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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. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
EPV - campylobacter - HSV
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
Spastic paraparesis

2. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Aphasia - neglect - agnosia - acalculia etc
Deficit in cranial nerve function
Femoral n lesion

3. When to suspect traumatic LP
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
RBC count >6000
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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

4. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Lesion in nondominant temporal lobe
Verapamil
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

5. stroke with lower facial palsy - pronator drift despite on aspirin
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal

6. What percent of dementia is reversible
Obturator n lesion
20%
Aphasia - neglect - agnosia - acalculia etc
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

7. differentiate lewy body dementia and vascular dementia
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
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
Diabetes insipidus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

8. impaired vibration and increased DTR
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
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.
Vitamin B12 deficiency

9. 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
Tunnel vision - diaphoresis - nausea - pallor
82% specific for dementia
Spastic paraparesis

10. benign essential tremor
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

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

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12. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis

13. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Upright supine position
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

14. How to perform apnea test
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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

15. 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
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

16. When to give aspirin when patient on tPA after stroke
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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.
Not within 24 hours; give afte 24-48 hours if patient stable
Acetylecholinersterase inhibitors

17. How to stop antiepileptic drugs
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Coronary artery disease
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse

18. Why V12 deficient develop hypokalemia after tx with b12
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

19. earliest sign of phenytoin toxicity
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Nystagmus on far lateral gaze
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Gilberts disease

20. How to differentiate medial and lateral medullary syndrome
Cerebellar lesion
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
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;

21. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS

22. 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 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
Acetylecholinersterase inhibitors
Gilberts disease

23. MG
Aphasia - neglect - agnosia - acalculia etc
Normal pressure hydrocephalus
Acetylecholinersterase inhibitors
Antitoxin

24. Tx of GBS
Femoral n lesion
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
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

25. MMSE score of less than 24
Corticosteroid and acyclovir
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
82% specific for dementia
MS

26. How to tx acute exacerbation of 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;
High dose IV methyleprednisone;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Botulism has descending paralysis in contrast othere have ascending paralysis

27. phenytoin and OCP
Reduced efficacy of OCP
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
IVIG and plasmapheresis

28. labyrinthitis
Antitoxin
Deficit in cranial nerve function
Not within 24 hours; give afte 24-48 hours if patient stable
Follows viral illness; vertigo - tinnitus - nausea. self limiting

29. brain stem lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Aspirin - control HTN and swallow eval before giving any oral meds
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Deficit in cranial nerve function

30. women with unilateral eye pain; neurlogic symptoms here there at different times
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Upright supine position

31. Tx of bells palsy
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
It patient has electrolyte imbalance and hypothermia
Corticosteroid and acyclovir
82% specific for dementia

32. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Botulism has descending paralysis in contrast othere have ascending paralysis
Diabetes insipidus
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

33. cortical 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
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc

34. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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
Construction apraxia; lesion in non dominant parietal lobe (right)
Obturator n lesion

35. contraindication of sumatripta
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Coronary artery disease
20%

36. oligoclonal band in CSF
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Coronary artery disease
MS

37. craniopharyngioma
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Diabetes insipidus
Difficulty in writing - calculating - distinguishing left and write
Tunnel vision - diaphoresis - nausea - pallor

38. Unable to copy of matchstick - unable to dress up
Acetylecholinersterase inhibitors
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
EPV - campylobacter - HSV
Construction apraxia; lesion in non dominant parietal lobe (right)

39. 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
Femoral n lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

40. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

41. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Distal lower motor neuron disease
Upright supine position

42. impaired perception of complex sounds
MS
Lesion in nondominant temporal lobe
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

43. dominant parietal lobe on the left side
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
90% of right handed and 60% of left handed persons; speech and language function
Deficit in cranial nerve function

44. Patient with carbamazepine; What should be advice?
Spastic paraparesis
It patient has electrolyte imbalance and hypothermia
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

45. What is pronator drift
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
Coronary artery disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

46. impaired hepatic conjugation of billirubin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Gilberts disease
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
Coronary artery disease

47. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)
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
20%

48. best diagnosis for parkinsonim
Autospy gold standard
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

49. acoustic neuroma
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Despite the term neuroma they arise from schwann cells - schwanoma
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

50. What mmse score suggest dementia
Reduced efficacy of OCP
Not within 24 hours; give afte 24-48 hours if patient stable
<20; if patient scores >25 benign forgetfulness
Cerebral palsy; dx mri