Cardiovascular System
11%of exam
Pulmonary System
9%of exam
Gastrointestinal Nutrition
8%of exam
Musculoskeletal System
8%of exam
Infectious Diseases
7%of exam
Neurologic System
7%of exam
Psychiatry Behavioral Science
7%of exam
Reproductive System
7%of exam
Endocrine System
6%of exam
Eyes Ears Nose Throat
6%of exam
Professional Practice
6%of exam
Hematologic System
5%of exam
Renal System
5%of exam
Dermatologic System
4%of exam
Genitourinary System
4%of exam
Quick Facts
- Exam
- PANCE
- Owner
- NCCPA
- Questions
- 300 multiple-choice
- Blocks
- 5 x 60
- Block time
- 60 minutes
- Exam time
- 5 hours
- Appointment
- About 6 hours
- Pass
- 350 scaled
- Scale
- 200 to 800
- Fee
- $550
- Attempts
- Six tries, six years
- First-time pass
- 92% (2024)
Top Blueprint Weights
Cardio 11, pulmonary 9, GI 8.
Cardiovascular 11%Pulmonary 9%GI nutrition 8%Musculoskeletal 8%
STEMI vs NSTEMI
STEMI
- ST elevation
- Immediate PCI
- Do not delay
NSTEMI
- Troponin rise only
- Risk stratify
- Early invasive
ECG sets urgency
Chest Pain Picker
- ST elevation→Cath lab(STEMI)
- Tearing pain to back→CT angiography(Dissection)
- Pleuritic with hypoxia→CT angiography(Embolism)
- Better sitting forward→NSAID plus colchicine(Pericarditis)
- Exertional, eased by rest→Stress testing(Stable angina)
- Burning after meals→PPI trial(GERD)
- Reproducible on palpation→NSAIDs(Costochondritis)
Cardiovascular Classics
- STEMI
- Immediate PCI
- NSTEMI
- Antiplatelets, then early cath
- Stable angina
- Beta blocker, nitrate PRN
- HFrEF
- ARNI, beta, MRA, SGLT2
- Acute heart failure
- IV loop diuretic
- Atrial fibrillation
- Rate control plus anticoagulation
- Aortic dissection
- CT angiography, esmolol first
- Pericarditis
- NSAID plus colchicine
- Hypertension
- Thiazide, CCB, ACE, ARB
- Cardiac tamponade
- Beck triad, pericardiocentesis
- Kawasaki disease
- IVIG plus aspirin
- Peripheral artery disease
- ABI under 0.9
Murmurs
- Aortic stenosis
- Systolic RUSB, carotid radiation
- Aortic regurgitation
- Diastolic decrescendo, wide pulse pressure
- Mitral regurgitation
- Holosystolic apex, axillary radiation
- Mitral stenosis
- Opening snap, diastolic rumble
- Mitral valve prolapse
- Mid-systolic click, louder standing
- HOCM
- Louder with Valsalva, standing
- VSD
- Harsh holosystolic, lower sternal
- ASD
- Fixed split S2
- PDA
- Continuous machinery murmur
- Tricuspid regurgitation
- Louder with inspiration
- Valsalva
- Softens all but HOCM, MVP
- Handgrip
- Louder regurgitant murmurs
ECG Findings
- ST elevation
- STEMI, activate cath lab
- Diffuse ST elevation
- Pericarditis, PR depression
- Delta wave
- Wolff-Parkinson-White
- Sawtooth waves
- Atrial flutter
- Irregularly irregular
- Atrial fibrillation, absent P
- Peaked T waves
- Hyperkalemia
- Long QT
- Torsades risk
- Electrical alternans
- Effusion, tamponade
- Lengthening PR
- Mobitz I, Wenckebach
- Dropped QRS
- Mobitz II, needs pacing
- AV dissociation
- Third-degree block
- S1Q3T3
- Classic but uncommon PE
Asthma vs COPD
Asthma
- Reversible obstruction
- ICS-formoterol base
- Younger onset
COPD
- Fixed obstruction
- LAMA plus LABA
- Smoking history
Reversibility separates them
Dyspnea Picker
- Wheeze, reversible obstruction→Spirometry(Asthma)
