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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. How to differentiate medial and lateral pontine syndrome
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in writing - calculating - distinguishing left and write

2. What is pronator drift
Propranolol or primidone
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

3. differentiate lewy body dementia and vascular dementia
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
20%
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

4. How to differentiate botulism from tick born paralysis - GBS and MG
Verapamil
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Botulism has descending paralysis in contrast othere have ascending paralysis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

5. impaired perception of complex sounds
IVIG and plasmapheresis
Obturator n lesion
90% of right handed and 60% of left handed persons; speech and language function
Lesion in nondominant temporal lobe

6. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS

7. How to differentiate medial and lateral medullary syndrome
Entacapone - COMT inhibitor
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
It patient has electrolyte imbalance and hypothermia
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;

8. How to prevent prevent frequency of MS exacerbation
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
Cerebral palsy; dx mri
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

9. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Spastic paraparesis
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

10. phenytoin and OCP
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

11. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Entacapone - COMT inhibitor

12. MG
Acetylecholinersterase inhibitors
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Aphasia - neglect - agnosia - acalculia etc
Verapamil

13. cortical lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aphasia - neglect - agnosia - acalculia etc
Get up from chair walk a short distance turn around and sit; screening test for fall
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

14. botulism
Antitoxin
Not within 24 hours; give afte 24-48 hours if patient stable
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

15. When to use brain spect scintigraphy to confirm brain death
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS
It patient has electrolyte imbalance and hypothermia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

16. benign essential tremor
Propranolol or primidone
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
82% specific for dementia

17. How to tx stroke patient came after 6h
82% specific for dementia
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aspirin - control HTN and swallow eval before giving any oral meds

18. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
<20; if patient scores >25 benign forgetfulness
RBC count >6000
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

19. infections in GBS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aspirin - control HTN and swallow eval before giving any oral meds

20. impaired vibration and increased DTR
Femoral n lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

21. Tx of bells palsy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Botulism has descending paralysis in contrast othere have ascending paralysis
Diabetes insipidus
Corticosteroid and acyclovir

22. 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
Gilberts disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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

23. stroke with lower facial palsy - pronator drift despite on aspirin
Antitoxin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

24. korsafoff psychosis
IVIG and plasmapheresis
Entacapone - COMT inhibitor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

25. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Coronary artery disease
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
Not within 24 hours; give afte 24-48 hours if patient stable

26. Patient with carbamazepine; What should be advice?
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
Autospy gold standard
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Get up from chair walk a short distance turn around and sit; screening test for fall

27. excessive elevation of legs during walking (toe touch floor earlier than heels)
MS
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
Distal lower motor neuron disease
Diabetes insipidus

28. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir

29. How to differentiate dementias
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Corticosteroid and acyclovir
RBC count >6000
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

30. at first tingling in toes and feet then weakness in extremities
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

31. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Cerebral palsy; dx mri

32. lesion in dominant parietal lobe
High dose IV methyleprednisone;
Difficulty in writing - calculating - distinguishing left and write
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebellar lesion

33. How to tx acute exacerbation of MS
Obturator n lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)

34. indication of plasmapheresis in GBS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aspirin - control HTN and swallow eval before giving any oral meds
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

35. What is can be used cluster headache prevention
Reduced efficacy of OCP
Verapamil
Femoral n lesion
IVIG and plasmapheresis

36. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
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
Aspirin - control HTN and swallow eval before giving any oral meds
Construction apraxia; lesion in non dominant parietal lobe (right)

37. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Diabetes insipidus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

38. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Nystagmus on far lateral gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

39. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Cerebellar lesion
Clonidine will take care both high bp and withdrawal
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

40. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir
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

41. oligoclonal band in CSF
20%
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.
MS
High dose IV methyleprednisone;

42. brain stem lesion
IVIG and plasmapheresis
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Deficit in cranial nerve function

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.
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

44. medial thigh sensory loss and weakness in addcution
High dose IV methyleprednisone;
Get up from chair walk a short distance turn around and sit; screening test for fall
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.
Obturator n lesion

45. acoustic neuroma
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Despite the term neuroma they arise from schwann cells - schwanoma
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

46. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion

47. When to suspect traumatic LP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

48. craniopharyngioma
RBC count >6000
Reduced efficacy of OCP
Diabetes insipidus
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

49. Should we tx htn in acute ischemic stroke

50. lesion in dominant tempora lobe
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Aspirin - control HTN and swallow eval before giving any oral meds