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PANCE Neurology Exam
| Questions and Verified
Correct Answers| Latest
Version 2026-2027|
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What is a concussion? Injury to the body or head that results in a force to the brain, it can be accompanied by transient loss of consciousness; but not always. Concussion vs. Mild TBI The term "concussion" is often used in the medical literature as a synonym for mild traumatic brain injury (mild TBI or mTBI). Mild TBI, or concussion has a GCS of 13 to 15 What are the symptoms of a concussion? Headache, dizziness (feeling off balance), confusion, retrograde/antegrade amnesia, and blurred vision. Symptoms typically resolve within 7 to 10 days postinjury.
What are the indications for CT scan of the head in a patient with a suspected concussion? Use validated clinical decision rules (such as the PECARN decision tool) to determine if imaging is warranted - No routine imaging of pediatric patients with mTBI. Indications for CT scan include prolonged loss of consciousness (>1 minute), persistent headache, altered mental status, repeated episodes of vomiting postinjury, history of repeated head injury/severe mechanism, or signs on physical examination of basilar skull fracture. What percent of CT scans in mild TBI are abnormal? Approximately 10 percent of CT scans in mild TBI are abnormal, showing mild subarachnoid hemorrhage, subdural hemorrhage, or contusions. MRI is more sensitive than CT scan, showing abnormalities in approximately 30 percent of patients with normal CT scans What is the acute management of patients with concussion? Rest, symptomatic treatment (for headaches and nausea), no contact sports, and decreased exposure to technology (television, cellular phones, computers, and electronic games). Athletes should be symptom free while at rest and exercise before returning to sports activities. Many states have laws requiring the patient be reevaluated and cleared before starting sports activities, and at times a stepwise progress for returning to activities is followed.
Which patients with PCS should have an MRI? Patient with PCS who have not had an MRI and have disabling complaints should have a brain MRI to exclude more serious pathology that would identify either a worse prognosis or an alternative cause for their symptoms. For patients with post concussion syndrome complaining of headache and dizziness, what is the first-line treatment? Treatment is symptomatic treat headaches like migraines with PRN analgesics, psychotherapy Recovery time from post concussion syndrome? Most patients recover quickly, within several weeks. A minority have prolonged disability A GCS of 13 to 15 indicates what Mild TBI, or concussion has a GCS of 13 to 15
A GCS of 9-12 indicates what? Moderate TBI has a GCS of 9 to 12 A GCS of 8 or less indicates what? Severe TBI has a GCS of 8 or less. When is a brain CT indicated for TBI? The brain CT is done for moderate and severe TBI, as well as in mild TBI where the individual has a worsening headache, persistent confusion, a focal neurological deficit, or is on anticoagulation therapy like warfarin Treatment of traumatic brain injury? General measures for treating TBI include lowering the ICP by elevating the head of the bed to 30 degrees, sedation, intubation and hyperventilation in order to achieve a partial pressure of carbon dioxide or PaCO2 between 35 and 45 millimeters of mercury, osmotic diuresis with mannitol or hypertonic saline, and finally if all else fails, a decompressive craniectomy. Specific lesions identified on CT scan such as epidural and subdural hematomas should be identified and evacuated On CT appear as a convex, “lens-shaped” hyperdense collection of blood that does not cross the suture lines. Epidural hematomas appear as a convex, "lens-shaped" hyperdense collection of blood that does not cross the suture lines.
How does cranial nerve III deficit present? Outward and downward deviation of the eye - Ptosis of the eyelid - Dilation of the ipsilateral pupil in complete palsy - CN III - Oculomotor nerve How does cranial nerve IV deficit present? Vertical diplopia - CN IV = Trochlear nerve How does cranial nerve V deficit present? Anesthesia of the forehead - Corneal drying - Decreased salivation - CN V = Trigeminal nerve How does cranial nerve VI deficit present? Medial turning of affected eye - CN VI = Abducens nerve How does cranial nerve VII deficit present?
Complete or partial paralysis of the face - CN VII = Facial nerve How does cranial nerve VIII deficit present? Positional vertigo - Tinnitus - Rarely hearing loss - CN VIII = Vestibulocochlear nerve How does cranial nerve IX deficit present? Dysphagia and dysarthria - CN IX = Glossopharyngeal nerve How does cranial nerve X deficit present? Focal: Aphonia dysphagia dysarthria - Systemic: (cardiac and GI most affected) - CN X = Vagus nerve How does cranial nerve XI deficit present? Weakness with turning of head - CN XI = Spinal accessory nerve
How does bovine spongiform encephalopathy (mad cow disease) relate to humans? Bovine spongiform encephalopathy (BSE), commonly known as mad cow disease, is an incurable and invariably fatal neurodegenerative disease of cattle. Symptoms include abnormal behavior, trouble walking, and weight loss. Later in the course of the disease the cow becomes unable to function normally. The time between infection and onset of symptoms is generally four to five years. Time from onset of symptoms to death is generally weeks to months. Spread to humans is believed to result in variant Creutzfeldt-Jakob disease (vCJD) Syndrome of acute or subacute encephalopathy that is associated with elevated anti- thyroid antibody titers? Hashimoto encephalopathy (HE) Diagnosis of Hashimoto encephalopathy? The presence of elevated antithyroid antibody titers and the exclusion of other causes of encephalopathy support the diagnosis of HE Treatment of Hashimoto encephalopathy? Treated with corticosteroids
A neurological disorder induced by thiamine, vitamin B1, deficiency. This is the most important encephalopathy due to a single vitamin deficiency and presents with the classic triad of ocular findings, cerebellar dysfunction, and confusion. Wernicke encephalopathy (WE) Treatment of Wernicke encephalopathy? This is a medical emergency and requires infusion of thiamine over a few days to normalized thiamine levels Occurs in individuals with chronic liver disease such as cirrhosis or hepatitis. Early symptoms include forgetfulness, confusion, and breath with a sweet or musty odor. Advanced symptoms include shaking of the hands or arms (asterixis), disorientation, slurred speech, and coma? Hepatic encephalopathy Treatment of hepatic encephalopathy?