- Smoker, fixed obstruction→LAMA plus LABA(COPD)
- Orthopnea with edema→BNP and echo(Heart failure)
- Sudden pleuritic dyspnea→CT angiography(Embolism)
- Absent sounds, hypotension→Needle decompression(Tension)
- Fever with consolidation→Chest x-ray(Pneumonia)
Pulmonary Classics
- Asthma
- ICS-formoterol controller, reliever
- Stable COPD
- LAMA plus LABA
- COPD exacerbation
- SABA, steroids, antibiotics
- Outpatient pneumonia
- Amoxicillin or doxycycline
- Pulmonary embolism
- CT angiography, then anticoagulate
- Tension pneumothorax
- Needle decompression now
- Obstructive PFT
- FEV1/FVC under 0.7
- Sleep apnea
- Polysomnography, then CPAP
- Active tuberculosis
- RIPE four-drug therapy
- Sarcoidosis
- Bilateral hilar adenopathy
- Bronchiolitis
- RSV infant, supportive care
- Croup
- Steeple sign, dexamethasone
Croup vs Epiglottitis
Croup
- Barking cough
- Steeple sign
- Dexamethasone
Epiglottitis
- Drooling, tripod
- Thumbprint sign
- Secure airway
Drooling means airway
Crohn vs Ulcerative Colitis
Crohn
- Skip lesions
- Transmural, fistulas
- Mouth to anus
Ulcerative colitis
- Continuous involvement
- Mucosal only
- Starts at rectum
Skip versus continuous
Abdominal Pain Picker
- Any reproductive-age female→hCG first(Always)
- RLQ with rebound→CT abdomen(Appendicitis)
- RUQ after fatty meal→Ultrasound(Biliary)
- Epigastric radiating to back→Lipase(Pancreatitis)
- LLQ fever, older adult→CT abdomen(Diverticulitis)
- Colicky flank, hematuria→Noncontrast CT(Stone)
- Pain out of proportion→CT angiography(Mesenteric ischemia)
GI Classics
- GERD
- PPI trial, no alarms
- Peptic ulcer
- Test, treat H pylori
- H pylori
- Bismuth quadruple therapy
- Acute pancreatitis
- Lipase, lactated Ringer fluids
- Cholecystitis
- Ultrasound first, then cholecystectomy
- Choledocholithiasis
- ERCP
- Appendicitis
- CT, then appendectomy
- Diverticulitis
- CT, bowel rest
- C difficile
- Fidaxomicin or oral vancomycin
- Celiac disease
- tTG-IgA, gluten-free diet
- Upper GI bleed
- IV PPI, urgent EGD
- Mesenteric ischemia
- Pain out of proportion
Liver and Ascites
- HBsAg positive
- Active hepatitis B
- Anti-HBs positive
- Immune, vaccinated or recovered
- Hepatitis C
- Direct-acting antivirals cure
- SAAG 1.1 or higher
- Portal hypertension
- SBP
- PMN 250, give ceftriaxone
- Hepatic encephalopathy
- Lactulose, add rifaximin
- Bleeding varices
- Octreotide, banding, ceftriaxone
- Wernicke
- Thiamine before glucose
Gout vs Pseudogout
Gout
- Needle crystals
- Negative birefringence
- First toe
Pseudogout
- Rhomboid crystals
- Positive birefringence
- Knee, wrist
Shape and birefringence
MSK Classics
- Gout
- Negatively birefringent needles
- Pseudogout
- Positively birefringent rhomboids
- Rheumatoid arthritis
- Symmetric small joints, methotrexate
- Osteoarthritis
- Asymmetric, brief morning stiffness
- Septic arthritis
- Aspirate, synovial WBC 50,000
- Compartment syndrome
- Pain on passive stretch
- Scaphoid fracture
- Snuffbox pain, thumb spica
- Cauda equina
- Urgent MRI, then decompression
- Osteoporosis
- T-score -2.5, bisphosphonate
- SCFE
- Obese adolescent, hip pain
- Nursemaid elbow
- Radial head subluxation
- Osteomyelitis
