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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. contraindication of sumatripta
Get up from chair walk a short distance turn around and sit; screening test for fall
Coronary artery disease
Acetylecholinersterase inhibitors
<20; if patient scores >25 benign forgetfulness

2. medial thigh sensory loss and weakness in addcution
82% specific for dementia
Propranolol or primidone
Obturator n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

3. GBS
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
IVIG and plasmapheresis
Get up from chair walk a short distance turn around and sit; screening test for fall
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

4. cluster headache
Reduced efficacy of OCP
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
RBC count >6000
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

5. impaired perception of complex sounds
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
RBC count >6000
Lesion in nondominant temporal lobe
Obturator n lesion

6. How to differentiate dementias
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function
Aphasia - neglect - agnosia - acalculia etc
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

7. excessive elevation of legs during walking (toe touch floor earlier than heels)
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero
Aspirin - control HTN and swallow eval before giving any oral meds
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc

8. botulism
Antitoxin
Tunnel vision - diaphoresis - nausea - pallor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cholinesterase inhibitor; and antiparkinsonism drugs

9. Unable to copy of matchstick - unable to dress up
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Upright supine position
Construction apraxia; lesion in non dominant parietal lobe (right)

10. Acute onset of left arm weakness
EPV - campylobacter - HSV
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

11. What mmse score suggest dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
82% specific for dementia
Verapamil
<20; if patient scores >25 benign forgetfulness

12. infections in GBS
Both in alcoholic; wernicke develop at first with horizontal nystagmus - and ataxia; if not treated they develop memory loss and psychosis which is named korsakoff
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
EPV - campylobacter - HSV

13. Blood transfusion in hypothermia
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

14. How to prevent prevent frequency of MS exacerbation
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aphasia - neglect - agnosia - acalculia etc

15. differentiate lewy body dementia and vascular dementia
Not within 24 hours; give afte 24-48 hours if patient stable
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero
MP: paralysis always medial due to involvement of f gracilis and f cunetus - so loss of touch and position sense and injury to hypglossal n in same side; lateral involve spinothalamic which has L; so pain and temp sensation altered;
Distal lower motor neuron disease

16. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Get up from chair walk a short distance turn around and sit; screening test for fall
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Botulism has descending paralysis in contrast othere have ascending paralysis

17. differentiate picks and huntington
Verapamil
Autospy gold standard
Taper gradually to prevent seizure relapse
Both slowly progressive; huntington with abrupt jerk of limb - trunk - grimacing - other abnormal movement - picks are irritable - quiet - sucks lip frequently and have symmetric atrophy of frontal/temporal lobes

18. at first tingling in toes and feet then weakness in extremities
MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebral palsy; dx mri

19. indication of plasmapheresis in GBS
First nerulogical exam must demonstrate absent cerebral and brainstem reflexes; absent motor response to pain - absent pupillary reflex - corneal reflex - cough reflex - and tracheal suctioning; then apnea test.
Entacapone - COMT inhibitor
Cluster; l for lacrimation - you for unilateral; episodes occur in cluster/grops; each last 30 min to 3h; c for conjunctival injection; r for retroorbital pain/rhinorhoea
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

20. What is pronator drift
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Both in alcoholic; wernicke develop at first with horizontal nystagmus - and ataxia; if not treated they develop memory loss and psychosis which is named korsakoff
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

21. What percent of dementia is reversible
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx
20%
IVIG and plasmapheresis
Propranolol or primidone

22. When to use dopamine agonist pramipexol in parkinson
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

23. best diagnosis for parkinsonim
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Autospy gold standard
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS

24. double vision at the end of day and ptosis
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Entacapone - COMT inhibitor

25. women with unilateral eye pain; neurlogic symptoms here there at different times
Corticosteroid and acyclovir
RBC count >6000
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

26. get up and go test
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Get up from chair walk a short distance turn around and sit; screening test for fall

27. Tx of bells palsy
Corticosteroid and acyclovir
Propranolol or primidone
Get up from chair walk a short distance turn around and sit; screening test for fall
Lateral involve trigeminal which has L and has limb ataxia ; medial - ipsilateral limb ataxia and contralateral eye deviation and paralysis of face - arm and leg

