PANCE

Every PANCE question is coded to one task category in addition to its organ-system content category. The task categories describe what the item asks you to do: gather the history and examine (16%), use diagnostic and laboratory studies (10%), formulate the most likely diagnosis (18%), promote health maintenance (11%), intervene (16%), prescribe (15%), and apply foundational science (8%); professional practice (6%) is covered in its own section. This section collects the cross-cutting skills — exam technique, reference ranges, test statistics, decision rules, screening, procedures, emergencies, and pharmacology principles — that apply to every organ system.

The history alone establishes roughly 70–80% of diagnoses, so items often hinge on the one historical detail or exam finding that separates look-alike conditions. Be systematic, listen actively, and avoid leading questions.

Component	WhattoCapture
Chiefcomplaint	Reasonforthevisitinthepatient'swords withduration ,
HPI(OLDCARTS)	Onset Location Duration Character Aggravating/Relievingfactors Timing Severity;associated , , , , , ,
	symptoms priortreatments ,
Pasthistory	Diagnoses hospitalizations surgeries injuries obstetrichistory , , , ,
Medicationsand	Prescription OTC herbals;adherence Recordthereaction:trueallergy(urticaria anaphylaxis)vs , , . ,
allergies	intolerance(GIupset)
Familyhistory	First-degree relatives: premature CAD (male <55 female <65) diabetes cancers with age at diagnosis , , , ,
	suddendeath
Socialhistory	Pack -years (packs/day × years); standard drinks/week (14 g: 12 oz beer 5 oz wine 1 .5 oz spirits); drugs; , ,
	occupation;housingandfoodsecurity;safety
Sexualhistory(5P's)	Partners Practices Protection PastSTIs Pregnancyintention;askidentityandpronounswithout , , , ,
	assumptions
Reviewofsystems	Screenforsymptomsnotvolunteered;pertinentpositivesandnegatives

Vital Signs and Triage

Measure BP after 5 minutes seated, arm at heart level, with a bladder width ~40% and length ~80% of arm circumference; a small cuff reads falsely high. Check both arms initially — asymmetry suggests subclavian stenosis, coarctation, or dissection. Count an irregular pulse for a full minute (pulse deficit in atrial fibrillation) and respirations unobtrusively. Rectal temperature is most accurate; oral runs ~0.5 °C (≈1 °F) lower. Pulse oximetry reads falsely normal in carbon monoxide poisoning and ~85% in methemoglobinemia.

Adultvitalsigns:Normalrangesandtriageredflags

Parameter	NormalAdult	RedFlag/ActionThreshold
Bloodpressure	<120/<80mmHg	SBP <90 or MAP <65; ≥180/120 with end -organ damage; orthostatic
		drop≥20/≥10within3min
Heartrate	60–100/min	Shock index (HR ÷ SBP) >1 .0 suggests shock (normal 0 .5–0 .7)
Respiratoryrate	12–20/min	≥22(qSOFA) <8;accessorymuscles cannotspeakfullsentences , ,
Temperature	36 .1–37 .2 °C (97–99 °F)	Fever≥380°C(1004°F);<35°Chypothermia;feverinyoung . .
		infantsneedsfullevaluation
SpO 2	95–100%onroomair	<90%significanthypoxemia;target88–92%inCOPDretainers

Pediatricvitalsigns(Approximate,Awake)

Age	HeartRate	Resp. Rate	Hypotension(SBP)
Newborn–1 month	100–160	30–60	<60mmHg
Infant(1–12mo)	100–160	30–50	<70mmHg
Toddler(1–3y)	90–150	24–40	<70 + (2 × age in years) ages 1–10 ,
Preschool(3–5y)	80–140	22–34
Schoolage(6–12y)	70–120	18–30
Adolescent	60–100	12–20	<90mmHg

Examination Technique

Inspection precedes touch. Palpation: fingertips for texture, palm for vibration (thrills, fremitus), dorsum for temperature; light before deep. Abdomen order: inspect → auscultate → percuss → palpate.

Percussion: resonant (lung), dull (solid organ, fluid), tympanic (bowel gas), hyperresonant (emphysema, pneumothorax). Auscultation: diaphragm for high-pitched sounds (S1, S2, breath sounds, regurgitant murmurs); bell for low-pitched (S3, S4, mitral stenosis rumble, bruits).