A 30-y/o F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of sinusitis. What's the diagnosis? Sinusitis A 50-y/o F presents with recurrent episodes of bilateral squeezing headaches that occur 3 – 4 times a week. She is experiencing significant stress in her life. What's the diagnosis? Tension headaches A 35-y/o M presents with sudden severe headache, vomiting, confusion, left hemiplegia, and nuchal rigidity. What's the diagnosis? Subarachnoid hemorrhage A 25-y/o M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig’s and Brudzinski’s signs are positive. What's the diagnosis? Meningitis
An 18-y/o obese F presents with headache, vomiting, and blurred vision for the past 2– 3 weeks. She is taking OCPs. What's the diagnosis? Pseudotumor cerebri A 47-y/o M c/o daily pain in the right cheek over the past month. The pain is electric in character and occurs while he is shaving. Each episode lasts 2–4 minutes. What's the diagnosis? Trigeminal neuralgia A female > 50, jaw claudication with chewing, visual disturbances (secondary to anterior ischemic optic neuritis), and constitutional symptoms - fever, anorexia, weight loss. What's the diagnosis? Temporal arteritis A 39-year-old man presents with intermittent episodes of severe headaches around the left eye and temple. His symptoms typically last less than an hour and resolve on their own. The headaches awaken him nightly for several days in a row then he is headache- free for a couple of months before another "round" begins. What is the most likely diagnosis?
Diagnosis is based on the distinctive symptom pattern and exclusion of intracranial abnormalities What are the abortive therapy options to treat cluster headaches? 100% oxygen, sumatriptan, or dihydroergotamine. What is the role of corticosteroids in the treatment of cluster headaches? Prednisone can be initiated at the beginning of a cluster cycle to effectively eliminate the patient's symptoms; most patients will be pain-free within 2 days. Long-term prophylaxis of cluster headaches? Verapamil is often used to prevent attacks in patients with chronic or episodic disease. Think of lithium next if verapamil isn't an option or isn't enough - requires monitoring of kidney and thyroid function, lithium levels, etc. What are some typical features of migraine without aura (formerly "common" migraine)? Unilateral, pulsating/throbbing, nausea/ vomiting, photophobia/phonophobia, worse with activity, headache lasting 4-72 hours, and positive family history
What is the usual age of onset of migraine? School-age or teenage years What distinguishes migraine with aura (formerly "classic" migraine)? Typical features of migraine plus gradual development of 1 or more transient focal neurologic symptoms, often preceding peak head pain and lasting <60 minutes What are some common auras associated with migraine? Ophthalmic (most common), hemiparesthetic, aphasic, and hemiplegic (formerly "complicated" migraine) Can someone have a migraine aura without head pain? Yes. These are termed "migraine equivalents" and are usually a diagnosis of exclusion. What are some typical migraine triggers? Stress, sleep deprivation, exertion or trauma, menses, bright lights, certain odors such as perfumes, and food or drink with nitrates, glutamate, aspartame, or tyramine
Because it is a habit-forming barbiturate What 5 prophylactic drug therapies prevent or reduce the frequency of migraine?
- β-Adrenergic blockers such as propranolol
- Calcium-channel blockers such as verapamil
- Tricyclic antidepressants such as amitriptyline
- Valproic acid
- Topiramate What constitutes chronic migraine? Migraine attacks >15 days per month for >3 months How do you "PIN" the migraine diagnosis? "PIN" the migraine diagnosis During the last three months, have you had the following with your headaches? P hotophopia - light bothered you more than when you don't have headaches
I mpairment - headaches limit the ability to work, study or do what you need to do N ausea - felt nauseated or sick to the stomach 2/3 Yes = migraine (93% predictive in primary care setting) Where in the head are the usual locations of tension headache? Bilateral occipital, nuchal, frontal, or encircling the head with bandlike tightness What is the presumed cause of pain in tension headache? Episodic tension headaches are usually associated with stress, and chronic tension headaches are usually associated with contracted muscles Tension headaches usually lead to constant pain for a duration greater than ______ minutes? Tension headaches usually lead to constant pain for a duration greater than 30 minutes