28. labyrinthitis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Entacapone - COMT inhibitor
Corticosteroid and acyclovir
Follows viral illness; vertigo - tinnitus - nausea. self limiting

29. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero

30. How to differentiate medial and lateral medullary syndrome
L for l ; lewy has lots of hallucination; parkinsonism like features - falls are common; presence lewy body in cytosplasm of brain cells; vascular demential develop very suddenly; hx dm -htn - athero
Clonidine will take care both high bp and withdrawal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MP: paralysis always medial due to involvement of f gracilis and f cunetus - so loss of touch and position sense and injury to hypglossal n in same side; lateral involve spinothalamic which has L; so pain and temp sensation altered;

31. anerior and anteriomedial thigh paresthesia - decreased DTR
Taper gradually to prevent seizure relapse
Femoral n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

32. oligoclonal band in CSF
Autospy gold standard
Entacapone - COMT inhibitor
MS
Clonidine will take care both high bp and withdrawal

33. craniopharyngioma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
Diabetes insipidus

34. phenytoin and OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pt is asked to hold both arms fully extended at shoulder level in front of him with palms upwards; unable to maintain such position means positive test; closing eye will accentuate the effect
Construction apraxia; lesion in non dominant parietal lobe (right)
Reduced efficacy of OCP

35. dementia plus urinary incontinence
90% of right handed and 60% of left handed persons; speech and language function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus

36. How to manage stroke patient came within 4 hours
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cerebellar lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

37. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Reduced efficacy of OCP
MP: paralysis always medial due to involvement of f gracilis and f cunetus - so loss of touch and position sense and injury to hypglossal n in same side; lateral involve spinothalamic which has L; so pain and temp sensation altered;
Autospy gold standard

38. benign essential tremor
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Both in alcoholic; wernicke develop at first with horizontal nystagmus - and ataxia; if not treated they develop memory loss and psychosis which is named korsakoff
Taper gradually to prevent seizure relapse

39. impaired vibration and increased DTR
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency

40. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Get up from chair walk a short distance turn around and sit; screening test for fall
Upright supine position
Tunnel vision - diaphoresis - nausea - pallor

41. impaired hepatic conjugation of billirubin
Clonidine will take care both high bp and withdrawal
Antitoxin
Tunnel vision - diaphoresis - nausea - pallor
Gilberts disease

42. How to differentiate parkinson and benign essential tremor
In BET - no resting tremor (tremor worsens at rest and improves with acitivity) - bradykinesia or slowing in voluntary movement; gait difficulty; have positive family hx
Lateral involve trigeminal which has L and has limb ataxia ; medial - ipsilateral limb ataxia and contralateral eye deviation and paralysis of face - arm and leg
Both slowly progressive; huntington with abrupt jerk of limb - trunk - grimacing - other abnormal movement - picks are irritable - quiet - sucks lip frequently and have symmetric atrophy of frontal/temporal lobes
Myasthenia; due to autoantibodies against acetylecholine receptor;

43. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Clonidine will take care both high bp and withdrawal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
20%

44. brain stem lesion
It patient has electrolyte imbalance and hypothermia
Deficit in cranial nerve function
Aspirin - control HTN and swallow eval before giving any oral meds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

45. Tx of GBS
EPV - campylobacter - HSV
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin
Diabetes insipidus

46. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
20%
It patient has electrolyte imbalance and hypothermia
Botulism has descending paralysis in contrast othere have ascending paralysis

47. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Myasthenia; due to autoantibodies against acetylecholine receptor;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

48. what drug is used to extend effects of levodopa
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Clonidine will take care both high bp and withdrawal
Entacapone - COMT inhibitor
Despite the term neuroma they arise from schwann cells - schwanoma

49. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Femoral n lesion
Normal pressure hydrocephalus
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

50. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
First nerulogical exam must demonstrate absent cerebral and brainstem reflexes; absent motor response to pain - absent pupillary reflex - corneal reflex - cough reflex - and tracheal suctioning; then apnea test.
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebral palsy; dx mri
Not within 24 hours; give afte 24-48 hours if patient stable