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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. 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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Reduced efficacy of OCP
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

2. impaired perception of complex sounds
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus
Distal lower motor neuron disease
Lesion in nondominant temporal lobe

3. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
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.
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
20%

4. double vision at the end of day and ptosis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

5. How to confirm braindeath?
Entacapone - COMT inhibitor
Difficulty in writing - calculating - distinguishing left and write
Cerebellar lesion
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.

6. prodrome of vasovagal syncope
<20; if patient scores >25 benign forgetfulness
RBC count >6000
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;

7. earliest sign of phenytoin toxicity
Cerebellar lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Nystagmus on far lateral gaze
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

8. How to differentiate parkinson and benign essential tremor
Diabetes insipidus
90% of right handed and 60% of left handed persons; speech and language function
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

9. benign essential tremor
Antitoxin
Acetylecholinersterase inhibitors
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone

10. How to differentiate medial and lateral medullary syndrome
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

11. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
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
82% specific for dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

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

13. GBS
IVIG and plasmapheresis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Gilberts disease
Femoral n lesion

14. Why V12 deficient develop hypokalemia after tx with b12
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Distal lower motor neuron disease
Follows viral illness; vertigo - tinnitus - nausea. self limiting

15. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
IVIG and plasmapheresis
RBC count >6000
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

16. MMSE score of less than 24
82% specific for dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
90% of right handed and 60% of left handed persons; speech and language function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

17. best diagnosis for parkinsonim
Nystagmus on far lateral gaze
Autospy gold standard
Cerebral palsy; dx mri
90% of right handed and 60% of left handed persons; speech and language function

18. korsafoff psychosis
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Vitamin B12 deficiency

19. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

20. How to manage stroke patient came within 4 hours
RBC count >6000
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Normal pressure hydrocephalus
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

21. dementia plus urinary incontinence
It patient has electrolyte imbalance and hypothermia
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
Normal pressure hydrocephalus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

22. What is can be used cluster headache prevention
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Myasthenia; due to autoantibodies against acetylecholine receptor;
Verapamil
Not within 24 hours; give afte 24-48 hours if patient stable

23. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Entacapone - COMT inhibitor
Nystagmus on far lateral gaze

24. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Gilberts disease
Femoral 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

25. What is pronator drift
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
Obturator n lesion
Antitoxin
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

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

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27. excessive elevation of legs during walking (toe touch floor earlier than heels)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Myasthenia; due to autoantibodies against acetylecholine receptor;
Distal lower motor neuron disease
Entacapone - COMT inhibitor

28. impaired hepatic conjugation of billirubin
Gilberts disease
82% specific for dementia
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

29. impaired vibration and increased DTR
It patient has electrolyte imbalance and hypothermia
Vitamin B12 deficiency
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function

30. How to differentiate medial and lateral pontine syndrome
Wernicke's encephalopathy; due to thiamine definition; medical emergency
EPV - campylobacter - HSV
RBC count >6000
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

31. How to differentiate dementias
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

32. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Femoral n lesion
MS
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;

33. When headache is presenting complaint of brain tumor
Cerebellar lesion
Diabetes insipidus
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

34. labyrinthitis
Obturator n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
High dose IV methyleprednisone;
Antitoxin

35. severe headache and high BP
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Normal pressure hydrocephalus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

36. How to perform apnea test
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.
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

37. brain stem lesion
Deficit in cranial nerve function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position
Obturator n lesion

38. stroke with lower facial palsy - pronator drift despite on aspirin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

39. When to start fibrinolytic therapy in stroke patient?
20%
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Antitoxin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

40. infections in GBS
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
Gilberts disease
EPV - campylobacter - HSV
Myasthenia; due to autoantibodies against acetylecholine receptor;

41. phenytoin and OCP
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP

42. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Entacapone - COMT inhibitor
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
Corticosteroid and acyclovir

43. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Upright supine position
Spastic paraparesis

44. acoustic neuroma
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

45. differentiate picks and huntington
Antitoxin
Cholinesterase inhibitor; and antiparkinsonism drugs
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
High dose IV methyleprednisone;

46. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
20%

47. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
20%
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebral palsy; dx mri

48. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Construction apraxia; lesion in non dominant parietal lobe (right)

49. Acute onset of left arm weakness
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

50. what drug is used to extend effects of levodopa
Coronary artery disease
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor