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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. acoustic neuroma
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Diabetes insipidus
20%
Despite the term neuroma they arise from schwann cells - schwanoma

2. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

3. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Lesion in nondominant temporal lobe
RBC count >6000

4. How to differentiate medial and lateral medullary 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
MS: CSF increased IgG -IgM and IgA also increased. not specific to 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;
Aspirin - control HTN and swallow eval before giving any oral meds

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

6. indication of plasmapheresis in GBS
Obturator n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
<20; if patient scores >25 benign forgetfulness

7. 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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

8. double vision at the end of day and ptosis
Not within 24 hours; give afte 24-48 hours if patient stable
Myasthenia; due to autoantibodies against acetylecholine receptor;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Femoral n lesion

9. infections in GBS
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
EPV - campylobacter - HSV
MS

10. lesion in dominant parietal lobe
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write
RBC count >6000

11. get up and go test
<20; if patient scores >25 benign forgetfulness
Get up from chair walk a short distance turn around and sit; screening test for fall
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

12. GBS
IVIG and plasmapheresis
Distal lower motor neuron disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

13. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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
Coronary artery disease
Taper gradually to prevent seizure relapse
Cerebral palsy; dx mri

14. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

15. differentiate lewy body dementia and vascular dementia
Verapamil
IVIG and plasmapheresis
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

16. what drug is used to extend effects of levodopa
Acetylecholinersterase inhibitors
Spastic paraparesis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Entacapone - COMT inhibitor

17. 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
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
Nystagmus on far lateral gaze

18. How to differentiate botulism from tick born paralysis - GBS and MG
Normal pressure hydrocephalus
Botulism has descending paralysis in contrast othere have ascending paralysis
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

19. MMSE score of less than 24
82% specific for dementia
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.
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse

20. What is can be used cluster headache prevention
Aspirin - control HTN and swallow eval before giving any oral meds
Antitoxin
Taper gradually to prevent seizure relapse
Verapamil

21. brain stem lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Normal pressure hydrocephalus
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Deficit in cranial nerve function

22. How to perform apnea test
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
82% specific for dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

23. Should we tx htn in acute ischemic stroke

24. best diagnosis for parkinsonim
Autospy gold standard
Corticosteroid and acyclovir
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

25. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
90% of right handed and 60% of left handed persons; speech and language function
Botulism has descending paralysis in contrast othere have ascending paralysis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

26. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds

27. oligoclonal band in CSF
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MS
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

28. MG
Acetylecholinersterase inhibitors
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

29. differentiate picks and huntington
Cerebellar lesion
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
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
Diabetes insipidus

30. dementia plus urinary incontinence
Propranolol or primidone
Normal pressure hydrocephalus
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;
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

31. When to start fibrinolytic therapy in stroke patient?
Femoral n lesion
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;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion

32. cluster headache
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
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
Despite the term neuroma they arise from schwann cells - schwanoma
High dose IV methyleprednisone;

33. Why V12 deficient develop hypokalemia after tx with b12
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

34. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in writing - calculating - distinguishing left and write
90% of right handed and 60% of left handed persons; speech and language function
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

35. botulism
Entacapone - COMT inhibitor
Antitoxin
Diabetes insipidus
Clonidine will take care both high bp and withdrawal

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

37. How to manage stroke patient came within 4 hours
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
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;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

38. benign essential tremor
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;
Propranolol or primidone
Obturator n lesion
MS

39. differentiate wenicke and korsakoff
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. prodrome of vasovagal syncope
Entacapone - COMT inhibitor
Tunnel vision - diaphoresis - nausea - pallor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Reduced efficacy of OCP

41. craniopharyngioma
Reduced efficacy of OCP
Femoral n lesion
Diabetes insipidus
Tunnel vision - diaphoresis - nausea - pallor

42. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Get up from chair walk a short distance turn around and sit; screening test for fall
Gilberts disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

43. When to suspect traumatic LP
Tunnel vision - diaphoresis - nausea - pallor
Clonidine will take care both high bp and withdrawal
RBC count >6000
Acetylecholinersterase inhibitors

44. contraindication of sumatripta
Coronary artery disease
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

45. impaired hepatic conjugation of billirubin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Gilberts disease
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;
Entacapone - COMT inhibitor

46. How to differentiate medial and lateral pontine syndrome
EPV - campylobacter - HSV
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
Gilberts disease

47. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Cholinesterase inhibitor; and antiparkinsonism drugs
It patient has electrolyte imbalance and hypothermia
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

48. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Diabetes insipidus
Aphasia - neglect - agnosia - acalculia etc

49. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
82% specific for dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Obturator n lesion

50. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acetylecholinersterase inhibitors
Autospy gold standard