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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. Tx of bells palsy
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Corticosteroid and acyclovir
Gilberts disease
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

2. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Vitamin B12 deficiency
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Entacapone - COMT inhibitor

3. Acute onset of left arm weakness
EPV - campylobacter - HSV
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

4. cluster headache
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

5. labyrinthitis
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)
Follows viral illness; vertigo - tinnitus - nausea. self limiting
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

6. excessive elevation of legs during walking (toe touch floor earlier than heels)
Normal pressure hydrocephalus
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
Distal lower motor neuron disease
Cerebral palsy; dx mri

7. How to differentiate medial and lateral pontine syndrome
It patient has electrolyte imbalance and hypothermia
20%
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
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

8. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Follows viral illness; vertigo - tinnitus - nausea. self limiting
It patient has electrolyte imbalance and hypothermia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

9. How to tx stroke patient came after 6h
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
Wernicke's encephalopathy; due to thiamine definition; medical emergency

10. Should we tx htn in acute ischemic stroke

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11. acoustic neuroma
Diabetes insipidus
Aspirin - control HTN and swallow eval before giving any oral meds
Despite the term neuroma they arise from schwann cells - schwanoma
Autospy gold standard

12. impaired vibration and increased DTR
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Verapamil
Cerebellar lesion
Vitamin B12 deficiency

13. what drug is used to extend effects of levodopa
Obturator n lesion
Entacapone - COMT inhibitor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cerebellar lesion

14. differentiate lewy body dementia and vascular dementia
Clonidine will take care both high bp and withdrawal
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
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

15. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

16. What percent of dementia is reversible
IVIG and plasmapheresis
Construction apraxia; lesion in non dominant parietal lobe (right)
20%
Entacapone - COMT inhibitor

17. How to differentiate traumatic LP and SAH
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;
Spastic paraparesis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

18. GBS
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
Get up from chair walk a short distance turn around and sit; screening test for fall
IVIG and plasmapheresis
Diabetes insipidus

19. 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.
Verapamil
Vitamin B12 deficiency
Cholinesterase inhibitor; and antiparkinsonism drugs

20. MG
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Acetylecholinersterase inhibitors
Antitoxin
Aspirin - control HTN and swallow eval before giving any oral meds

21. MMSE score of less than 24
Despite the term neuroma they arise from schwann cells - schwanoma
High dose IV methyleprednisone;
Corticosteroid and acyclovir
82% specific for dementia

22. When to use dopamine agonist pramipexol in parkinson
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

23. Blood transfusion in hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Aspirin - control HTN and swallow eval before giving any oral meds
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

24. botulism
Antitoxin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Acetylecholinersterase inhibitors
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

25. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
20%
Cerebellar lesion
Entacapone - COMT inhibitor
Despite the term neuroma they arise from schwann cells - schwanoma

26. dominant parietal lobe on the left side
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
90% of right handed and 60% of left handed persons; speech and language function
Acetylecholinersterase inhibitors

27. craniopharyngioma
Diabetes insipidus
Verapamil
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness

28. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Femoral n lesion

29. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Upright supine position
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

30. get up and go test
Tunnel vision - diaphoresis - nausea - pallor
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Diabetes insipidus

31. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

32. impaired perception of complex sounds
Antitoxin
Cerebellar lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe

33. What is pronator drift
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
MS
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
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. Why V12 deficient develop hypokalemia after tx with b12
IVIG and plasmapheresis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in writing - calculating - distinguishing left and write
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

35. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Spastic paraparesis

36. contraindication of sumatripta
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Upright supine position
Autospy gold standard
Coronary artery disease

37. earliest sign of phenytoin toxicity
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Nystagmus on far lateral gaze
90% of right handed and 60% of left handed persons; speech and language function

38. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
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
Distal lower motor neuron disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

39. double vision at the end of day and ptosis
Obturator n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;

40. severe headache and high BP
Vitamin B12 deficiency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;
Femoral n lesion

41. How to differentiate medial and lateral medullary syndrome
Not within 24 hours; give afte 24-48 hours if patient stable
Myasthenia; due to autoantibodies against acetylecholine receptor;
MS: CSF increased IgG -IgM and IgA also increased. not specific to 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;

42. When to use brain spect scintigraphy to confirm brain death
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Get up from chair walk a short distance turn around and sit; screening test for fall
It patient has electrolyte imbalance and hypothermia

43. Tx of GBS
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
EPV - campylobacter - HSV
MS

44. How to tx lewy body dementia
Clonidine will take care both high bp and withdrawal
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;
Femoral n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs

45. How to perform apnea test
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Myasthenia; due to autoantibodies against acetylecholine receptor;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

46. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in writing - calculating - distinguishing left and write
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

47. impaired hepatic conjugation of billirubin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Follows viral illness; vertigo - tinnitus - nausea. self limiting
IVIG and plasmapheresis
Gilberts disease

48. at first tingling in toes and feet then weakness in extremities
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

49. best diagnosis for parkinsonim
Upright supine position
Autospy gold standard
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors

50. How to tx acute exacerbation of MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
High dose IV methyleprednisone;
RBC count >6000
Cholinesterase inhibitor; and antiparkinsonism drugs