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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. phenytoin and OCP
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Reduced efficacy of OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

2. anerior and anteriomedial thigh paresthesia - decreased DTR
Aphasia - neglect - agnosia - acalculia etc
Femoral n lesion
<20; if patient scores >25 benign forgetfulness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

3. Tx of GBS
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis

4. cluster headache
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
Tunnel vision - diaphoresis - nausea - pallor
EPV - campylobacter - HSV
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

5. at first tingling in toes and feet then weakness in extremities
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
If develop fever - mouth ulcer - easy brusing - petechie - see a doc ; the drug cause neutropenia - and bone marrow suppression; elderly are at risk of SIADH
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;

6. Tx of bells palsy
EPV - campylobacter - HSV
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Corticosteroid and acyclovir
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

7. get up and go test
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

8. How to manage stroke patient came within 4 hours
Follows viral illness; vertigo - tinnitus - nausea. self limiting
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Diabetes insipidus
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

9. infections in GBS
Antitoxin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
EPV - campylobacter - HSV
Propranolol or primidone

10. indication of plasmapheresis in GBS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
High dose IV methyleprednisone;
Diabetes insipidus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

11. benign essential tremor
Propranolol or primidone
High dose IV methyleprednisone;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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.

12. How to differentiate medial and lateral medullary syndrome
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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;
Femoral n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

13. lesion in dominant tempora lobe
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Spastic paraparesis
MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

14. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Upright supine position
Femoral n lesion

15. medial thigh sensory loss and weakness in addcution
Diabetes insipidus
Antitoxin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Obturator n lesion

16. what drug is used to extend effects of levodopa
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Entacapone - COMT inhibitor
Reduced efficacy of OCP
Get up from chair walk a short distance turn around and sit; screening test for fall

17. Why V12 deficient develop hypokalemia after tx with b12
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write
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

18. dementia plus urinary incontinence
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus

19. oligoclonal band in CSF
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
Clonidine will take care both high bp and withdrawal
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
MS

20. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor
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;
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

21. alcoholic p/w confusion - ataxia - tremor - nystamgus

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22. Unable to copy of matchstick - unable to dress up
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard
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)

23. MG
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Deficit in cranial nerve function
Acetylecholinersterase inhibitors

24. double vision at the end of day and ptosis
Tunnel vision - diaphoresis - nausea - pallor
RBC count >6000
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Myasthenia; due to autoantibodies against acetylecholine receptor;

25. How to tx acute exacerbation of MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
High dose IV methyleprednisone;

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Cholinesterase inhibitor; and antiparkinsonism drugs
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
90% of right handed and 60% of left handed persons; speech and language function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

27. cortical lesion
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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aphasia - neglect - agnosia - acalculia etc
RBC count >6000

28. botulism
Antitoxin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Aphasia - neglect - agnosia - acalculia etc
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

29. labyrinthitis
Autospy gold standard
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds

30. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease
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

31. women with unilateral eye pain; neurlogic symptoms here there at different times
Verapamil
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;

32. craniopharyngioma
Obturator n lesion
Clonidine will take care both high bp and withdrawal
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
Diabetes insipidus

33. dominant parietal lobe on the left side
RBC count >6000
90% of right handed and 60% of left handed persons; speech and language function
Verapamil
Upright supine position

34. best diagnosis for parkinsonim
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function
It patient has electrolyte imbalance and hypothermia
Autospy gold standard

35. MMSE score of less than 24
IVIG and plasmapheresis
82% specific for dementia
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

36. When to give aspirin when patient on tPA after stroke
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Distal lower motor neuron disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

37. Acute onset of left arm weakness
Aphasia - neglect - agnosia - acalculia etc
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

38. How to differentiate traumatic LP and SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
Normal pressure hydrocephalus
Lesion in nondominant temporal lobe
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

39. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
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
90% of right handed and 60% of left handed persons; speech and language function
Spastic paraparesis

40. differentiate wenicke and korsakoff
Cerebral palsy; dx mri
<20; if patient scores >25 benign forgetfulness
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

41. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

42. When to use dopamine agonist pramipexol in parkinson
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acetylecholinersterase inhibitors
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Deficit in cranial nerve function

43. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal
Femoral n lesion

44. acoustic neuroma
Propranolol or primidone
Despite the term neuroma they arise from schwann cells - schwanoma
Aphasia - neglect - agnosia - acalculia etc
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

45. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)

46. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cerebellar lesion
Obturator n lesion

47. How to differentiate parkinson and benign essential tremor
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis
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
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

48. What mmse score suggest dementia
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
RBC count >6000
<20; if patient scores >25 benign forgetfulness
Propranolol or primidone

49. How to tx stroke patient came after 6h
Construction apraxia; lesion in non dominant parietal lobe (right)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spastic paraparesis
Aspirin - control HTN and swallow eval before giving any oral meds

50. impaired hepatic conjugation of billirubin
Deficit in cranial nerve function
Entacapone - COMT inhibitor
Gilberts disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate