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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. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
Obturator n lesion

2. When to use brain spect scintigraphy to confirm brain death
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
It patient has electrolyte imbalance and hypothermia
Antitoxin

3. 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
MS
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

4. differentiate wenicke and korsakoff
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
Propranolol or primidone
Diabetes insipidus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

5. at first tingling in toes and feet then weakness in extremities
Tunnel vision - diaphoresis - nausea - pallor
Antitoxin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

6. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Antitoxin
Femoral n lesion

7. Acute onset of left arm weakness
82% specific for dementia
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting

8. How to differentiate dementias
90% of right handed and 60% of left handed persons; speech and language function
MS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Myasthenia; due to autoantibodies against acetylecholine receptor;

9. differentiate picks and huntington
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acetylecholinersterase inhibitors
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

10. When to use dopamine agonist pramipexol in parkinson
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs

11. How to perform apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Coronary artery disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

12. labyrinthitis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Antitoxin
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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

13. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Vitamin B12 deficiency
RBC count >6000

14. MG
Acetylecholinersterase inhibitors
Antitoxin
Not within 24 hours; give afte 24-48 hours if patient stable
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

15. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

16. dementia plus urinary incontinence
Get up from chair walk a short distance turn around and sit; screening test for fall
Normal pressure hydrocephalus
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs

17. women with unilateral eye pain; neurlogic symptoms here there at different times
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
EPV - campylobacter - HSV

18. Unable to copy of matchstick - unable to dress up
Propranolol or primidone
Construction apraxia; lesion in non dominant parietal lobe (right)
<20; if patient scores >25 benign forgetfulness
RBC count >6000

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Verapamil
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

20. What is pronator drift
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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)
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

21. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Difficulty in writing - calculating - distinguishing left and write
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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;

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

23. what drug is used to extend effects of levodopa
Coronary artery disease
Entacapone - COMT inhibitor
Antitoxin
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

24. How to tx acute exacerbation of MS
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
High dose IV methyleprednisone;
Cerebral palsy; dx mri
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

25. Blood transfusion in hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Construction apraxia; lesion in non dominant parietal lobe (right)

26. Tx of bells palsy
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir
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;

27. When to suspect traumatic LP
Tunnel vision - diaphoresis - nausea - pallor
Reduced efficacy of OCP
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

28. oligoclonal band in CSF
Construction apraxia; lesion in non dominant parietal lobe (right)
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS

29. phenytoin and OCP
Diabetes insipidus
Reduced efficacy of OCP
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
It patient has electrolyte imbalance and hypothermia

30. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Gilberts disease
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
<20; if patient scores >25 benign forgetfulness
Antitoxin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

32. When to give aspirin when patient on tPA after stroke
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable

33. excessive elevation of legs during walking (toe touch floor earlier than heels)
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Autospy gold standard

34. infections in GBS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
EPV - campylobacter - HSV

35. How to differentiate medial and lateral medullary syndrome
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
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;

36. Patient with carbamazepine; What should be advice?
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Coronary artery disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

37. How to differentiate traumatic LP and SAH
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Vitamin B12 deficiency
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

38. medial thigh sensory loss and weakness in addcution
Myasthenia; due to autoantibodies against acetylecholine receptor;
Obturator n lesion
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

39. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebellar lesion
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

40. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Get up from chair walk a short distance turn around and sit; screening test for fall
Upright supine position
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

41. lesion in dominant tempora lobe
RBC count >6000
Cerebral palsy; dx mri
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

42. benign essential tremor
Not within 24 hours; give afte 24-48 hours if patient stable
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Propranolol or primidone
Cerebral palsy; dx mri

43. How to confirm braindeath?
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.
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis

44. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
20%
Cholinesterase inhibitor; and antiparkinsonism drugs
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

45. stroke with lower facial palsy - pronator drift despite on aspirin
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion

46. When headache is presenting complaint of brain tumor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
IVIG and plasmapheresis
Spastic paraparesis

47. indication of plasmapheresis in GBS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Coronary artery disease
Aspirin - control HTN and swallow eval before giving any oral meds

48. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Gilberts disease
Lesion in nondominant temporal lobe
Nystagmus on far lateral gaze
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

49. best diagnosis for parkinsonim
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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;

50. cluster headache
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)
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