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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. When to use brain spect scintigraphy to confirm brain death
Distal lower motor neuron disease
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis

2. phenytoin and OCP
Vitamin B12 deficiency
Reduced efficacy of OCP
Diabetes insipidus
Entacapone - COMT inhibitor

3. acoustic neuroma
Autospy gold standard
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebral palsy; dx mri

4. infections in GBS
EPV - campylobacter - HSV
Reduced efficacy of OCP
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Despite the term neuroma they arise from schwann cells - schwanoma

5. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
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
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function

6. differentiate lewy body dementia and vascular dementia
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
Reduced efficacy of OCP
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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

7. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

8. indication of plasmapheresis in GBS
Taper gradually to prevent seizure relapse
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Entacapone - COMT inhibitor

9. How to differentiate dementias
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
Reduced efficacy of OCP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Antitoxin

10. What percent of dementia is reversible
20%
Gilberts disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

11. How to manage stroke patient came within 4 hours
Diabetes insipidus
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
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

12. Should we tx htn in acute ischemic stroke

13. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Gilberts disease
RBC count >6000
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

14. best diagnosis for parkinsonim
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Autospy gold standard
Follows viral illness; vertigo - tinnitus - nausea. self limiting

15. How to tx lewy body dementia
Aspirin - control HTN and swallow eval before giving any oral meds
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
Antitoxin
Cholinesterase inhibitor; and antiparkinsonism drugs

16. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

17. Blood transfusion in hypothermia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Femoral n lesion
MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

18. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

19. double vision at the end of day and ptosis
Vitamin B12 deficiency
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
90% of right handed and 60% of left handed persons; speech and language function
Myasthenia; due to autoantibodies against acetylecholine receptor;

20. Unable to copy of matchstick - unable to dress up
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Normal pressure hydrocephalus
Construction apraxia; lesion in non dominant parietal lobe (right)

21. impaired hepatic conjugation of billirubin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri
Gilberts disease

22. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
20%
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

23. at first tingling in toes and feet then weakness in extremities
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Follows viral illness; vertigo - tinnitus - nausea. self limiting

24. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
IVIG and plasmapheresis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

25. How to differentiate parkinson and benign essential tremor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Taper gradually to prevent seizure relapse
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

26. excessive elevation of legs during walking (toe touch floor earlier than heels)
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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;
Distal lower motor neuron disease

27. How to differentiate medial and lateral pontine syndrome
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Distal lower motor neuron disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

28. get up and go test
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;
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir

29. When to give aspirin when patient on tPA after stroke
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Distal lower motor neuron disease

30. 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
High dose IV methyleprednisone;
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

31. cortical lesion
Diabetes insipidus
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Aphasia - neglect - agnosia - acalculia etc

32. impaired vibration and increased DTR
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
Vitamin B12 deficiency
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor

33. contraindication of sumatripta
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
Propranolol or primidone
Coronary artery disease
Not within 24 hours; give afte 24-48 hours if patient stable

34. When headache is presenting complaint of brain tumor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

35. impaired perception of complex sounds
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
Lesion in nondominant temporal lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;

36. How to prevent prevent frequency of MS exacerbation
Tunnel vision - diaphoresis - nausea - pallor
Nystagmus on far lateral gaze
20%
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

37. What is pronator drift
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
20%
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

38. How to perform apnea test
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Corticosteroid and acyclovir
Upright supine position

39. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion
IVIG and plasmapheresis

40. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Cerebellar lesion
Reduced efficacy of OCP
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

41. dominant parietal lobe on the left side
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Autospy gold standard
90% of right handed and 60% of left handed persons; speech and language function

42. dementia plus urinary incontinence
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Nystagmus on far lateral gaze

43. earliest sign of phenytoin toxicity
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Nystagmus on far lateral gaze
Aphasia - neglect - agnosia - acalculia etc
Get up from chair walk a short distance turn around and sit; screening test for fall

44. benign essential tremor
Propranolol or primidone
Difficulty in writing - calculating - distinguishing left and write
Normal pressure hydrocephalus
20%

45. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Taper gradually to prevent seizure relapse
Reduced efficacy of OCP
Clonidine will take care both high bp and withdrawal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

46. How to stop antiepileptic drugs
Not within 24 hours; give afte 24-48 hours if patient stable
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease

47. oligoclonal band in CSF
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

48. what drug is used to extend effects of levodopa
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Entacapone - COMT inhibitor
Normal pressure hydrocephalus

49. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Normal pressure hydrocephalus
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

50. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel