How To Answer PANCE / PANRE Examination Questions Sucessfully

You just have to know how to think about answering a question so that you can narrow down your choices.

Questions are usually written in a format that follows a consistent formula. For example, you might have a question that focuses on a particular clinical problem. You will be given four to five choices, all of which will either be a physical examination finding, a diagnosis, a laboratory test to order, or treatment plan. The hard part for you is to figure out which of these similar answers is correct. This is where test-taking strategy can help. First, let’s focus on types of questions, then discuss answer types, and conclude on making the best choice.

Most questions asked on the examination can be placed into certain categories.

In general, questions will be based on either a major medical problem or a situation that requires you to think about the next step in a clinical scenario.

Before we describe type of questions that will be on the examination, here are some question types that you
will not see on the examination:
- True/False questions
- Matching
- Questions of negation (i.e., … all of the following EXCEPT…)
- “Type K” questions (i.e., choices that have more than one answer, e.g., A and B)

Almost all of the questions will come in the form of clinical vignettes. These types of questions are used because they can assess an individual’s knowledge in many different ways. The questions are generally straightforward and most good questions will test an individual to the general knowledge of a subject. With that in mind, you need to take your time in reading the question carefully to determine what it is asking. The first part of the question that you will read is called the stem. The stem is the precursor to the actual question that will be asked. Take this question for example:

A 22-year-old male patient has a 4-day history of periumbilical pain that has migrated to the right lower quadrant over the last 24 hours. He complains of fever, nausea, and a sharp pain to the right lower quadrant on movement. On examination, he has a temperature of 100.7°F, P: 92, R: 16, BP 133 / 88; head and neck examination is normal and cardiac examination has a regular rate and rhythm. Abdominal examination reveals a flat abdomen without scars, normal active bowel sounds are present, and pain on palpation to the right lower quadrant with rebound tenderness at McBurneys point. Laboratory results
reveal a WBC count of 12,000/mm3 with a left shift, urinalysis is negative, and acute abdominal series X-ray has nonspecific bowel gas patterns. Which of the following is the most appropriate diagnosis?

You will notice that the first part of the question is the clinical vignette—this is the stem. By reading the vignette, you should be able to determine that the case is pointing to an acute appendicitis as the most likely diagnosis. The next part of the question, usually the last sentence, is what will determine how you need to answer. Based on the last sentence, this same scenario could change and ask you to determine the next step in treatment, or whether or not to give a certain medication, or if evaluation by a surgeon is warranted. Regardless of any question being asked in the last sentence, you should be able to read the vignette (stem), think about the entire clinical situation (symptoms, examination findings, predictable laboratory results, diagnostic tests, and treatment plans), and be able to answer questions that relate to that clinical scenario.

If you notice the question above, you will see that there is a pattern to how the question is written. Most of the questions that are written in clinical vignette format have a basic flow to the stem.

Here are some basics to most clinical scenario questions:
- Patient demographics (age, gender, ethnicity)
- Presenting problem or chief complaint
- Past history including:
- Medical history
- Surgical history
- Medications
- Family/social history may also be listed
- Details of the physical examination
- Laboratory data and any testing (CT, MRI, X-rays, etc.)

Why is this important to know? If you can learn how questions are written, then you can start to try to understand how to think about what may be asked. A good test taker has the ability to infer all of the necessary information about a clinical scenario from the stem that will be needed to answer any question that comes from the information supplied. In the case of the acute appendicitis question above, while reading the question one should be already thinking about appendicitis and the details associated with the condition: presenting signs and symptoms, typical physical examination findings, differential diagnosis, laboratory and testing findings, and lastly treatment plans. By using this technique, you can make a reasonable guess to what possible questions could be asked, and by the time you get to the actual question you have already assessed possible paths that may need to be taken to get to the correct answer. By the time you get to the answer options to the question, you can already have a good idea on the correct choice without having even looked at them yet. This can help minimize making an incorrect choice. As you look to the choices, try to think in terms of the most common issue or most commonly treated condition. Try to avoid thinking in terms of what is done sometimes in practice. This may not always be the treatment of choice or standard of care.

Some questions will require you to answer about treatment plans. These questions are trying to test you on the gold standard for a condition or treatment of a disease. Remember, these questions are not here to trick you. In this type of examination, you should not see questions that would be considered too detailed or too specific in nature. The “zebras” that can be seen in medicine are usually not the type of questions that are asked in an examination such as the PANCE or PANRE. The questions are written to assess your basic knowledge of medicine and are written in a way to make sure that you understand the basic concepts of the material that is listed within the blueprint of the examination. They are also written in a way to assess your ability to take a question, think about the question from a standpoint of clinical practicality, and be able to choose the best answer based on the information provided. A majority of the questions that are asked should be formatted in a way where you will be able to have an idea on what the answer is even before looking at the choices given.

Now that we have looked at how questions are presented, let’s think about choosing an answer. There will be questions that may have more than one correct answer that you can choose. You need to determine not only what you think is correct, but what is the best choice available.

