PANCE Neurologic System 5 — Questions and Answers
Question 1: A 30-year-old woman has recurrent episodes of vertigo lasting 20–30 minutes associated with tinnitus and low-frequency hearing loss. The most likely diagnosis is:
- Benign paroxysmal positional vertigo
- Ménière disease (Correct answer)
- Acoustic neuroma
- Vestibular neuritis
Correct answer: Ménière disease
Ménière disease presents with episodic vertigo (20 min–12 hr), fluctuating low-frequency sensorineural hearing loss, tinnitus, and aural fullness.
Question 2: A neonate develops seizures at 36 hours of life after a prolonged difficult delivery. Brain MRI shows restricted diffusion in watershed zones. What is the most appropriate intervention?
- IV phenobarbital only
- Therapeutic hypothermia (whole-body cooling) (Correct answer)
- High-dose corticosteroids
- Emergent neurosurgical decompression
Correct answer: Therapeutic hypothermia (whole-body cooling)
Therapeutic hypothermia (33–34°C for 72 hours) is the standard of care for hypoxic-ischemic encephalopathy in neonates ≥ 36 weeks when initiated within 6 hours of birth.
Question 3: A 55-year-old man with small cell lung cancer develops ascending weakness and areflexia two weeks after chemotherapy. Anti-Hu antibodies are detected. This is an example of:
- Direct tumor invasion of the spinal cord
- Chemotherapy-induced peripheral neuropathy
- Paraneoplastic encephalomyelitis/sensory neuronopathy (Correct answer)
- Lambert-Eaton myasthenic syndrome
Correct answer: Paraneoplastic encephalomyelitis/sensory neuronopathy
Anti-Hu antibodies are associated with paraneoplastic sensory neuronopathy/encephalomyelitis, an immune-mediated syndrome triggered by SCLC.
Question 4: Which of the following features best differentiates essential tremor from Parkinson tremor?
- Essential tremor is a resting tremor that improves with intention
- Essential tremor is an action/postural tremor that worsens at rest (Correct answer)
- Essential tremor is associated with cogwheel rigidity
- Essential tremor improves with levodopa
Correct answer: Essential tremor is an action/postural tremor that worsens at rest
Essential tremor is a kinetic/postural tremor that occurs during movement and is suppressed at rest, whereas Parkinson tremor is a resting 'pill-rolling' tremor.
Question 5: A 19-year-old has her first generalized tonic-clonic seizure. Post-ictal she is confused and has a bitten tongue. EEG shows generalized spike-and-wave discharges at 3–4 Hz. What is the most appropriate initial medication?
- Ethosuximide
- Carbamazepine
- Valproic acid (Correct answer)
- Oxcarbazepine
Correct answer: Valproic acid
Valproic acid is first-line for juvenile myoclonic epilepsy and generalized epilepsies with tonic-clonic seizures; carbamazepine can worsen generalized epilepsies.
Question 6: A patient presents with sudden painless monocular vision loss lasting 10 minutes, described as a 'curtain coming down.' Fundoscopy during the episode shows a pale retina. What is the most likely diagnosis?
- Optic neuritis
- Amaurosis fugax due to carotid artery stenosis (Correct answer)
- Central retinal vein occlusion
- Acute angle-closure glaucoma
Correct answer: Amaurosis fugax due to carotid artery stenosis
Amaurosis fugax (transient monocular blindness) caused by cholesterol emboli from ipsilateral carotid artery stenosis produces the classic 'curtain' vision loss.
Question 7: A 45-year-old woman is brought in after a witnessed tonic-clonic seizure. She takes no medications. Blood glucose is 45 mg/dL. After dextrose administration, the seizure does not recur. What is the most appropriate next step?
- Start long-term antiepileptic drug therapy
- Admit for 24-hour video EEG monitoring
- Treat underlying hypoglycemia cause; no antiepileptic drug needed (Correct answer)
- Perform emergent MRI brain
Correct answer: Treat underlying hypoglycemia cause; no antiepileptic drug needed
A provoked seizure secondary to an identifiable metabolic cause (hypoglycemia) does not require antiepileptic drug therapy; correction of the underlying cause is sufficient.
PANCE Neurologic System 5
A 30-year-old woman has recurrent episodes of vertigo lasting 20–30 minutes associated with tinnitus and low-frequency hearing loss.
The most likely diagnosis is: