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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. MG
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Aspirin - control HTN and swallow eval before giving any oral meds
Acetylecholinersterase inhibitors

2. lesion in dominant tempora lobe
Distal lower motor neuron disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

3. Why V12 deficient develop hypokalemia after tx with b12
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Entacapone - COMT inhibitor
Obturator n lesion

4. craniopharyngioma
Diabetes insipidus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

5. brain stem lesion
Nystagmus on far lateral gaze
Coronary artery disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Deficit in cranial nerve function

6. When to start fibrinolytic therapy in stroke patient?
Upright supine position
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin

7. How to perform apnea test
MS
It patient has electrolyte imbalance and hypothermia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

8. lesion in dominant parietal lobe
Normal pressure hydrocephalus
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
20%

9. phenytoin and OCP
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.
Reduced efficacy of OCP
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

10. dominant parietal lobe on the left side
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
Autospy gold standard
RBC count >6000

11. 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
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Gilberts disease

12. labyrinthitis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

13. headache - non reactive pupil - fall on both sides during walking - impaired upward 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.
Antitoxin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Get up from chair walk a short distance turn around and sit; screening test for fall

14. What is pronator drift
Antitoxin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Normal pressure hydrocephalus
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

15. best diagnosis for parkinsonim
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Entacapone - COMT inhibitor
Autospy gold standard

16. How to stop antiepileptic drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Taper gradually to prevent seizure relapse
Coronary artery disease
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

17. When to use dopamine agonist pramipexol in parkinson
Botulism has descending paralysis in contrast othere have ascending paralysis
Aspirin - control HTN and swallow eval before giving any oral meds
Femoral n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

18. acoustic neuroma
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Despite the term neuroma they arise from schwann cells - schwanoma
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

19. What mmse score suggest dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
<20; if patient scores >25 benign forgetfulness
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

20. earliest sign of phenytoin toxicity
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Nystagmus on far lateral gaze

21. differentiate lewy body dementia and vascular dementia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Reduced efficacy of 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

22. What is can be used cluster headache prevention
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard
Difficulty in writing - calculating - distinguishing left and write

23. How to differentiate dementias
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
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

24. medial thigh sensory loss and weakness in addcution
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion
<20; if patient scores >25 benign forgetfulness
Get up from chair walk a short distance turn around and sit; screening test for fall

25. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
20%
RBC count >6000

26. How to tx stroke patient came after 6h
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Deficit in cranial nerve function

27. infections in GBS
Vitamin B12 deficiency
EPV - campylobacter - HSV
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus

28. contraindication of sumatripta
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in writing - calculating - distinguishing left and write
Coronary artery disease
Obturator n lesion

29. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Normal pressure hydrocephalus
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
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

30. How to differentiate medial and lateral pontine syndrome
Botulism has descending paralysis in contrast othere have ascending paralysis
Propranolol or primidone
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 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.

31. How to manage stroke patient came within 4 hours
Wernicke's encephalopathy; due to thiamine definition; medical emergency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Verapamil
Corticosteroid and acyclovir

32. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri

33. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma
Get up from chair walk a short distance turn around and sit; screening test for fall

34. double vision at the end of day and ptosis
Acetylecholinersterase inhibitors
Myasthenia; due to autoantibodies against acetylecholine receptor;
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

35. How to prevent prevent frequency of MS exacerbation
Taper gradually to prevent seizure relapse
Reduced efficacy of OCP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Wernicke's encephalopathy; due to thiamine definition; medical emergency

36. prodrome of vasovagal syncope
Despite the term neuroma they arise from schwann cells - schwanoma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor

37. what drug is used to extend effects of levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Entacapone - COMT inhibitor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

38. Unable to copy of matchstick - unable to dress up
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Deficit in cranial nerve function

39. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin
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

40. How to differentiate parkinson and benign essential tremor
Get up from chair walk a short distance turn around and sit; screening test for fall
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Propranolol or primidone

41. indication of plasmapheresis in GBS
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

42. Should we tx htn in acute ischemic stroke

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43. How to confirm braindeath?
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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.
MS
Lesion in nondominant temporal lobe

44. How to tx lewy body dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Cholinesterase inhibitor; and antiparkinsonism drugs
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;
Femoral n lesion

45. How to differentiate medial and lateral medullary syndrome
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

46. oligoclonal band in CSF
Diabetes insipidus
It patient has electrolyte imbalance and hypothermia
MS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

47. How to tx acute exacerbation of MS
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
High dose IV methyleprednisone;

48. Blood transfusion in hypothermia
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
Propranolol or primidone
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

49. botulism
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Antitoxin
MS
Construction apraxia; lesion in non dominant parietal lobe (right)

50. benign essential tremor
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48