In many of the questions your objective should be to seek out the answer that is the “most common,” “most likely,” or “next best step” in regards to the clinical scenario provided. This means that you have to know the general knowledge of a disease or pathology as well as how to prioritize these choices into a list from most correct to least. Let’s give some examples of how this works:

The pathogen that is most responsible for community-acquired pneumonia in an outpatient setting is:

A. Haemophilus influenza
B. Streptococcus pneumoniae
C. Moraxella catarrhalis
D. Staphylococcus aureus
E. Mycoplasma pneumoniae

From this question, you can see that there are several correct answers to this question. While it is true that H. influenza, S. aureus, and M. pneumoniae can all cause community-acquired pneumonia, the
best choice for this question is
B (or Streptococcus pneumoniae). To dig a little deeper into the question, you could also consider M. catarrhalis as a choice. However, this pathogen is seen more in patients with comorbidity like COPD. You have to consider what the most likely pathogen would be. Let’s give another example:

What test is the standard test for confirmation of a pulmonary embolus?

A. Chest X-ray
B. Ventilation to perfusion scan
C. CT scan
D. Pulmonary angiography
E. MRI

There are a few correct answers that could be used clinically to find a pulmonary embolus. However, when considering the
best choice and what is considered the gold standard, the answer for this question is
D (or Pulmonary angiography). This is one of the aspects to this test that you must remember—many of the questions will be looking for the gold standard of care. While you may remember that there are other choices that can be used in everyday medicine to either diagnose or treat a disease, the test question is looking for the best choice, not just any correct choice. Having clinical experience is very helpful when testing. However, be careful to remember the standards of care as some clinical practices are more advanced than what a question will ask.
For some questions, you may read the entire scenario but still fall short on knowing what the correct answer is. In this situation, try to think about the most common findings that are associated with this clinical question and then look at the choices. In some cases, you may be able to deduce what the best possible guess may be. A goal in the completion of taking the test is to answer every question that is given to you. Not answering a question can mean points against you, thus lowering your overall performance on the examination.


OTHER CONSIDERATIONS
There are aspects to many questions where you will be given an image to evaluate in order to answer the question or test results. Some things you will see on the examination are:
- ECG
- An X-ray, CT scan, or MRI
- Laboratory values (blood, urine, other tests)
- Photographs, usually of a physical examination finding

A question will usually refer to the information provided by these visual aides. It is worth spending a little time discussing what you need to think about when confronted with these types of questions.

Most of the electrocardiograms that will be given to you will have some basic pathology on the ECG. The tracing will either be in a rhythm strip, and in some cases a 12-lead ECG. You should consider a simple approach to determine what the basic problem may be. Think of each ECG in this easy to remember rhyme: “Narrow or wide, fast or slow, kill my patient, yes or no.” If you can approach the ECG and ask yourself what could be the most life-threatening thing that you may see on the ECG, you should be able to figure out what the question is trying to ask. Try to think about the most common types of ECG rhythms/problems that you will encounter in medicine and have a good general knowledge of their etiology, different presentations, and lastly treatment for the problem.
Several questions may be present that will give you one or two views from an X-ray, a CT scan, or an MRI. With regard to X-rays, try to keep a methodical approach in looking at the films. First understand what you are viewing with regard to anatomy and the type of film that was performed.

Next, make sure you can identify anatomic reference points on the film that will help you assess the entire film.

For example, let’s consider a chest X-ray. For starters, think about your
ABCs as an easy approach.
- A (Airway): Look at the airway, alignment, and the lung tissue and note in your mind any abnormalities. Infiltrates, nodules, masses, atelectasis, and loss of lung tissue as in a pneumothorax and any fluid that may be present are some things to consider.
- B (Bone): Look at the boney structures for any abnormalities. Look at the contour of the ribs and at spine from the AP view and try to determine if there are any abnormalities that stick out on the film.
- C (Cardiac): Look at the cardiac silhouette. Is it large or normal appearance in size? Is there any evidence that there is obstruction of the silhouette by another structure such as a widened mediastinum, mass, or fluid?
- D (Diaphragm): Does the diaphragm appear to be normal? Is there an effusion present that obscures your view of the diaphragm, and do the borders anatomically appear to be in the correct position?
- E (Everything else): Look at the soft tissue for any abnormalities (free air, foreign body, etc.).

This is one way to try to stay organized while taking the test. That way, as you look at the picture or X-ray on the screen, you can determine what the abnormality is, which can give you a better idea on how to answer the question before you see the choices.

In several of the questions you will be given a series of laboratory results, blood, urine, and other tests. Remember, the testing material that you are given will provide you with a list of all laboratory tests and their normal values. These are usually available to you at all times on the test in a separate page on the computer that is easy to pull up at any time. Just remember that if you cannot recall what a normal value is, reference it by utilizing the laboratory value page that is provided. That way, if you get stuck on a question where you may not recall the significance of a laboratory test, you can try to work through the problem by understanding how the laboratory value is abnormal (either elevated, low, positive when a normal value is negative, and so forth).

In some cases, you will encounter a photo that will be provided with a question. In most instances the photo will be directly related to the condition that you are being questioned. This will be in the form of a physical examination finding, a blood smear, a gram stain photo, or some other type of photo that will aid in the question. Remember to use a methodical approach in trying to answer in your mind what you are looking at before you make a decision on the choices that will be given.