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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.
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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. differentiate picks and huntington
Coronary artery disease
Antitoxin
Distal lower motor neuron disease
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

2. GBS
IVIG and plasmapheresis
Cholinesterase inhibitor; and antiparkinsonism drugs
Tunnel vision - diaphoresis - nausea - pallor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

3. medial thigh sensory loss and weakness in addcution
Deficit in cranial nerve function
Obturator n lesion
Nystagmus on far lateral gaze
Entacapone - COMT inhibitor

4. anerior and anteriomedial thigh paresthesia - decreased DTR
Cerebellar lesion
Femoral n lesion
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

5. phenytoin and OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position
<20; if patient scores >25 benign forgetfulness
Reduced efficacy of OCP

6. MG
Acetylecholinersterase inhibitors
Distal lower motor neuron disease
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease

7. 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
Diabetes insipidus
MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

8. excessive elevation of legs during walking (toe touch floor earlier than heels)
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Entacapone - COMT inhibitor
20%
Distal lower motor neuron disease

9. Tx of bells palsy
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir

10. craniopharyngioma
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.
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

11. When to give aspirin when patient on tPA after stroke
Botulism has descending paralysis in contrast othere have ascending paralysis
Not within 24 hours; give afte 24-48 hours if patient stable
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

12. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV

13. 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
It patient has electrolyte imbalance and hypothermia
RBC count >6000
MS

14. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
RBC count >6000
Antitoxin

15. brain stem lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Diabetes insipidus
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;
Deficit in cranial nerve function

16. How to differentiate botulism from tick born paralysis - GBS and MG
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Botulism has descending paralysis in contrast othere have ascending paralysis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
It patient has electrolyte imbalance and hypothermia

17. labyrinthitis
RBC count >6000
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Acetylecholinersterase inhibitors
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

18. impaired hepatic conjugation of billirubin
IVIG and plasmapheresis
Autospy gold standard
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis

19. When to start fibrinolytic therapy in stroke patient?
Entacapone - COMT inhibitor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Obturator n lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

20. Blood transfusion in hypothermia
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

21. dominant parietal lobe on the left side
Reduced efficacy of OCP
Antitoxin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
90% of right handed and 60% of left handed persons; speech and language function

22. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Diabetes insipidus

23. oligoclonal band in CSF
MS
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

24. How to tx stroke patient came after 6h
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aspirin - control HTN and swallow eval before giving any oral meds
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

25. What is can be used cluster headache prevention
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Verapamil
90% of right handed and 60% of left handed persons; speech and language function
Lesion in nondominant temporal lobe

26. severe headache and high BP
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
90% of right handed and 60% of left handed persons; speech and language function
Wernicke's encephalopathy; due to thiamine definition; medical emergency

27. How to prevent prevent frequency of MS exacerbation
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Coronary artery disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

28. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

29. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Entacapone - COMT inhibitor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

30. benign essential tremor
Tunnel vision - diaphoresis - nausea - pallor
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Propranolol or primidone
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

31. prodrome of vasovagal syncope
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Tunnel vision - diaphoresis - nausea - pallor

32. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Vitamin B12 deficiency
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aphasia - neglect - agnosia - acalculia etc
90% of right handed and 60% of left handed persons; speech and language function

33. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Aphasia - neglect - agnosia - acalculia etc
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebral palsy; dx mri

34. How to differentiate medial and lateral pontine syndrome
20%
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Botulism has descending paralysis in contrast othere have ascending paralysis

35. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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
<20; if patient scores >25 benign forgetfulness
Clonidine will take care both high bp and withdrawal

36. botulism
Antitoxin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Upright supine position

37. How to tx acute exacerbation of MS
Tunnel vision - diaphoresis - nausea - pallor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma

38. How to confirm braindeath?
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.
Corticosteroid and acyclovir
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

39. earliest sign of phenytoin toxicity
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Nystagmus on far lateral gaze
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
Entacapone - COMT inhibitor

40. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Acetylecholinersterase inhibitors
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

41. How to differentiate traumatic LP and SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Femoral n lesion
Aphasia - neglect - agnosia - acalculia etc

42. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
82% specific for dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

43. Tx of GBS
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
<20; if patient scores >25 benign forgetfulness
Spastic paraparesis

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

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45. cortical lesion
MS
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
Botulism has descending paralysis in contrast othere have ascending paralysis

46. what drug is used to extend effects of levodopa
20%
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease
Entacapone - COMT inhibitor

47. indication of plasmapheresis in GBS
Distal lower motor neuron disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Taper gradually to prevent seizure relapse

48. differentiate lewy body dementia and vascular dementia
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
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

49. What is pronator drift
Spontaneous remission; admit if suspected and monitor pulse ox for 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
Reduced efficacy of OCP
Diabetes insipidus

50. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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