Just like you, I've been on the journey to becoming a physician assistant/associate (PA).
So, believe me when I say I understand how pivotal passing your PANCE, PANRE, EOR, and EOC exams is to not only achieve your professional dreams but also maintain your livelihood.
These exams are high stakes and high anxiety. They induce fear and panic in even the most seasoned test taker. To truly conquer them, we need to delve into the anatomy of their questions, much like having a treasure map in a quest for hidden gold.
Here's the silver lining - there's a universal blueprint or 'treasure map' that all creators of these high-stakes exam questions adhere to. This knowledge is taught to PA program faculty and delivered through multi-day workshops such as those offered by the National Board of Medical Examiners (NBME).
In this article, we will discuss the construction rules of high-quality exam questions and provide a treasure map to navigate and decode their structure. By doing so, we will begin to unlock the secrets to mastering your PANCE, PANRE, and summative exams.
The PANCE and PANRE Clinical Vignette Cheat Sheet
A 15-year-old female presents to the emergency department with a 2-week history of a rash on her back. She takes no medications and has an aunt with lupus. Temperature is 7oC (98oF), pulse rate is 88/min, respirations are 16/min, and blood pressure is 120/80 mmHg. She has fine lesions, 5 to 10 mm in diameter, across the trunk, along with some scattered lesions on the extremities. These lesions are salmon-colored, ovoid, and raised, with fine scaling and a collarette appearance. Complete blood count and blood chemistries are normal. Which of the following is the most likely diagnosis?
- The first sentence will include the patient’s age, gender, and setting
- Example: A 15-year-old female presents to the emergency department. . .
- HPI to include details about the presentation, including duration, severity, etc.
- Example: . . . with a 2-week history of a rash on her back.
- Pertinent past medical history (PMHx) and/or family medical history (FMHx) are provided
- Example: She takes no medications and has an aunt with lupus.
- The physical examination (PE) and vital signs are next
- Example: Temperature is 7oC (98oF), pulse rate is 88/min, respirations are 16/min, and blood pressure is 120/80 mmHg. She has fine lesions, 5 to 10 mm in diameter, across the trunk, along with some scattered lesions on the extremities. These lesions are salmon-colored, ovoid, and raised, with fine scaling and a collarette appearance.
- Lab and X-ray findings are provided
- Example: Complete blood count and blood chemistries are normal.
- A focused, lead-in question is then asked
- Example: Which of the following is the most likely diagnosis?
- You’ll have five options from which to choose from
- There is only one correct answer. The other four options must be plausible but incorrect.
The Anatomy of PANCE and PANRE Exam Questions Explained
1. The First Sentence - will include the patient’s age, gender, and setting
A 15-year-old female presents to the emergency department . . .
The first sentence of a test question is like the opening scene of a movie. It sets the stage by providing the patient’s age, gender, complaint, and setting - by far, the most important details of the vignette. This information is crucial as it lays the groundwork for the clinical scenario that follows.
For instance, “A 15-year-old female presents to the emergency department…” is a classic opening. It tells you who the patient is and where they are. In just a few words, you can already begin to think about where this question might be going.
2. HPI - to include details about the presentation, including duration, severity, etc.
. . . with a 2-week history of a rash on her back.
Obviously, you need a little bit more information. And the remainder of that first sentence often contains the patient's chief complaint. For example, “…with a 2-week history of a rash on her back.” This information is vital as it starts to paint the clinical picture.
3. Pertinent past medical history (PMHx) and/or family medical history (FMHx) are provided
She takes no medications and has an aunt with lupus.
This 15-year-old girl presents to the emergency department with a two-week history of a rash on her back. As we follow the construct down, there's pertinent past medical or family history that's provided.
Pertinent past medical history (PMHx) and family medical history (FMHx) are the pillars that support the structure of the question.
This information is not random; it’s a clue to what the question might be testing. For example, “She takes no medication and has an aunt with lupus” provides context and background that could be relevant to the diagnosis. The fact that she takes no medication is an important pertinent negative and should register significantly.
4. The physical examination (PE) and vital signs are next
Temperature is 7oC (98oF), pulse rate is 88/min, respirations are 16/min, and blood pressure is 120/80 mmHg. She has fine lesions, 5 to 10 mm in diameter, across the trunk, along with some scattered lesions on the extremities. These lesions are salmon-colored, ovoid, and raised, with fine scaling and a collarette appearance.
The physical exam and vital signs are the lens through which you can view the patient’s current state. They are the pulse of the question. For example, “Temperature is 7oC (98oF), pulse rate is 88/min, respirations are 16/min, and blood pressure is 120/80 mmHg.” These details are crucial in narrowing down the diagnosis.
The physical exam often includes a description of clinical findings. For example, “She has fine lesions, 5 to 10 mm in diameter, across the trunk, along with some scattered lesions on the extremities. These lesions are salmon-colored, ovoid, and raised, with fine scaling and a collarette appearance.” This description is a clinical portrait that guides you in visualizing the patient’s condition.
These are salmon covered. They're ovid. They're raised. They have the same collarette of scales to them. So now you're painting a picture in your head of what this looks like, where they're located, all important information.
5. Laboratory and X-Ray findings are next
Complete blood count and blood chemistries are normal.
As you navigate the question, lab and X-ray findings are often provided and supply additional clues. For instance, “Complete blood count and blood chemistries are normal.” This information, combined with the history and physical examination, creates a comprehensive clinical scenario.
6. The focused lead-in question is then asked
Which of the following is the most likely diagnosis?
at the end of the vignette, there will always be a focused lead-in question that's asked, such as, in this case, “Which of the following is the most likely diagnosis?” This is where the treasure hunt begins. This question is the compass that guides your thought process in a specific direction.
7. Five answer choices
Following the lead-in, you are presented with five options. Most high-stakes exams, including the PANCE and PANRE, will contain five options. There is only one correct answer, and the other four options must be plausible but incorrect.
For example, in this question, an exam writer may offer the following 5 answer choices:
This is where your clinical knowledge and understanding of the question's anatomy come into play.
You must navigate through these options like a seasoned sailor, using the clues provided in the vignette to steer you toward the correct answer.
The Takeaway: Empowerment Through Understanding
Understanding the anatomy of PANCE and PANRE exam questions empowers you to approach these high-stakes exams with confidence. The knowledge of how these questions are constructed and the strategies to decode them (more detail in a future post) are the keys to unlocking your potential.
As you prepare for your PANCE, PANRE, or summative exams, remember that each question is an opportunity to apply your clinical knowledge and test-taking strategies.
These exams are not about trickery. They are about assessing your competency and knowledge. So, go forth with confidence. You’ve got this!
Stephen Pasquini PA-C
