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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. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

2. Tx of GBS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Botulism has descending paralysis in contrast othere have ascending paralysis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc

3. differentiate picks and huntington
Obturator n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Corticosteroid and acyclovir

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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
Lesion in nondominant temporal lobe

5. Should we tx htn in acute ischemic stroke

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6. 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
Taper gradually to prevent seizure relapse
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe

7. prodrome of vasovagal syncope
MS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Tunnel vision - diaphoresis - nausea - pallor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

8. impaired hepatic conjugation of billirubin
Lesion in nondominant temporal lobe
Gilberts disease
Cholinesterase inhibitor; and antiparkinsonism drugs
82% specific for dementia

9. indication of plasmapheresis in GBS
Vitamin B12 deficiency
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

10. women with unilateral eye pain; neurlogic symptoms here there at different times
Autospy gold standard
Taper gradually to prevent seizure relapse
<20; if patient scores >25 benign forgetfulness
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

11. lesion in dominant parietal lobe
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in writing - calculating - distinguishing left and write
Cerebral palsy; dx mri
Reduced efficacy of OCP

12. Unable to copy of matchstick - unable to dress up
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aphasia - neglect - agnosia - acalculia etc
Construction apraxia; lesion in non dominant parietal lobe (right)
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

13. infections in GBS
EPV - campylobacter - HSV
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Despite the term neuroma they arise from schwann cells - schwanoma

14. MG
Acetylecholinersterase inhibitors
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Distal lower motor neuron disease

15. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Construction apraxia; lesion in non dominant parietal lobe (right)
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

16. 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
Propranolol or primidone
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
IVIG and plasmapheresis

17. impaired vibration and increased DTR
Vitamin B12 deficiency
82% specific for dementia
Lesion in nondominant temporal lobe
Cerebral palsy; dx mri

18. lesion in dominant tempora lobe
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

19. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency
Myasthenia; due to autoantibodies against acetylecholine receptor;
Spastic paraparesis

20. What is can be used cluster headache prevention
Tunnel vision - diaphoresis - nausea - pallor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Verapamil

21. Why V12 deficient develop hypokalemia after tx with b12
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

22. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
Cerebellar lesion
Taper gradually to prevent seizure relapse

23. How to differentiate medial and lateral pontine syndrome
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;
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

24. GBS
Femoral n lesion
IVIG and plasmapheresis
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

25. When to start fibrinolytic therapy in stroke patient?
Normal pressure hydrocephalus
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
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

26. contraindication of sumatripta
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall
Coronary artery disease

27. How to stop antiepileptic drugs
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse
Difficulty in writing - calculating - distinguishing left and write

28. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Cholinesterase inhibitor; and antiparkinsonism drugs
Gilberts disease
Difficulty in writing - calculating - distinguishing left and write

29. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal

30. double vision at the end of day and ptosis
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
EPV - campylobacter - HSV

31. korsafoff psychosis
Taper gradually to prevent seizure relapse
Obturator 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
Upright supine position

32. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cerebellar lesion

33. How to differentiate botulism from tick born paralysis - GBS and MG
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Obturator n lesion

34. dementia plus urinary incontinence
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Normal pressure hydrocephalus
Reduced efficacy of OCP
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

35. botulism
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

36. How to confirm braindeath?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spastic paraparesis
Nystagmus on far lateral gaze
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.

37. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebellar lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Aphasia - neglect - agnosia - acalculia etc
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

39. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Verapamil
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
Difficulty in writing - calculating - distinguishing left and write

40. oligoclonal band in CSF
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Obturator n lesion
MS

41. craniopharyngioma
Femoral n lesion
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

42. How to tx acute exacerbation of MS
Taper gradually to prevent seizure relapse
High dose IV methyleprednisone;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Diabetes insipidus

43. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
RBC count >6000
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

44. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Clonidine will take care both high bp and withdrawal
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

45. impaired perception of complex sounds
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spastic paraparesis
Lesion in nondominant temporal lobe
20%

46. What is pronator drift
Reduced efficacy of OCP
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
Acetylecholinersterase inhibitors

47. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

48. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir
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

49. brain stem lesion
Deficit in cranial nerve function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Normal pressure hydrocephalus

50. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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;
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