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

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2. cortical lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Aphasia - neglect - agnosia - acalculia etc
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

3. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebellar lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Cerebral palsy; dx mri

4. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
EPV - campylobacter - HSV
Reduced efficacy of OCP
Cerebellar lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

5. How to differentiate medial and lateral medullary 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;
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

6. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Normal pressure hydrocephalus
20%
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

7. medial thigh sensory loss and weakness in addcution
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Obturator n lesion
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

8. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;
Clonidine will take care both high bp and withdrawal
Coronary artery disease

9. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Upright supine position
Difficulty in writing - calculating - distinguishing left and write

10. lesion in dominant parietal lobe
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
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

11. Why V12 deficient develop hypokalemia after tx with b12
Spastic paraparesis
Upright supine position
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

12. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Entacapone - COMT inhibitor
RBC count >6000

13. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Clonidine will take care both high bp and withdrawal
Not within 24 hours; give afte 24-48 hours if patient stable
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

14. anerior and anteriomedial thigh paresthesia - decreased DTR
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
MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

15. Should we tx htn in acute ischemic stroke

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16. double vision at the end of day and ptosis
Nystagmus on far lateral gaze
Coronary artery disease
82% specific for dementia
Myasthenia; due to autoantibodies against acetylecholine receptor;

17. 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
Gilberts disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

18. impaired hepatic conjugation of billirubin
Gilberts disease
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

19. labyrinthitis
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
RBC count >6000
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting

20. 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
20%
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
RBC count >6000

21. How to differentiate medial and lateral pontine syndrome
Aphasia - neglect - agnosia - acalculia etc
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
Normal pressure hydrocephalus

22. oligoclonal band in CSF
Entacapone - COMT inhibitor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS

23. impaired vibration and increased DTR
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in writing - calculating - distinguishing left and write
Vitamin B12 deficiency
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

24. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cerebellar lesion
Reduced efficacy of OCP
Corticosteroid and acyclovir

25. When to suspect traumatic LP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
RBC count >6000
Cerebellar lesion

26. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Entacapone - COMT inhibitor

27. differentiate lewy body dementia and vascular dementia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Deficit in cranial nerve function
Vitamin B12 deficiency
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

28. What mmse score suggest dementia
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

29. Unable to copy of matchstick - unable to dress up
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Cholinesterase inhibitor; and antiparkinsonism drugs
Nystagmus on far lateral gaze

30. korsafoff psychosis
Femoral n lesion
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
Clonidine will take care both high bp and withdrawal

31. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
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.
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Femoral n lesion

32. brain stem lesion
Obturator n lesion
Corticosteroid and acyclovir
Deficit in cranial nerve function
Entacapone - COMT inhibitor

33. infections in GBS
MS
EPV - campylobacter - HSV
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
IVIG and plasmapheresis

34. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Femoral n lesion
Clonidine will take care both high bp and withdrawal
Upright supine position

35. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Entacapone - COMT inhibitor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cholinesterase inhibitor; and antiparkinsonism drugs

36. dominant parietal lobe on the left side
Clonidine will take care both high bp and withdrawal
90% of right handed and 60% of left handed persons; speech and language function
Normal pressure hydrocephalus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

37. MMSE score of less than 24
82% specific for dementia
Gilberts disease
Aphasia - neglect - agnosia - acalculia etc
Coronary artery disease

38. earliest sign of phenytoin toxicity
Spastic paraparesis
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
Nystagmus on far lateral gaze

39. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Gilberts disease

40. women with unilateral eye pain; neurlogic symptoms here there at different times
High dose IV methyleprednisone;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia

41. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Corticosteroid and acyclovir
Entacapone - COMT inhibitor

42. What is can be used cluster headache prevention
Aspirin - control HTN and swallow eval before giving any oral meds
Femoral n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Verapamil

43. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Distal lower motor neuron disease

44. prodrome of vasovagal syncope
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease
Tunnel vision - diaphoresis - nausea - pallor
90% of right handed and 60% of left handed persons; speech and language function

45. Acute onset of left arm weakness
Spastic paraparesis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebral palsy; dx mri

46. How to differentiate traumatic LP and SAH
Femoral n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aphasia - neglect - agnosia - acalculia etc

47. stroke with lower facial palsy - pronator drift despite on aspirin
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

48. best diagnosis for parkinsonim
Deficit in cranial nerve function
Autospy gold standard
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
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.

49. get up and go test
82% specific for dementia
Propranolol or primidone
Get up from chair walk a short distance turn around and sit; screening test for fall
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

50. indication of plasmapheresis in GBS
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
Propranolol or primidone
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty