
guidelines recommend adding a third agent from a different class, typically a calcium
channel blocker (amlodipine), before escalating existing agents. Spironolactone is an
option but is typically used as fourth-line therapy. Renal artery stenosis evaluation is not
indicated without suggestive features.
