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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. When to start fibrinolytic therapy in stroke patient?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
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

2. Why V12 deficient develop hypokalemia after tx with b12
Acetylecholinersterase inhibitors
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Gilberts disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

3. craniopharyngioma
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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;
Diabetes insipidus

4. differentiate wenicke and korsakoff
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma

5. What is can be used cluster headache prevention
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Verapamil
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

6. How to perform apnea test
Botulism has descending paralysis in contrast othere have ascending paralysis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Lesion in nondominant temporal lobe
Gilberts disease

7. When to use brain spect scintigraphy to confirm brain death
Autospy gold standard
It patient has electrolyte imbalance and hypothermia
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Construction apraxia; lesion in non dominant parietal lobe (right)

8. 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.
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

9. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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.
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

10. brain stem lesion
Spastic paraparesis
Upright supine position
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

11. differentiate lewy body dementia and vascular dementia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency
Upright supine position
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

12. What percent of dementia is reversible
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus
Upright supine position
20%

13. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
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;
Upright supine position
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

14. How to differentiate traumatic LP and SAH
IVIG and plasmapheresis
Spastic paraparesis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

15. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Botulism has descending paralysis in contrast othere have ascending paralysis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

16. 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
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
Difficulty in writing - calculating - distinguishing left and write

17. get up and go test
Propranolol or primidone
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Get up from chair walk a short distance turn around and sit; screening test for fall
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

18. How to differentiate parkinson and benign essential tremor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Gilberts disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

19. Tx of bells palsy
Corticosteroid and acyclovir
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

20. When to suspect traumatic LP
RBC count >6000
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)

21. dominant parietal lobe on the left side
Antitoxin
High dose IV methyleprednisone;
90% of right handed and 60% of left handed persons; speech and language function
Spastic paraparesis

22. impaired vibration and increased DTR
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Vitamin B12 deficiency

23. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acetylecholinersterase inhibitors
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Reduced efficacy of OCP

24. acoustic neuroma
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus

25. MG
Construction apraxia; lesion in non dominant parietal lobe (right)
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Acetylecholinersterase inhibitors
Deficit in cranial nerve function

26. Tx of GBS
Botulism has descending paralysis in contrast othere have ascending paralysis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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;
Diabetes insipidus

27. earliest sign of phenytoin toxicity
Entacapone - COMT inhibitor
Taper gradually to prevent seizure relapse
Nystagmus on far lateral gaze
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

28. what drug is used to extend effects of levodopa
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Clonidine will take care both high bp and withdrawal
Entacapone - COMT inhibitor
Reduced efficacy of OCP

29. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Obturator n lesion
<20; if patient scores >25 benign forgetfulness

30. double vision at the end of day and ptosis
82% specific for dementia
Verapamil
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri

31. phenytoin and OCP
Reduced efficacy of OCP
Cerebral palsy; dx mri
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Distal lower motor neuron disease

32. Blood transfusion in hypothermia
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

33. at first tingling in toes and feet then weakness in extremities
Botulism has descending paralysis in contrast othere have ascending paralysis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

34. differentiate picks and huntington
MS
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
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
Diabetes insipidus

35. cortical lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aphasia - neglect - agnosia - acalculia etc
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

36. cluster headache
20%
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
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

37. lesion in dominant tempora lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Verapamil

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

39. Should we tx htn in acute ischemic stroke

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40. How to tx acute exacerbation of MS
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

41. MMSE score of less than 24
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
<20; if patient scores >25 benign forgetfulness
Wernicke's encephalopathy; due to thiamine definition; medical emergency

42. indication of plasmapheresis in GBS
Spastic paraparesis
Distal lower motor neuron disease
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

43. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

44. botulism
Reduced efficacy of OCP
Antitoxin
Normal pressure hydrocephalus
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

45. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Autospy gold standard
Diabetes insipidus
Spastic paraparesis
Construction apraxia; lesion in non dominant parietal lobe (right)

46. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Gilberts disease
Acetylecholinersterase inhibitors
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

47. dementia plus urinary incontinence
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
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus

48. impaired perception of complex sounds
82% specific for dementia
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
RBC count >6000
Lesion in nondominant temporal lobe

49. best diagnosis for parkinsonim
Get up from chair walk a short distance turn around and sit; screening test for fall
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Autospy gold standard
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.

50. How to differentiate medial and lateral medullary syndrome
Antitoxin
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;
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone