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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. What percent of dementia is reversible
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.
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
20%

2. women with unilateral eye pain; neurlogic symptoms here there at different times
Coronary artery disease
Verapamil
Aspirin - control HTN and swallow eval before giving any oral meds
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

3. How to differentiate botulism from tick born paralysis - GBS and MG
Taper gradually to prevent seizure relapse
Lesion in nondominant temporal lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
Autospy gold standard

4. cluster headache
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
Gilberts disease
IVIG and plasmapheresis
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

5. What is pronator drift
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis
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

6. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Normal pressure hydrocephalus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

7. Unable to copy of matchstick - unable to dress up
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus
MS

8. Tx of bells palsy
Reduced efficacy of OCP
Corticosteroid and acyclovir
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

9. what drug is used to extend effects of levodopa
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
Entacapone - COMT inhibitor
90% of right handed and 60% of left handed persons; speech and language function

10. brain stem lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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;
It patient has electrolyte imbalance and hypothermia
Deficit in cranial nerve function

11. lesion in dominant tempora lobe
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

12. contraindication of sumatripta
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Autospy gold standard
It patient has electrolyte imbalance and hypothermia
Coronary artery disease

13. indication of plasmapheresis in GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Botulism has descending paralysis in contrast othere have ascending paralysis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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

14. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
MS
82% specific for dementia

15. How to confirm braindeath?
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
82% specific for dementia
Deficit in cranial nerve 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.

16. differentiate picks and huntington
Difficulty in writing - calculating - distinguishing left and write
It patient has electrolyte imbalance and hypothermia
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
Aspirin - control HTN and swallow eval before giving any oral meds

17. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Myasthenia; due to autoantibodies against acetylecholine receptor;
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write

18. medial thigh sensory loss and weakness in addcution
Tunnel vision - diaphoresis - nausea - pallor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Obturator n lesion
Despite the term neuroma they arise from schwann cells - schwanoma

19. Acute onset of left arm weakness
Nystagmus on far lateral gaze
Spastic paraparesis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting

20. How to perform apnea test
Vitamin B12 deficiency
Entacapone - COMT inhibitor
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

21. impaired perception of complex sounds
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Autospy gold standard
Lesion in nondominant temporal lobe

22. MMSE score of less than 24
Verapamil
82% specific for dementia
Lesion in nondominant temporal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

23. at first tingling in toes and feet then weakness in extremities
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Reduced efficacy of OCP
EPV - campylobacter - HSV

24. When to give aspirin when patient on tPA after stroke
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Construction apraxia; lesion in non dominant parietal lobe (right)
Reduced efficacy of OCP
Not within 24 hours; give afte 24-48 hours if patient stable

25. Should we tx htn in acute ischemic stroke

26. impaired vibration and increased DTR
82% specific for 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
Deficit in cranial nerve function
Vitamin B12 deficiency

27. earliest sign of phenytoin toxicity
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
Nystagmus on far lateral gaze
Reduced efficacy of OCP

28. When to suspect traumatic LP
Obturator n lesion
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
RBC count >6000
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

29. Patient with carbamazepine; What should be advice?
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

30. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Cholinesterase inhibitor; and antiparkinsonism drugs
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
90% of right handed and 60% of left handed persons; speech and language function

31. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
It patient has electrolyte imbalance and hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

32. korsafoff psychosis
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

33. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Follows viral illness; vertigo - tinnitus - nausea. self limiting
82% specific for dementia

34. How to prevent prevent frequency of MS exacerbation
Spontaneous remission; admit if suspected and monitor pulse ox for 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
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

35. How to differentiate traumatic LP and SAH
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

36. When to use dopamine agonist pramipexol in parkinson
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze

37. craniopharyngioma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
It patient has electrolyte imbalance and hypothermia
Diabetes insipidus

38. botulism
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Antitoxin

39. differentiate wenicke and korsakoff
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir
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
Propranolol or primidone

40. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Upright supine position
Clonidine will take care both high bp and withdrawal
Obturator n lesion
Verapamil

41. dementia plus urinary incontinence
Normal pressure hydrocephalus
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors
Antitoxin

42. best diagnosis for parkinsonim
Difficulty in writing - calculating - distinguishing left and write
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cerebellar lesion
Autospy gold standard

43. impaired hepatic conjugation of billirubin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease

44. When to start fibrinolytic therapy in stroke patient?
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Despite the term neuroma they arise from schwann cells - schwanoma
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

45. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Vitamin B12 deficiency
Cerebellar lesion

46. acoustic neuroma
Aspirin - control HTN and swallow eval before giving any oral meds
Cholinesterase inhibitor; and antiparkinsonism drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Despite the term neuroma they arise from schwann cells - schwanoma

47. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
IVIG and plasmapheresis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

48. differentiate lewy body dementia and vascular dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Femoral n lesion
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

49. How to differentiate medial and lateral medullary syndrome
High dose IV methyleprednisone;
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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

50. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Aspirin - control HTN and swallow eval before giving any oral meds
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
High dose IV methyleprednisone;