Condition	Fremitus	Percussion	BreathSounds	Trachea/Other
Consolidation	↑	Dull	Bronchial;crackles	Midline; egophony (E →A) ,
				whisperedpectoriloquy
Pleuraleffusion	↓	Dull("stony")	↓orabsent	Shiftsawayiflarge
Pneumothorax	↓	Hyperresonant	↓orabsent	Shiftsawayiftension
Atelectasis	↓	Dull	↓	Shiftstowardlesion
COPD/emphysema	↓	Hyperresonant	↓;prolongedexpiration wheeze ,	Barrelchest low , diaphragm

Cardiac Auscultation

The PMI is normally at the 5th ICS midclavicular line; lateral displacement suggests LV dilation. Listen at the aortic, pulmonic, Erb's point, tricuspid, and mitral areas. S3 = volume overload (normal in children and pregnancy); S4 = stiff ventricle (LVH), absent in atrial fibrillation. Fixed split S2 = ASD; wide split = RBBB or pulmonic stenosis; paradoxical split = LBBB or severe aortic stenosis; opening snap = mitral stenosis; midsystolic click = mitral valve prolapse.

Dynamicauscultation:Murmurresponsetomaneuvers

Maneuver	PhysiologicEffect	MurmurResponse
Valsalva (strain) or squat-to-	↓Preload	↑HCM;MVPclickearlierandmurmurlonger;mostothermurmurs
stand		(AS MR)↓ ,
Squattingorpassivelegraise	↑Preload(squatalso↑	Mostmurmurs↑(AS MR AR);HCM↓;MVPclicklater murmur , , ,
	afterload)	shorter
Sustainedhandgrip	↑Afterload	↑MR AR VSD;↓ASandHCM , ,
Inspiration	↑Venousreturntoright	↑ Right-sided murmurs (TR — Carvallo sign , PS); expiration favors
	heart	left-sided
Amylnitrite	↓Afterload(vasodilation)	↑ASandHCM;↓MR AR VSD , ,

Only two murmurs get louder with Valsalva/standing: hypertrophic cardiomyopathy and mitral valve prolapse. A young athlete with syncope and a systolic murmur that increases with Valsalva is HCM until proven otherwise — next step is echocardiography.

Neurologic, HEENT, and Musculoskeletal Essentials

Sign	Finding	AssociatedCondition
Murphysign	InspiratoryarrestonRUQpalpation	Acutecholecystitis
McBurney Rovsing psoas , , ,	RLQtenderness;RLQpainwithLLQpressure;pain	Appendicitis
obturator	withhipextension/internalrotation
Cullen/GreyTurner Kehrsign	Periumbilical/flankecchymosis Leftshoulderpain	Hemorrhagicpancreatitis retroperito1 neal , bleed Splenicrupture(diaphragmaticirritation)

Classicexaminationsigns(Continued)

Sign	Finding	AssociatedCondition
Becktriad;pulsusparadoxus	Hypotension JVD muffledheartsounds;SBPfall , ,	Cardiactamponade
	>10mmHgoninspiration
Oslernodes Janewaylesions , ,	Painfulfingerpads;painlesspalmmacules;retinal	Infectiveendocarditis
Rothspots	hemorrhages
Kernig/Brudzinski	Resistedkneeextension/hipflexionwithneck	Meningitis
	flexion
Chvostek/Trousseau	FacialtwitchontappingCNVII/carpalspasmwith	Hypocalcemia
	BPcuff
Battlesign raccooneyes ,	Mastoid/periorbitalecchymosis	Basilarskullfracture
Lachman;McMurray	Anteriortibialtranslation;clickwithtibialrotation	ACLtear(mostsensitivetest);meniscal
		tear
Phalen/Tinel;Finkelstein	Paresthesiaswithwristflexionortapping;painon	Carpaltunnel;deQuervaintenosynovitis
	ulnardeviation
Drop arm; Spurling; straight-leg	Armdrops;radicularpainwithneckcompression;	Rotatorcufftear;cervicalradiculopathy;
raise	legpainat30–70°	lumbardischerniation

Describe skin lesions by primary morphology (macule, papule, plaque, nodule, vesicle, bulla, pustule, wheal), secondary change (scale, crust, erosion, ulcer), and distribution. Document objectively, with pertinent positives and negatives, timed and signed.

OLDCARTS for every symptom; pack-years = packs/day ×

Valsalva ↑ only HCM and MVP; handgrip ↑ MR/AR/VSD and

years.

↓ AS/HCM.

Small cuff → falsely high BP; check both arms at the first

Consolidation ↑ fremitus; effusion and pneumothorax ↓

visit.

fremitus.

Shock index >1.0, SBP <90, or MAP <65 = hemodynamic

Weber lateralizes toward conductive loss and away from

instability.

sensorineural loss.