- MRI, bone biopsy culture
Ortho Special Tests
- Lachman
- ACL tear
- Anterior drawer
- ACL tear
- McMurray
- Meniscal tear
- Empty can
- Supraspinatus injury
- Neer, Hawkins
- Shoulder impingement
- Drop arm
- Rotator cuff tear
- Finkelstein
- De Quervain tenosynovitis
- Phalen, Tinel
- Carpal tunnel syndrome
- Straight leg raise
- Lumbar disc herniation
- Thompson
- Achilles tendon rupture
- Trendelenburg
- Gluteus medius weakness
- Ottawa rules
- Decide ankle, knee imaging
Antibiotic First-Line
- Strep pharyngitis
- Penicillin or amoxicillin
- Nonpurulent cellulitis
- Cephalexin
- Skin abscess
- Drain, then TMP-SMX
- Acute otitis media
- High-dose amoxicillin
- Bacterial sinusitis
- Amoxicillin-clavulanate
- Uncomplicated cystitis
- Nitrofurantoin or TMP-SMX
- Pyelonephritis
- Ceftriaxone or ciprofloxacin
- Pneumonia with comorbidity
- Amoxicillin-clavulanate plus macrolide
- Bacterial meningitis
- Vancomycin plus ceftriaxone
- Lyme disease
- Doxycycline
- Rocky Mountain fever
- Doxycycline, any age
- Impetigo
- Topical mupirocin
STI Treatment
- Gonorrhea
- Ceftriaxone 500 mg IM
- Chlamydia
- Doxycycline, seven days
- Syphilis
- Benzathine penicillin G
- PID
- Ceftriaxone, doxycycline, metronidazole
- Trichomonas
- Metronidazole
- Bacterial vaginosis
- Metronidazole, clue cells
- Genital herpes
- Acyclovir or valacyclovir
- HIV
- Start ART for everyone
Infection Classics
- Sepsis
- Cultures, antibiotics, fluids fast
- Influenza
- Oseltamivir within 48 hours
- Mononucleosis
- EBV, avoid contact sports
- Latent TB
- IGRA positive, clear x-ray
- Endocarditis
- Duke criteria, three cultures
- PrEP
- Tenofovir-emtricitabine daily
- Shingles
- Antivirals within 72 hours
- Candidiasis
- Fluconazole or topical azole
- Malaria
- Thick and thin smears
- Tetanus booster
- Every ten years
Stroke FAST
Face, arm, speech, time to act.
Face droopArm driftSpeech slurredTime critical
UMN vs LMN Lesions
Upper motor
- Hyperreflexia
- Spasticity
- Babinski present
Lower motor
- Hyporeflexia
- Flaccid atrophy
- Fasciculations
Tone and reflexes decide
Headache Picker
- Thunderclap, worst ever→Noncontrast CT(Then LP)
- Fever with neck stiffness→LP plus antibiotics(Meningitis)
- Over 50, jaw claudication→ESR and steroids(Arteritis)
- Unilateral with photophobia→Triptan(Migraine)
- Orbital, tearing, clustered→High-flow oxygen(Cluster)
- Papilledema or focal deficit→Neuroimaging(Mass lesion)
Neuro Classics
- Ischemic stroke
- Thrombolysis within 4.5 hours
- Thrombectomy window
- Selected patients, 24 hours
- TIA
- Deficit resolves, no infarct
- Subarachnoid hemorrhage
- Thunderclap, CT then LP
- Bacterial meningitis
- Do not delay antibiotics
- Status epilepticus
- IV lorazepam first
- Migraine
- Triptan or NSAID
- Cluster headache
- High-flow oxygen, sumatriptan
- Giant cell arteritis
- Steroids now, biopsy after
- Multiple sclerosis
- MRI plaques, oligoclonal bands
- Guillain-Barre
- Ascending weakness, IVIG
- Myasthenia gravis
- Fatigable ptosis, pyridostigmine
- Parkinson disease
- Resting tremor, carbidopa-levodopa
- Bell palsy
- Forehead involved, prednisone
- Trigeminal neuralgia
- Carbamazepine
Depression SIG E CAPS
Sleep, interest, guilt, energy, concentration.
Sleep changeInterest lostGuiltEnergy lowConcentration poorAppetite changePsychomotor changeSuicidal thoughts
Delirium vs Dementia
Delirium
- Acute onset
- Attention impaired
- Fluctuates, reversible
Dementia
- Gradual months
- Memory impaired
- Progressive course
Attention versus memory
Psych Classics
- Major depression
- Two weeks, SSRI, therapy
- Bipolar I
- Mania seven days, lithium
- Schizophrenia
- Six months, antipsychotic
- Schizophreniform
- One to six months
- Brief psychotic
- Under one month
- Generalized anxiety
- Six months worry, SSRI
- Panic disorder
- SSRI plus CBT
- PTSD
- Over one month, SSRI
- Anorexia
- Refeeding drops phosphate
- Bulimia
- Fluoxetine, avoid bupropion
- ADHD
- Stimulants first-line
- Alcohol withdrawal
- Benzodiazepines, watch seizures
- Opioid overdose
- Naloxone, pinpoint pupils
- Lithium toxicity
- Tremor, ataxia, confusion
Serotonin Syndrome vs NMS
Serotonin syndrome
- Onset within hours
- Clonus, hyperreflexia
- Cyproheptadine
NMS
- Onset over days
- Lead-pipe rigidity
- Dantrolene
Clonus versus rigidity
Previa vs Abruption
Previa
- Painless bleeding
- No digital exam
- Ultrasound diagnoses
Abruption
- Painful bleeding
- Rigid uterus
- Clinical diagnosis
Pain marks abruption
Pregnancy Classics
- Ectopic pregnancy
- hCG, ultrasound, methotrexate
- Preeclampsia
- 140/90 after 20 weeks
- Eclampsia
- Magnesium sulfate, then delivery
- Gestational diabetes
- Screen 24-28 weeks
- Placenta previa
- Painless bleeding, no exam
- Placental abruption
- Painful bleeding, rigid uterus
- Postpartum hemorrhage
- Atony, oxytocin, massage
- Rh negative mother
- RhoGAM at 28 weeks
- Group B strep
- Screen 36-37 weeks
- Tdap
- Every pregnancy, 27-36 weeks
GYN Classics
- PCOS
- OCP; letrozole for fertility
- Endometriosis
- Cyclic pain, laparoscopy diagnoses
- Leiomyoma
- Heavy menses, ultrasound
- Menopause
- Twelve months amenorrhea
- Abnormal bleeding
- Pregnancy test first
- Mastitis
- Keep feeding, dicloxacillin
- Emergency contraception
- Levonorgestrel or copper IUD
- Breast mass
- Ultrasound young, mammogram older
DKA vs HHS
DKA
- Ketones, acidosis
- Type 1 typical
- Anion gap
HHS
- Glucose over 600
- Minimal ketones
- High osmolality
Acidosis versus osmolality
Endocrine Classics
- Type 2 diabetes
- Metformin first for most
- Diabetes with ASCVD
- Add SGLT2 or GLP-1
- Diagnostic A1c
- 6.5% or higher
- DKA
- Fluids, insulin, replace potassium
- Hypothyroidism
- High TSH, levothyroxine
- Graves disease
- Low TSH, methimazole
- Thyroid storm
- PTU, beta blocker, steroids
- Thyroid nodule
- TSH, ultrasound, then FNA
- Cushing syndrome
- Dexamethasone suppression testing
- Addison disease
- Low sodium, high potassium
- Pheochromocytoma
- Plasma metanephrines, alpha first
- Acromegaly
- IGF-1 screening
- SIADH
- Euvolemic hyponatremia, restrict fluids
- Hyperparathyroidism
- High calcium, high PTH
Hyper vs Hypothyroid
Hyperthyroid
- Low TSH
- Weight loss, tremor
- Methimazole
Hypothyroid
- High TSH
- Fatigue, cold intolerance
- Levothyroxine
TSH moves opposite
Centor Criteria
Fever, exudate, nodes, no cough.
