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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. What is pronator drift
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in writing - calculating - distinguishing left and write
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
Taper gradually to prevent seizure relapse

2. Blood transfusion in hypothermia
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
Verapamil
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

3. When to suspect traumatic LP
Antitoxin
RBC count >6000
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

4. When headache is presenting complaint of brain tumor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

5. 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;
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

6. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Reduced efficacy of OCP

7. impaired perception of complex sounds
Lesion in nondominant temporal lobe
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
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP

8. How to tx acute exacerbation of 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;
High dose IV methyleprednisone;
Spastic paraparesis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

9. differentiate picks and huntington
Antitoxin
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

10. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
High dose IV methyleprednisone;

11. acoustic neuroma
Aspirin - control HTN and swallow eval before giving any oral meds
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
Despite the term neuroma they arise from schwann cells - schwanoma
Aphasia - neglect - agnosia - acalculia etc

12. 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
EPV - campylobacter - HSV
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

13. When to give aspirin when patient on tPA after stroke
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Vitamin B12 deficiency
Not within 24 hours; give afte 24-48 hours if patient stable
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

14. impaired hepatic conjugation of billirubin
Despite the term neuroma they arise from schwann cells - schwanoma
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Gilberts disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

15. labyrinthitis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting

16. How to confirm braindeath?
Propranolol or primidone
Deficit in cranial nerve function
Nystagmus on far lateral gaze
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.

17. MG
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
Acetylecholinersterase inhibitors
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

18. prodrome of vasovagal syncope
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor

19. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Botulism has descending paralysis in contrast othere have ascending paralysis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;
Obturator n lesion

20. cluster headache
Aspirin - control HTN and swallow eval before giving any oral meds
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

21. indication of plasmapheresis in GBS
Spastic paraparesis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

22. women with unilateral eye pain; neurlogic symptoms here there at different times
<20; if patient scores >25 benign forgetfulness
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. What mmse score suggest dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor
<20; if patient scores >25 benign forgetfulness

24. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
EPV - campylobacter - HSV
Diabetes insipidus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

25. differentiate wenicke and korsakoff
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Femoral n lesion
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

26. korsafoff psychosis
82% specific for dementia
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

27. What is can be used cluster headache prevention
Construction apraxia; lesion in non dominant parietal lobe (right)
Verapamil
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall

28. at first tingling in toes and feet then weakness in extremities
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
<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

29. Acute onset of left arm weakness
Tunnel vision - diaphoresis - nausea - pallor
Obturator n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cerebellar lesion

30. When to use dopamine agonist pramipexol in parkinson
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

31. Should we tx htn in acute ischemic stroke

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32. Unable to copy of matchstick - unable to dress up
Taper gradually to prevent seizure relapse
Normal pressure hydrocephalus
Tunnel vision - diaphoresis - nausea - pallor
Construction apraxia; lesion in non dominant parietal lobe (right)

33. How to tx lewy body dementia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs
It patient has electrolyte imbalance and hypothermia

34. How to differentiate medial and lateral medullary syndrome
Spastic paraparesis
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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;

35. How to differentiate botulism from tick born paralysis - GBS and MG
Despite the term neuroma they arise from schwann cells - schwanoma
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Botulism has descending paralysis in contrast othere have ascending paralysis
EPV - campylobacter - HSV

36. lesion in dominant parietal lobe
Coronary artery disease
MS
Difficulty in writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)

37. What bp med to be given in a patient with high bp and signs of opioid withdrawal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Clonidine will take care both high bp and withdrawal
Propranolol or primidone

38. contraindication of sumatripta
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Coronary artery disease
Lesion in nondominant temporal lobe

39. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acetylecholinersterase inhibitors
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

40. How to tx stroke patient came after 6h
Obturator n lesion
Propranolol or primidone
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Aspirin - control HTN and swallow eval before giving any oral meds

41. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Despite the term neuroma they arise from schwann cells - schwanoma

42. How to differentiate medial and lateral pontine syndrome
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Taper gradually to prevent seizure relapse

43. botulism
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin
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

44. excessive elevation of legs during walking (toe touch floor earlier than heels)
Acetylecholinersterase inhibitors
Distal lower motor neuron disease
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
Cerebral palsy; dx mri

45. When to use brain spect scintigraphy to confirm brain death
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
It patient has electrolyte imbalance and hypothermia

46. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Deficit in cranial nerve function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
It patient has electrolyte imbalance and hypothermia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

47. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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;
Construction apraxia; lesion in non dominant parietal lobe (right)

48. How to differentiate parkinson and benign essential tremor
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
Coronary artery disease
<20; if patient scores >25 benign forgetfulness

49. what drug is used to extend effects of levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Corticosteroid and acyclovir
Entacapone - COMT inhibitor
Tunnel vision - diaphoresis - nausea - pallor

50. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
MS
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebral palsy; dx mri
Nystagmus on far lateral gaze