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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. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Taper gradually to prevent seizure relapse
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Entacapone - COMT inhibitor

2. craniopharyngioma
RBC count >6000
Cerebellar lesion
Diabetes insipidus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

3. Acute onset of left arm weakness
Autospy gold standard
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

4. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
High dose IV methyleprednisone;
82% specific for dementia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. What is pronator drift
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
20%
Femoral n lesion

6. Patient with carbamazepine; What should be advice?
Cholinesterase inhibitor; and antiparkinsonism drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

7. How to differentiate botulism from tick born paralysis - GBS and MG
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;
Vitamin B12 deficiency
MS
Botulism has descending paralysis in contrast othere have ascending paralysis

8. Tx of bells palsy
Corticosteroid and acyclovir
Obturator n lesion
90% of right handed and 60% of left handed persons; speech and language function
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;

9. How to prevent prevent frequency of MS exacerbation
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Spastic paraparesis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

10. double vision at the end of day and ptosis
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency

11. When to use brain spect scintigraphy to confirm brain death
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
Clonidine will take care both high bp and withdrawal
It patient has electrolyte imbalance and hypothermia

12. contraindication of sumatripta
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;
Coronary artery disease
Vitamin B12 deficiency
Nystagmus on far lateral gaze

13. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Nystagmus on far lateral gaze
90% of right handed and 60% of left handed persons; speech and language function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

14. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

15. What is can be used cluster headache prevention
Distal lower motor neuron disease
Verapamil
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

16. benign essential tremor
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Diabetes insipidus
Propranolol or primidone

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

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18. differentiate picks and huntington
Deficit in cranial nerve function
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
Spastic paraparesis
Normal pressure hydrocephalus

19. medial thigh sensory loss and weakness in addcution
EPV - campylobacter - HSV
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
Verapamil
Obturator n lesion

20. How to manage stroke patient came within 4 hours
Femoral n lesion
It patient has electrolyte imbalance and hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Upright supine position

21. oligoclonal band in CSF
Diabetes insipidus
Obturator n lesion
Autospy gold standard
MS

22. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

23. indication of plasmapheresis in GBS
Difficulty in writing - calculating - distinguishing left and write
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

24. what drug is used to extend effects of levodopa
Distal lower motor neuron disease
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
Spastic paraparesis
Entacapone - COMT inhibitor

25. lesion in dominant tempora lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Coronary artery disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Corticosteroid and acyclovir

26. lesion in dominant parietal lobe
Nystagmus on far lateral gaze
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

27. dementia plus urinary incontinence
Normal pressure hydrocephalus
Coronary artery disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Vitamin B12 deficiency

28. differentiate lewy body dementia and vascular dementia
Tunnel vision - diaphoresis - nausea - pallor
Cerebellar lesion
Gilberts disease
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

29. get up and go test
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Normal pressure hydrocephalus

30. How to tx acute exacerbation of MS
RBC count >6000
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
High dose IV methyleprednisone;
Coronary artery disease

31. differentiate wenicke and korsakoff
Gilberts disease
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
Tunnel vision - diaphoresis - nausea - pallor
Normal pressure hydrocephalus

32. earliest sign of phenytoin toxicity
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;
Nystagmus on far lateral gaze
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

33. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
High dose IV methyleprednisone;
MS
Femoral n lesion

34. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
EPV - campylobacter - HSV
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
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

35. Unable to copy of matchstick - unable to dress up
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
Reduced efficacy of OCP
Construction apraxia; lesion in non dominant parietal lobe (right)

36. impaired hepatic conjugation of billirubin
Verapamil
Gilberts disease
82% specific for dementia
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

37. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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.
EPV - campylobacter - HSV
Clonidine will take care both high bp and withdrawal
Cholinesterase inhibitor; and antiparkinsonism drugs

38. How to differentiate dementias
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

39. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
90% of right handed and 60% of left handed persons; speech and language function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Follows viral illness; vertigo - tinnitus - nausea. self limiting
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

40. brain stem lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

41. stroke with lower facial palsy - pronator drift despite on aspirin
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Coronary artery disease

42. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion
Get up from chair walk a short distance turn around and sit; screening test for fall

43. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Autospy gold standard
Nystagmus on far lateral gaze

44. cluster headache
Botulism has descending paralysis in contrast othere have ascending paralysis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Upright supine position

45. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Cerebellar lesion

46. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Upright supine position

47. 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.
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Normal pressure hydrocephalus

48. impaired perception of complex sounds
Spastic paraparesis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe

49. women with unilateral eye pain; neurlogic symptoms here there at different times
Lesion in nondominant temporal lobe
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
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

50. How to tx stroke patient came after 6h
Despite the term neuroma they arise from schwann cells - schwanoma
IVIG and plasmapheresis
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