PANCE, Medical exams, 9%

Pulmonary System

Pulmonary medicine is the second-highest weighted clinical system, spanning obstructive and restrictive disease, infections, malignancy, pleural disorders, and pulmonary vascular disease. Expect questions that hinge on pulmonary function patterns, imaging descriptions, and stepwise therapy.

Position: 2 of 15 content areas
Published weighting: 9% in the official framework
Topics covered: 7 topics in this guide

What is covered

Topics inside this content area.

These topics describe the scope students most often review for this part of PANCE. Treat them as a study checklist rather than an exhaustive list of what a single exam form can sample.

Asthma and COPD: Stepwise controller therapy, exacerbation management, and spirometry patterns that separate the two.
Pulmonary infections: Community and hospital pneumonia, tuberculosis screening and treatment, and pertussis and bronchiolitis patterns.
Pulmonary embolism and pulmonary hypertension: Pretest probability tools, diagnostic pathways, and anticoagulation decisions.
Pleural disease: Effusion transudate versus exudate criteria, pneumothorax types, and management thresholds.
Restrictive and interstitial disease: Fibrosis, pneumoconioses, and sarcoidosis presentations with their imaging vocabulary.
Pulmonary neoplasms: Solitary nodules, primary lung cancer types, and paraneoplastic associations.
Sleep-disordered breathing: Obstructive sleep apnea risk factors, screening, and first-line therapy.

Study tips

How to practice Pulmonary.

Section-specific guidance that follows from how this material is usually tested.

Build one comparison table for obstructive versus restrictive spirometry and review it weekly.
Tie each pneumonia setting to its typical organisms and empiric choices with active recall rather than rereading.
Rehearse the pulmonary embolism diagnostic pathway aloud until the branching feels automatic.

Where this fits

Pulmonary System is 2 of 15 content areas in the PANCE guide, and it carries a published weighting of 9% in the official framework. Use the full guide to balance it against everything else you have to review.

Back to the PANCE guide Official exam information

Sample Pulmonary questions

Practice questions, not yet expert-reviewed

Original practice questions written to the published framework for this section. No expert has reviewed them, and they are not taken from any official exam. Try each one before you open the answer.

Question 1Foundational
Which spirometry finding defines an obstructive ventilatory pattern such as that seen in COPD?
1. AA reduced FEV1/FVC ratio
2. BA reduced FVC with a normal or increased FEV1/FVC ratio
3. CAn increased FEV1 with a normal FVC
4. DA normal FEV1/FVC ratio with an isolated reduction in diffusing capacity
Show answer
Answer: A. A reduced FEV1/FVC ratio
Airflow obstruction slows expiration, so the volume exhaled in the first second falls disproportionately and the FEV1/FVC ratio drops. A reduced FVC with a preserved or high ratio is the restrictive pattern, in which lung volumes shrink but airflow itself is not limited.
Key insight: Obstruction lowers the ratio; restriction lowers the volumes and leaves the ratio normal or high.
Question 2Foundational
A tall, thin 24-year-old man develops sudden pleuritic right-sided chest pain and dyspnea; examination shows decreased breath sounds and hyperresonance to percussion over the right hemithorax. What is the most likely diagnosis?
1. ALobar pneumonia
2. BPleural effusion
3. CSpontaneous pneumothorax
4. DAcute asthma exacerbation
Show answer
Answer: C. Spontaneous pneumothorax
Primary spontaneous pneumothorax classically strikes tall, thin young men with sudden unilateral pleuritic pain, and air in the pleural space produces decreased breath sounds with hyperresonance on the affected side. A pleural effusion is the tempting distractor but produces dullness to percussion, not hyperresonance, because fluid rather than air fills the space.
Key insight: Unilateral decreased breath sounds plus hyperresonance means air in the pleural space; dullness means fluid.
Question 3Intermediate
Which set of criteria uses pleural fluid to serum protein and LDH ratios to classify a pleural effusion as exudative rather than transudative?
1. ARanson criteria
2. BLight criteria
3. CWells criteria
4. DDuke criteria
Show answer
Answer: B. Light criteria
Light criteria call an effusion exudative when the pleural fluid to serum protein ratio exceeds 0.5, the pleural fluid to serum LDH ratio exceeds 0.6, or the pleural fluid LDH exceeds two thirds of the upper limit of normal serum LDH. Ranson criteria grade the severity of acute pancreatitis and have nothing to do with pleural fluid analysis.
Key insight: Meeting any one of the three Light criteria makes the effusion an exudate and sends you looking for infection, malignancy, or inflammation.
Question 4Intermediate
In a hemodynamically stable adult with a high pretest probability of pulmonary embolism and normal kidney function, which imaging study is the preferred test to confirm the diagnosis?
1. AChest radiography
2. BLower extremity venous duplex ultrasonography
3. CCT pulmonary angiography
4. DVentilation-perfusion scanning
Show answer
Answer: C. CT pulmonary angiography
CT pulmonary angiography visualizes the pulmonary arteries directly, is widely available, and is the first-line confirmatory study when kidney function and hemodynamics allow contrast. Ventilation-perfusion scanning is the tempting alternative but is reserved for patients who cannot receive iodinated contrast, because indeterminate results are common.
Key insight: High pretest probability sends you straight to imaging; a D-dimer only helps when the pretest probability is low.
Question 5Advanced
Which paraneoplastic syndrome associated with small cell lung carcinoma produces euvolemic hyponatremia with concentrated urine?
1. ASyndrome of inappropriate antidiuretic hormone secretion
2. BHumoral hypercalcemia of malignancy
3. CHypertrophic pulmonary osteoarthropathy
4. DLambert-Eaton myasthenic syndrome
Show answer
Answer: A. Syndrome of inappropriate antidiuretic hormone secretion
Small cell carcinoma cells can secrete antidiuretic hormone ectopically, causing water retention, dilutional hyponatremia, and inappropriately concentrated urine in a clinically euvolemic person. Humoral hypercalcemia of malignancy from parathyroid hormone-related peptide is the classic paraneoplastic syndrome of squamous cell lung cancer and raises calcium rather than lowering sodium.
Key insight: Small cell lung cancer secretes hormones: think ADH and ACTH; squamous cell lung cancer raises calcium.

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Pulmonary System