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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. women with unilateral eye pain; neurlogic symptoms here there at different times
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Reduced efficacy of OCP
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

2. korsafoff psychosis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Deficit in cranial nerve function
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

3. dominant parietal lobe on the left side
Get up from chair walk a short distance turn around and sit; screening test for fall
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Gilberts disease
90% of right handed and 60% of left handed persons; speech and language function

4. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Get up from chair walk a short distance turn around and sit; screening test for fall
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Upright supine position
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

5. 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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus

6. excessive elevation of legs during walking (toe touch floor earlier than heels)
Propranolol or primidone
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebral palsy; dx mri
Distal lower motor neuron disease

7. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Obturator n lesion
Clonidine will take care both high bp and withdrawal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

8. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Normal pressure hydrocephalus

9. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Difficulty in writing - calculating - distinguishing left and write
Diabetes insipidus

10. oligoclonal band in CSF
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus

11. 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
Cholinesterase inhibitor; and antiparkinsonism drugs
Cerebellar lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

12. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS

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

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14. medial thigh sensory loss and weakness in addcution
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion
Femoral n lesion
Cerebellar lesion

15. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Nystagmus on far lateral gaze
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;
Clonidine will take care both high bp and withdrawal

16. How to confirm braindeath?
Myasthenia; due to autoantibodies against acetylecholine receptor;
Clonidine will take care both high bp and withdrawal
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.
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

17. craniopharyngioma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Diabetes insipidus
Upright supine position
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

18. When to use brain spect scintigraphy to confirm brain death
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Follows viral illness; vertigo - tinnitus - nausea. self limiting
It patient has electrolyte imbalance and hypothermia
EPV - campylobacter - HSV

19. labyrinthitis
High dose IV methyleprednisone;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Entacapone - COMT inhibitor
Follows viral illness; vertigo - tinnitus - nausea. self limiting

20. How to differentiate medial and lateral pontine syndrome
90% of right handed and 60% of left handed persons; speech and language function
MS
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
Nystagmus on far lateral gaze

21. at first tingling in toes and feet then weakness in extremities
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
IVIG and plasmapheresis

22. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
82% specific for dementia
Normal pressure hydrocephalus

23. differentiate picks and huntington
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Obturator n lesion
Cerebellar lesion
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

24. dementia plus urinary incontinence
Construction apraxia; lesion in non dominant parietal lobe (right)
Normal pressure hydrocephalus
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus

25. what drug is used to extend effects of levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis
Diabetes insipidus
Entacapone - COMT inhibitor

26. botulism
Antitoxin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Propranolol or primidone
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

27. indication of plasmapheresis in GBS
Cerebral palsy; dx mri
<20; if patient scores >25 benign forgetfulness
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

28. What is can be used cluster headache prevention
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
Verapamil
Get up from chair walk a short distance turn around and sit; screening test for fall
Vitamin B12 deficiency

29. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Diabetes insipidus
Spastic paraparesis
Deficit in cranial nerve function

30. GBS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
IVIG and plasmapheresis

31. Tx of GBS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

32. When to start fibrinolytic therapy in stroke patient?
Coronary artery disease
Cholinesterase inhibitor; and antiparkinsonism drugs
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
<20; if patient scores >25 benign forgetfulness

33. MMSE score of less than 24
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
82% specific for dementia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Femoral n lesion

34. stroke with lower facial palsy - pronator drift despite on aspirin
Entacapone - COMT inhibitor
IVIG and plasmapheresis
Antitoxin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

35. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Entacapone - COMT inhibitor
Obturator n lesion
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

36. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus
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

37. When to suspect traumatic LP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Gilberts disease
RBC count >6000

38. What percent of dementia is reversible
IVIG and plasmapheresis
Cerebral palsy; dx mri
20%
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

39. lesion in dominant parietal lobe
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 writing - calculating - distinguishing left and write
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

40. When headache is presenting complaint of brain tumor
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
Gilberts disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

41. impaired perception of complex sounds
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Lesion in nondominant temporal lobe
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

42. How to stop antiepileptic drugs
It patient has electrolyte imbalance and hypothermia
Taper gradually to prevent seizure relapse
Femoral n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

43. What mmse score suggest dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Autospy gold standard
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds

44. phenytoin and OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Reduced efficacy of OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Corticosteroid and acyclovir

45. cluster headache
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
Aphasia - neglect - agnosia - acalculia etc
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Upright supine position

46. lesion in dominant tempora lobe
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
It patient has electrolyte imbalance and hypothermia
Obturator n lesion

47. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Lesion in nondominant temporal lobe
EPV - campylobacter - HSV
82% specific for dementia
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

48. How to differentiate botulism from tick born paralysis - GBS and MG
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
<20; if patient scores >25 benign forgetfulness
Botulism has descending paralysis in contrast othere have ascending paralysis
Distal lower motor neuron disease

49. Why V12 deficient develop hypokalemia after tx with b12
Not within 24 hours; give afte 24-48 hours if patient stable
Reduced efficacy of OCP
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

50. brain stem lesion
Deficit in cranial nerve function
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
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;