Fever over 38Tonsillar exudateTender anterior nodesCough absent
Red Eye Picker
- Purulent discharge, no pain→Topical antibiotic(Bacterial)
- Watery, highly contagious→Supportive care(Viral)
- Itching, both eyes→Antihistamine drops(Allergic)
- Fixed mid-dilated pupil→Emergency referral(Angle closure)
- Contact lens, ulcer→Urgent ophthalmology(Keratitis)
- Pain on eye movement→CT, IV antibiotics(Orbital cellulitis)
EENT Classics
- Acute otitis media
- Bulging drum, amoxicillin
- Otitis externa
- Tragal pain, topical drops
- Angle-closure glaucoma
- Fixed mid-dilated pupil, emergency
- Open-angle glaucoma
- Cupping, latanoprost first
- Bacterial conjunctivitis
- Purulent, topical antibiotic
- Retinal detachment
- Flashes, floaters, curtain
- Retinal artery occlusion
- Painless loss, cherry-red spot
- Orbital cellulitis
- Painful movement, IV antibiotics
- Epistaxis
- Kiesselbach plexus, anterior pressure
- Peritonsillar abscess
- Uvula deviation, muffled voice
- Meniere disease
- Vertigo, hearing loss, tinnitus
- BPPV
- Dix-Hallpike, then Epley
Professional Practice
- Informed consent
- Risks, benefits, alternatives
- Capacity
- Decision-specific, clinician assesses
- HIPAA
- Minimum necessary disclosure
- Emancipated minor
- Consents without parent
- Mandatory reporting
- Abuse, notifiable infections
- Error disclosure
- Tell the patient promptly
- Sensitivity
- High value rules out
- Specificity
- High value rules in
- Positive predictive value
- Rises with prevalence
- NNT
- 1 divided by ARR
- Type I error
- False positive, alpha
- Randomized trial
- Strongest single study design
Screening Ages
- Colorectal cancer
- Start age 45
- Mammography
- Biennial, ages 40-74
- Cervical cytology
- Start age 21
- HPV co-testing
- Every five years, 30-65
- Lung CT
- Ages 50-80, 20 pack-years
- AAA ultrasound
- Men 65-75 who smoked
- Hepatitis C
- All adults once
- HIV
- Ages 15-65 once
- Osteoporosis DEXA
- Women 65 and older
- Prostate PSA
- Shared decision, 55-69
- Diabetes screening
- Ages 35-70 if overweight
- Zoster vaccine
- Two doses, age 50
Exam Logistics
- Format
- Five blocks, 60 questions
- Block time
- 60 minutes per block
- Break time
- 45 minutes total
- Tutorial
- 15 minutes before start
- Score scale
- 200 to 800
- Passing standard
- 350 or higher
- Eligibility window
- 180 days to schedule
- Attempt limit
- Six tries, six years
- Exam fee
- $550 with application
- Test centers
- Pearson VUE, 300+ sites
Warfarin vs Heparin
Warfarin
- Follow INR
- Vitamin K reverses
- Slow onset
Heparin
- Follow PTT
- Protamine reverses
- Immediate onset
INR versus PTT
Anemia Picker
- MCV under 80→Iron studies(Microcytic)
- Low ferritin→Iron deficiency(Find bleeding)
- Normal ferritin, high RBC→Hemoglobin electrophoresis(Thalassemia)
- MCV over 100→B12 and folate(Macrocytic)
- Macrocytic with neuropathy→B12 replacement(Check MMA)
- Normocytic, low reticulocytes→Marrow workup(Underproduction)
Heme Classics
- Iron deficiency
- Microcytic, low ferritin
- Thalassemia
- Microcytic, normal ferritin
- B12 deficiency
- Macrocytic with neuropathy
- Folate deficiency
- Macrocytic, no neuropathy
- Chronic disease anemia
- Normocytic, low iron binding
- G6PD deficiency
- Bite cells, Heinz bodies
- Sickle cell
- Hydroxyurea reduces crises
- ITP
- Isolated low platelets
- TTP
- Schistocytes, plasma exchange
- DIC
- Low fibrinogen, high D-dimer
- Hemophilia A
- Long PTT, factor VIII
- von Willebrand
- Most common inherited bleeding
- HIT
- Platelets fall day 5-10
- CLL
- Smudge cells, older adults
- CML
- Philadelphia chromosome, imatinib
- AML
- Auer rods
Dialysis AEIOU
Acidosis, electrolytes, ingestion, overload, uremia.
AcidosisElectrolytesIngestionOverloadUremia
Nephrotic vs Nephritic
Nephrotic
- Heavy proteinuria
- Edema, low albumin
- Hyperlipidemia
Nephritic
- Hematuria, RBC casts
- Hypertension
- Oliguria
Protein versus blood
Renal and Electrolytes
- Prerenal AKI
- BUN:Cr above 20
- Acute tubular necrosis
- Muddy brown casts
- Postrenal AKI
- Hydronephrosis on ultrasound
- FeNa under 1%
- Prerenal pattern
- Hyperkalemia
- Calcium gluconate stabilizes first
- Hyponatremia
- Correct under 8 daily
- Hypercalcemia
- Saline, then bisphosphonate
- Hypokalemia
- Check magnesium too
- Nephrolithiasis
- Noncontrast CT, 5 mm
- Nephrotic syndrome
- Over 3.5 grams proteinuria
- Nephritic syndrome
- RBC casts, hypertension
- CKD staging
- Based on eGFR
Anion Gap MUDPILES
Methanol, uremia, ketoacidosis, isoniazid, lactate, salicylates.
MethanolUremiaDiabetic ketoacidosisPropylene glycolIsoniazidLactic acidosisEthylene glycolSalicylates
Melanoma ABCDE
Asymmetry, border, color, diameter, evolving.
AsymmetryIrregular borderVaried colorDiameter over 6mmEvolving lesion
Cellulitis vs Abscess
Cellulitis
- Diffuse erythema
- No fluctuance
- Cephalexin
Abscess
- Fluctuant pocket
- Drain first
- Cover MRSA
Fluid needs drainage
Derm Classics
- Melanoma
- Excisional biopsy, full thickness
- Basal cell
- Pearly, telangiectatic papule
- Squamous cell
- Scaly, ulcerated, sun-exposed
- Actinic keratosis
- Precursor to squamous cell
- Psoriasis
- Silvery plaques, extensor surfaces
- Atopic dermatitis
- Flexural, topical steroids
- Tinea
- KOH shows hyphae
- Scabies
- Burrows, treat with permethrin
- Impetigo
- Honey-colored crusts
- Pityriasis rosea
- Herald patch, Christmas tree
- SJS and TEN
- Stop drug, BSA grades
- Acne
- Retinoid; isotretinoin if severe
- Erythema migrans
- Target rash, doxycycline
Torsion vs Epididymitis
Torsion
- Sudden severe pain
- Absent cremasteric
- Surgery now
Epididymitis
- Gradual onset
- Relief with elevation
- Antibiotics
Sudden pain means surgery
GU Classics
- Cystitis
- Dysuria, frequency, nitrofurantoin
- Pyelonephritis
- Fever, flank tenderness
- Kidney stone
- Colicky flank, hematuria
- BPH
- Alpha blocker first
- Prostate cancer
- PSA, Gleason grading
- Testicular torsion
- Absent cremasteric, operate fast
- Epididymitis
- Relief with elevation
- Testicular cancer
- Painless mass, ultrasound first
- Erectile dysfunction
- PDE5, never with nitrates
- Varicocele
- Bag of worms
- Hydrocele
- Transilluminates, painless
- Stress incontinence
- Leaks with cough
- Urge incontinence
- Sudden urgency, antimuscarinics
Common Traps
Chlamydia therapy
Doxycycline seven days ≠ Single-dose azithromycin
Hyperkalemia sequence
Calcium stabilizes first ≠ Insulin given first
Abscess management
Drainage comes first ≠ Antibiotics alone
H pylori regimen
Bismuth quadruple therapy ≠ Clarithromycin triple therapy
C difficile therapy
Fidaxomicin or vancomycin ≠ Metronidazole first
Guillain-Barre treatment
IVIG or plasmapheresis ≠ Corticosteroids
Facial weakness
Forehead involved is Bell ≠ Forehead spared is stroke
Mononucleosis
EBV, withhold amoxicillin ≠ Strep, give amoxicillin
Pheochromocytoma blockade
Alpha blockade first ≠ Beta blockade first
PDE5 and nitrates
Absolute contraindication ≠ Cautious co-prescribing
Pregnancy testing
hCG before imaging ≠ Imaging, then hCG
Small content areas
Derm and GU tested ≠ Safe to skip
Last Minute
- 1.Fifteen content areas total
- 2.Cardio 11%, pulmonary 9%, GI 8%
- 3.300 questions, five 60-question blocks
- 4.60 minutes per block
- 5.Passing scaled score = 350
- 6.Scale runs 200 to 800
- 7.Peds is 12-15% of questions
- 8.Surgical topics are 8-10%
- 9.Unstable patient: treat before testing
- 10.Reproductive age: check hCG first
- 11.Hyperkalemia: calcium gluconate first
- 12.Drain abscess before antibiotics
- 13.Chlamydia = doxycycline seven days
- 14.Stroke: thrombolysis within 4.5 hours
- 15.Metformin first for type 2
- 16.Answer every question
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