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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. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Verapamil
Entacapone - COMT inhibitor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function

2. impaired hepatic conjugation of billirubin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Antitoxin
Gilberts disease

3. impaired perception of complex sounds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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.
Clonidine will take care both high bp and withdrawal
Lesion in nondominant temporal lobe

4. korsafoff psychosis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Nystagmus on far lateral gaze

5. What percent of dementia is reversible
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
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

6. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

7. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Spastic paraparesis
Coronary artery disease
Normal pressure hydrocephalus

8. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
<20; if patient scores >25 benign forgetfulness
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write

9. When to use dopamine agonist pramipexol in parkinson
Spastic paraparesis
<20; if patient scores >25 benign forgetfulness
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

10. craniopharyngioma
Diabetes insipidus
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

11. what drug is used to extend effects of levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
Entacapone - COMT inhibitor
90% of right handed and 60% of left handed persons; speech and language function

12. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Normal pressure hydrocephalus
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

13. Why V12 deficient develop hypokalemia after tx with b12
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

14. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
EPV - campylobacter - HSV
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
90% of right handed and 60% of left handed persons; speech and language function

15. Patient with carbamazepine; What should be advice?
Upright supine position
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;
MS
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

16. What is pronator drift
Taper gradually to prevent seizure relapse
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
Normal pressure hydrocephalus
Reduced efficacy of OCP

17. lesion in dominant tempora lobe
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
Reduced efficacy of OCP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

18. differentiate wenicke and korsakoff
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
Normal pressure hydrocephalus
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

19. differentiate lewy body dementia and vascular dementia
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.
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
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

20. How to confirm braindeath?
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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.
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
EPV - campylobacter - HSV

21. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Aspirin - control HTN and swallow eval before giving any oral meds
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

22. oligoclonal band in CSF
Nystagmus on far lateral gaze
MS
Acetylecholinersterase inhibitors
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

23. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
RBC count >6000
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

24. double vision at the end of day and ptosis
Entacapone - COMT inhibitor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Myasthenia; due to autoantibodies against acetylecholine receptor;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

25. Acute onset of left arm weakness
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

26. labyrinthitis
Spastic paraparesis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aphasia - neglect - agnosia - acalculia etc

27. impaired vibration and increased DTR
Vitamin B12 deficiency
Cerebral palsy; dx mri
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.
Myasthenia; due to autoantibodies against acetylecholine receptor;

28. cluster headache
Cholinesterase inhibitor; and antiparkinsonism drugs
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
82% specific for dementia
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;

29. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

30. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Aphasia - neglect - agnosia - acalculia etc
20%
Gilberts disease
Cerebellar lesion

31. What mmse score suggest dementia
MS
Gilberts disease
82% specific for dementia
<20; if patient scores >25 benign forgetfulness

32. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

33. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Antitoxin
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

34. at first tingling in toes and feet then weakness in extremities
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Coronary artery disease
Spastic paraparesis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

35. How to differentiate medial and lateral pontine syndrome
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

36. Tx of GBS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Follows viral illness; vertigo - tinnitus - nausea. self limiting
82% specific for dementia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

37. MMSE score of less than 24
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable
82% specific for dementia
Tunnel vision - diaphoresis - nausea - pallor

38. How to differentiate parkinson and benign essential tremor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

39. 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
Diabetes insipidus
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

40. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Tunnel vision - diaphoresis - nausea - pallor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Propranolol or primidone

41. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Diabetes insipidus
Tunnel vision - diaphoresis - nausea - pallor
Get up from chair walk a short distance turn around and sit; screening test for fall

42. women with unilateral eye pain; neurlogic symptoms here there at different times
82% specific for dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

43. 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
<20; if patient scores >25 benign forgetfulness
IVIG and plasmapheresis
Cholinesterase inhibitor; and antiparkinsonism drugs

44. phenytoin and OCP
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;
Reduced efficacy of OCP
MS

45. contraindication of sumatripta
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Upright supine position
Cholinesterase inhibitor; and antiparkinsonism drugs

46. How to differentiate medial and lateral medullary syndrome
Acetylecholinersterase inhibitors
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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;
Cholinesterase inhibitor; and antiparkinsonism drugs

47. dementia plus urinary incontinence
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Normal pressure hydrocephalus
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma

48. Tx of bells palsy
Corticosteroid and acyclovir
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

49. How to differentiate botulism from tick born paralysis - GBS and MG
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Botulism has descending paralysis in contrast othere have ascending paralysis

50. benign essential tremor
Aphasia - neglect - agnosia - acalculia etc
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
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness