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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. What percent of dementia is reversible
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Not within 24 hours; give afte 24-48 hours if patient stable
20%
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

3. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

4. differentiate lewy body dementia and vascular dementia
Entacapone - COMT inhibitor
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

5. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Aphasia - neglect - agnosia - acalculia etc
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus

6. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Cholinesterase inhibitor; and antiparkinsonism drugs
Not within 24 hours; give afte 24-48 hours if patient stable
Gilberts disease
Spastic paraparesis

7. women with unilateral eye pain; neurlogic symptoms here there at different times
Construction apraxia; lesion in non dominant parietal lobe (right)
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Tunnel vision - diaphoresis - nausea - pallor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

8. excessive elevation of legs during walking (toe touch floor earlier than heels)
Cerebral palsy; dx mri
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Distal lower motor neuron disease
RBC count >6000

9. impaired vibration and increased DTR
Vitamin B12 deficiency
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

10. what drug is used to extend effects of levodopa
Femoral n lesion
Entacapone - COMT inhibitor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

11. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs

12. indication of plasmapheresis in GBS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Antitoxin
Tunnel vision - diaphoresis - nausea - pallor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

13. Patient with carbamazepine; What should be advice?
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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;

14. 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.
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
Antitoxin
Reduced efficacy of OCP

15. best diagnosis for parkinsonim
Autospy gold standard
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Spastic paraparesis
Diabetes insipidus

16. 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
Taper gradually to prevent seizure relapse
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Verapamil
Cerebellar lesion

18. cortical lesion
Antitoxin
Aphasia - neglect - agnosia - acalculia etc
Autospy gold standard
MS

19. When to give aspirin when patient on tPA after stroke
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Entacapone - COMT inhibitor
High dose IV methyleprednisone;

20. lesion in dominant tempora lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Entacapone - COMT inhibitor
Deficit in cranial nerve function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

21. prodrome of vasovagal syncope
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

22. Blood transfusion in hypothermia
90% of right handed and 60% of left handed persons; speech and language function
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

23. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
EPV - campylobacter - HSV
RBC count >6000

24. How to tx lewy body dementia
Femoral n lesion
Entacapone - COMT inhibitor
Cholinesterase inhibitor; and antiparkinsonism drugs
Corticosteroid and acyclovir

25. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Myasthenia; due to autoantibodies against acetylecholine receptor;

26. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Femoral n lesion
Cerebellar lesion

27. cluster headache
MS
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
Propranolol or primidone
Taper gradually to prevent seizure relapse

28. Acute onset of left arm weakness
Construction apraxia; lesion in non dominant parietal lobe (right)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cerebral palsy; dx mri
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

29. contraindication of sumatripta
Myasthenia; due to autoantibodies against acetylecholine receptor;
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;
Coronary artery disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

30. How to differentiate medial and lateral medullary syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
IVIG and plasmapheresis
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;
Cerebral palsy; dx mri

31. craniopharyngioma
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Diabetes insipidus
Reduced efficacy of OCP

32. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Upright supine position
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil

33. When to suspect traumatic LP
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
<20; if patient scores >25 benign forgetfulness
RBC count >6000

34. severe headache and high BP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease

35. How to differentiate botulism from tick born paralysis - GBS and MG
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Get up from chair walk a short distance turn around and sit; screening test for fall

36. infections in GBS
Cerebellar lesion
Lesion in nondominant temporal lobe
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
EPV - campylobacter - HSV

37. anerior and anteriomedial thigh paresthesia - decreased DTR
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.
Entacapone - COMT inhibitor
Femoral n lesion
Vitamin B12 deficiency

38. MMSE score of less than 24
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Antitoxin
EPV - campylobacter - HSV

39. How to differentiate dementias
Coronary artery disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

40. 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
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor

41. oligoclonal band in CSF
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS

42. Should we tx htn in acute ischemic stroke

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43. stroke with lower facial palsy - pronator drift despite on aspirin
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.
Cholinesterase inhibitor; and antiparkinsonism drugs
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Taper gradually to prevent seizure relapse

44. earliest sign of phenytoin toxicity
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze
Clonidine will take care both high bp and withdrawal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

45. When to use dopamine agonist pramipexol in parkinson
RBC count >6000
Get up from chair walk a short distance turn around and sit; screening test for fall
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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

46. How to differentiate traumatic LP and SAH
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
It patient has electrolyte imbalance and hypothermia
Autospy gold standard
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

47. Unable to copy of matchstick - unable to dress up
Reduced efficacy of OCP
Construction apraxia; lesion in non dominant parietal lobe (right)
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.
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

48. What is can be used cluster headache prevention
Construction apraxia; lesion in non dominant parietal lobe (right)
Myasthenia; due to autoantibodies against acetylecholine receptor;
Verapamil
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. When to use brain spect scintigraphy to confirm brain death
Vitamin B12 deficiency
Get up from chair walk a short distance turn around and sit; screening test for fall
It patient has electrolyte imbalance and hypothermia
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;

50. When headache is presenting complaint of brain tumor
Clonidine will take care both high bp and withdrawal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Distal lower motor neuron disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;