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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. Why V12 deficient develop hypokalemia after tx with b12
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

2. infections in GBS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
EPV - campylobacter - HSV
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

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

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4. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

5. What is can be used cluster headache prevention
Corticosteroid and acyclovir
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
Verapamil

6. How to manage stroke patient came within 4 hours
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spastic paraparesis
Get up from chair walk a short distance turn around and sit; screening test for fall

7. impaired perception of complex sounds
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Lesion in nondominant temporal lobe

8. best diagnosis for parkinsonim
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

9. cortical lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Verapamil
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Aphasia - neglect - agnosia - acalculia etc

10. How to confirm braindeath?
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
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.
20%
Diabetes insipidus

11. phenytoin and OCP
IVIG and plasmapheresis
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
Cerebellar lesion
Reduced efficacy of OCP

12. women with unilateral eye pain; neurlogic symptoms here there at different times
Taper gradually to prevent seizure relapse
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

13. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Acetylecholinersterase inhibitors
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
90% of right handed and 60% of left handed persons; speech and language function
MS

14. stroke with lower facial palsy - pronator drift despite on aspirin
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

15. botulism
Antitoxin
<20; if patient scores >25 benign forgetfulness
Distal lower motor neuron disease
Propranolol or primidone

16. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
<20; if patient scores >25 benign forgetfulness
Nystagmus on far lateral gaze

17. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS
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

18. How to perform apnea test
Cerebellar lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position
Spastic paraparesis

19. How to tx acute exacerbation of MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Vitamin B12 deficiency
High dose IV methyleprednisone;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

20. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS
Autospy gold standard

21. at first tingling in toes and feet then weakness in extremities
Corticosteroid and acyclovir
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia

22. How to stop antiepileptic drugs
Myasthenia; due to autoantibodies against acetylecholine receptor;
Obturator n lesion
Coronary artery disease
Taper gradually to prevent seizure relapse

23. differentiate lewy body dementia and vascular dementia
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
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
Diabetes insipidus
<20; if patient scores >25 benign forgetfulness

24. excessive elevation of legs during walking (toe touch floor earlier than heels)
Aspirin - control HTN and swallow eval before giving any oral meds
Distal lower motor neuron disease
It patient has electrolyte imbalance and hypothermia
MS

25. How to differentiate traumatic LP and SAH
EPV - campylobacter - HSV
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri

26. oligoclonal band in CSF
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS
Botulism has descending paralysis in contrast othere have ascending paralysis

27. Tx of GBS
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

28. Patient with carbamazepine; What should be advice?
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
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
Obturator n lesion

29. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
RBC count >6000
Cerebral palsy; dx mri
Clonidine will take care both high bp and withdrawal

30. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir

31. MMSE score of less than 24
82% specific for dementia
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

32. How to differentiate medial and lateral pontine syndrome
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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.
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
Cholinesterase inhibitor; and antiparkinsonism drugs

33. contraindication of sumatripta
Coronary artery disease
90% of right handed and 60% of left handed persons; speech and language function
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
82% specific for dementia

34. differentiate wenicke and korsakoff
Distal lower motor neuron disease
90% of right handed and 60% of left handed persons; speech and language function
Diabetes insipidus
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

35. double vision at the end of day and ptosis
MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;
Construction apraxia; lesion in non dominant parietal lobe (right)

36. lesion in dominant parietal lobe
Taper gradually to prevent seizure relapse
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
Difficulty in writing - calculating - distinguishing left and write

37. When to suspect traumatic LP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
RBC count >6000
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

38. labyrinthitis
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion
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

39. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc
Normal pressure hydrocephalus

40. craniopharyngioma
Autospy gold standard
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Diabetes insipidus

41. benign essential tremor
Propranolol or primidone
Obturator n lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aphasia - neglect - agnosia - acalculia etc

42. GBS
Get up from chair walk a short distance turn around and sit; screening test for fall
IVIG and plasmapheresis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

43. When headache is presenting complaint of brain tumor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
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

44. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Nystagmus on far lateral gaze
Cerebellar lesion
Distal lower motor neuron disease

45. impaired hepatic conjugation of billirubin
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.
Deficit in cranial nerve function
Aphasia - neglect - agnosia - acalculia etc
Gilberts disease

46. How to tx stroke patient came after 6h
Normal pressure hydrocephalus
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aspirin - control HTN and swallow eval before giving any oral meds
Construction apraxia; lesion in non dominant parietal lobe (right)

47. 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Acetylecholinersterase inhibitors
Difficulty in writing - calculating - distinguishing left and write

48. Should we tx htn in acute ischemic stroke

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49. What is pronator drift
Nystagmus on far lateral gaze
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
High dose IV methyleprednisone;

50. What percent of dementia is reversible
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%
Spontaneous remission; admit if suspected and monitor pulse ox for 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