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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. impaired hepatic conjugation of billirubin
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Distal lower motor neuron disease
Cerebral palsy; dx mri

2. Blood transfusion in hypothermia
Spastic paraparesis
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Vitamin B12 deficiency

3. infections in GBS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Autospy gold standard
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;
EPV - campylobacter - HSV

4. How to differentiate medial and lateral pontine syndrome
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
Cerebellar lesion
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

5. prodrome of vasovagal syncope
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;
Distal lower motor neuron disease

6. What mmse score suggest dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
<20; if patient scores >25 benign forgetfulness
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

7. craniopharyngioma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus
Upright supine position
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

8. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position

9. How to differentiate traumatic LP and 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Nystagmus on far lateral gaze

10. lesion in dominant parietal lobe
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors
Difficulty in writing - calculating - distinguishing left and write
Aspirin - control HTN and swallow eval before giving any oral meds

11. brain stem lesion
Deficit in cranial nerve function
Cholinesterase inhibitor; and antiparkinsonism drugs
Taper gradually to prevent seizure relapse
Entacapone - COMT inhibitor

12. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Antitoxin

13. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000
Cholinesterase inhibitor; and antiparkinsonism drugs

14. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
Deficit in cranial nerve function
Spastic paraparesis

15. 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.
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Nystagmus on far lateral gaze

16. When to use brain spect scintigraphy to confirm brain death
Despite the term neuroma they arise from schwann cells - schwanoma
Taper gradually to prevent seizure relapse
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors

17. cortical lesion
Antitoxin
Aphasia - neglect - agnosia - acalculia etc
Botulism has descending paralysis in contrast othere have ascending paralysis
Cholinesterase inhibitor; and antiparkinsonism drugs

18. acoustic neuroma
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Despite the term neuroma they arise from schwann cells - schwanoma
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

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Obturator n lesion
Clonidine will take care both high bp and withdrawal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

20. GBS
IVIG and plasmapheresis
Reduced efficacy of OCP
RBC count >6000
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.

21. 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
Acetylecholinersterase inhibitors
Cerebellar lesion
90% of right handed and 60% of left handed persons; speech and language function

22. labyrinthitis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
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;

23. medial thigh sensory loss and weakness in addcution
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Obturator n lesion
Femoral 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

24. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acetylecholinersterase inhibitors
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Tunnel vision - diaphoresis - nausea - pallor

25. Unable to copy of matchstick - unable to dress up
Femoral n lesion
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

26. How to perform apnea test
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Taper gradually to prevent seizure relapse
EPV - campylobacter - HSV

27. What is can be used cluster headache prevention
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis
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. What percent of dementia is reversible
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.
Tunnel vision - diaphoresis - nausea - pallor
EPV - campylobacter - HSV

29. When to start fibrinolytic therapy in stroke patient?
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Autospy gold standard

30. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Taper gradually to prevent seizure relapse
RBC count >6000
Aspirin - control HTN and swallow eval before giving any oral meds
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. Acute onset of left arm weakness
Antitoxin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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.
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

32. How to tx acute exacerbation of MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;
Obturator n lesion

33. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)

34. differentiate wenicke and korsakoff
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Get up from chair walk a short distance turn around and sit; screening test for fall
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

35. at first tingling in toes and feet then weakness in extremities
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

36. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Coronary artery disease
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

37. How to stop antiepileptic drugs
Autospy gold standard
Acetylecholinersterase inhibitors
Taper gradually to prevent seizure relapse
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

38. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin
Femoral n lesion

39. When to use dopamine agonist pramipexol in parkinson
EPV - campylobacter - HSV
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
IVIG and plasmapheresis

40. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function

41. MG
Femoral n lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Acetylecholinersterase inhibitors
Verapamil

42. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Clonidine will take care both high bp and withdrawal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

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

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44. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Entacapone - COMT inhibitor
High dose IV methyleprednisone;

45. impaired vibration and increased DTR
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Vitamin B12 deficiency
Obturator n lesion
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

46. benign essential tremor
Construction apraxia; lesion in non dominant parietal lobe (right)
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
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

47. phenytoin and 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
Reduced efficacy of OCP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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;

48. contraindication of sumatripta
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

49. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Verapamil
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

50. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
High dose IV methyleprednisone;
Autospy gold standard
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