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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 mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
EPV - campylobacter - HSV
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Botulism has descending paralysis in contrast othere have ascending paralysis

2. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
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
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

3. cluster headache
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Acetylecholinersterase inhibitors
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

4. How to perform apnea test
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

5. How to differentiate parkinson and benign essential tremor
IVIG and plasmapheresis
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
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.
Despite the term neuroma they arise from schwann cells - schwanoma

6. lesion in dominant tempora lobe
Not within 24 hours; give afte 24-48 hours if patient stable
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
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

7. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Entacapone - COMT inhibitor
Propranolol or primidone
Construction apraxia; lesion in non dominant parietal lobe (right)

8. How to tx acute exacerbation of MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Vitamin B12 deficiency
High dose IV methyleprednisone;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

9. Tx of GBS
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
RBC count >6000
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

10. Tx of bells palsy
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Corticosteroid and acyclovir

11. korsafoff psychosis
Get up from chair walk a short distance turn around and sit; screening test for fall
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

12. botulism
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Antitoxin
90% of right handed and 60% of left handed persons; speech and language function

13. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Cerebellar lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

14. infections in GBS
EPV - campylobacter - HSV
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tunnel vision - diaphoresis - nausea - pallor
Despite the term neuroma they arise from schwann cells - schwanoma

15. When headache is presenting complaint of brain tumor
Difficulty in writing - calculating - distinguishing left and write
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

16. When to suspect traumatic LP
Get up from chair walk a short distance turn around and sit; screening test for fall
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
RBC count >6000
Upright supine position

17. When to use brain spect scintigraphy to confirm brain death
Femoral n lesion
<20; if patient scores >25 benign forgetfulness
It patient has electrolyte imbalance and hypothermia
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. excessive elevation of legs during walking (toe touch floor earlier than heels)
Upright supine position
Taper gradually to prevent seizure relapse
90% of right handed and 60% of left handed persons; speech and language function
Distal lower motor neuron disease

19. what drug is used to extend effects of levodopa
Normal pressure hydrocephalus
It patient has electrolyte imbalance and hypothermia
Entacapone - COMT inhibitor
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

20. How to manage stroke patient came within 4 hours
Not within 24 hours; give afte 24-48 hours if patient stable
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Diabetes insipidus

21. prodrome of vasovagal syncope
RBC count >6000
Verapamil
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
Tunnel vision - diaphoresis - nausea - pallor

22. double vision at the end of day and ptosis
Antitoxin
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Femoral n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;

23. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

24. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Corticosteroid and acyclovir
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

25. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
It patient has electrolyte imbalance and hypothermia
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

26. How to stop antiepileptic drugs
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Taper gradually to prevent seizure relapse

27. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone

28. Acute onset of left arm weakness
Difficulty in writing - calculating - distinguishing left and write
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
Corticosteroid and acyclovir
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

29. best diagnosis for parkinsonim
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze
Autospy gold standard
Coronary artery disease

30. oligoclonal band in CSF
Construction apraxia; lesion in non dominant parietal lobe (right)
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

31. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Reduced efficacy of OCP

32. Patient with carbamazepine; What should be advice?
High dose IV methyleprednisone;
Femoral n lesion
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

33. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Aphasia - neglect - agnosia - acalculia etc
Lesion in nondominant temporal lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Upright supine position

34. phenytoin and OCP
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
It patient has electrolyte imbalance and hypothermia
82% specific for dementia

35. impaired vibration and increased DTR
Coronary artery disease
Cerebellar lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Vitamin B12 deficiency

36. impaired perception of complex sounds
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe

37. contraindication of sumatripta
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis
Coronary artery disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

38. 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
Clonidine will take care both high bp and withdrawal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Antitoxin

39. impaired hepatic conjugation of billirubin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
High dose IV methyleprednisone;
Gilberts disease

40. craniopharyngioma
Clonidine will take care both high bp and withdrawal
Not within 24 hours; give afte 24-48 hours if patient stable
Normal pressure hydrocephalus
Diabetes insipidus

41. MMSE score of less than 24
Obturator n lesion
82% specific for dementia
Get up from chair walk a short distance turn around and sit; screening test for fall
Deficit in cranial nerve function

42. differentiate picks and huntington
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Deficit in cranial nerve function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

43. labyrinthitis
Coronary artery disease
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aphasia - neglect - agnosia - acalculia etc

44. Blood transfusion in hypothermia
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin
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

45. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Aphasia - neglect - agnosia - acalculia etc
Cholinesterase inhibitor; and antiparkinsonism drugs
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
<20; if patient scores >25 benign forgetfulness

46. stroke with lower facial palsy - pronator drift despite on aspirin
82% specific for dementia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

47. differentiate lewy body dementia and vascular dementia
Botulism has descending paralysis in contrast othere have ascending paralysis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

48. How to prevent prevent frequency of MS exacerbation
Acetylecholinersterase inhibitors
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aspirin - control HTN and swallow eval before giving any oral meds

49. Unable to copy of matchstick - unable to dress up
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

50. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
EPV - campylobacter - HSV
Gilberts disease
Taper gradually to prevent seizure relapse