PANCE Neurologic System 4 — Questions and Answers
Question 1: A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. What is the immediate treatment?
- Glucose infusion alone
- Thiamine before glucose (Correct answer)
- Naloxone IV push
- Haloperidol for agitation
Correct answer: Thiamine before glucose
Wernicke encephalopathy requires immediate IV thiamine before glucose, as glucose administration can precipitate or worsen thiamine deficiency.
Question 2: A 25-year-old woman has recurrent episodes of unilateral throbbing headache with photophobia, phonophobia, and nausea lasting 12–24 hours. What is the acute treatment of choice?
- Opioids
- Triptans (e.g., sumatriptan) (Correct answer)
- Beta-blockers
- Topiramate
Correct answer: Triptans (e.g., sumatriptan)
Triptans are serotonin 5-HT1B/1D receptor agonists and are first-line acute therapy for moderate-to-severe migraine.
Question 3: A 70-year-old woman develops diplopia and dysphagia after recovering from a respiratory infection 3 weeks ago. Tensilon (edrophonium) test is positive. What is the underlying mechanism?
- Autoimmune destruction of motor neuron cell bodies
- Antibodies against acetylcholine receptors at the neuromuscular junction (Correct answer)
- Antibodies against voltage-gated calcium channels
- Demyelination of cranial nerve axons
Correct answer: Antibodies against acetylcholine receptors at the neuromuscular junction
Myasthenia gravis results from anti-AChR antibodies blocking neuromuscular transmission, and symptoms improve with edrophonium (acetylcholinesterase inhibitor).
Question 4: A patient with a seizure disorder is started on valproic acid. Which laboratory value must be monitored due to a serious adverse effect?
- Serum creatinine
- Liver function tests (Correct answer)
- Complete blood count only
- Thyroid function tests
Correct answer: Liver function tests
Valproic acid can cause hepatotoxicity (particularly in children < 2 years) and pancreatitis; LFTs and amylase/lipase should be monitored.
Question 5: A right-handed patient has an infarct of the left middle cerebral artery territory. Which deficit is most expected?
- Left homonymous hemianopia only
- Right hemiplegia with expressive aphasia (Correct answer)
- Left hemiplegia with neglect
- Bilateral lower extremity weakness
Correct answer: Right hemiplegia with expressive aphasia
Left MCA stroke in a right-handed person causes contralateral (right) hemiplegia and Broca or global aphasia since language centers are in the left hemisphere.
Question 6: A 40-year-old HIV-positive patient (CD4 count 80 cells/μL) presents with headache, fever, and altered mental status. CSF India ink preparation shows encapsulated organisms. What is the treatment?
- Acyclovir IV
- Liposomal amphotericin B plus flucytosine (Correct answer)
- Fluconazole monotherapy
- Ceftriaxone plus vancomycin
Correct answer: Liposomal amphotericin B plus flucytosine
Cryptococcal meningitis is treated with induction using liposomal amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole consolidation.
Question 7: A patient with chronic low back pain and left leg radiculopathy has weakness of ankle dorsiflexion and great toe extension. Which nerve root is most likely affected?
- L3
- L4
- L5 (Correct answer)
- S1
Correct answer: L5
L5 nerve root compression causes weakness of ankle dorsiflexion (tibialis anterior) and great toe extension (extensor hallucis longus).
PANCE Neurologic System 4
A 50-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia.
What is the immediate treatment?