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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. botulism
Antitoxin
Cerebellar lesion
82% specific for dementia
Get up from chair walk a short distance turn around and sit; screening test for fall

2. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
RBC count >6000

3. 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.
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Lesion in nondominant temporal lobe

4. MG
Acetylecholinersterase inhibitors
Cerebral palsy; dx mri
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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. lesion in dominant tempora lobe
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
It patient has electrolyte imbalance and hypothermia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

6. impaired vibration and increased DTR
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;
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in writing - calculating - distinguishing left and write
Vitamin B12 deficiency

7. How to differentiate dementias
Propranolol or primidone
Obturator 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

8. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Propranolol or primidone

9. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Cholinesterase inhibitor; and antiparkinsonism drugs
82% specific for dementia
Gilberts disease

10. excessive elevation of legs during walking (toe touch floor earlier than heels)
Gilberts disease
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Nystagmus on far lateral gaze

11. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Corticosteroid and acyclovir
Distal lower motor neuron disease
Despite the term neuroma they arise from schwann cells - schwanoma

12. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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;
Autospy gold standard

13. benign essential tremor
Botulism has descending paralysis in contrast othere have ascending paralysis
Propranolol or primidone
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write

14. severe headache and high BP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
High dose IV methyleprednisone;
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

15. impaired hepatic conjugation of billirubin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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
Gilberts disease

16. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Clonidine will take care both high bp and withdrawal

17. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
EPV - campylobacter - HSV
Nystagmus on far lateral gaze

18. what drug is used to extend effects of levodopa
Deficit in cranial nerve function
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor
Obturator n lesion

19. How to prevent prevent frequency of MS exacerbation
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
Spastic paraparesis
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. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Upright supine position
Verapamil
Reduced efficacy of OCP

21. differentiate lewy body dementia and vascular dementia
It patient has electrolyte imbalance and hypothermia
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
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

22. When to use dopamine agonist pramipexol in parkinson
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Autospy gold standard
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

23. women with unilateral eye pain; neurlogic symptoms here there at different times
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Normal pressure hydrocephalus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Taper gradually to prevent seizure relapse

24. brain stem lesion
Taper gradually to prevent seizure relapse
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Acetylecholinersterase inhibitors
Deficit in cranial nerve function

25. How to differentiate medial and lateral medullary syndrome
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

26. contraindication of sumatripta
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Acetylecholinersterase inhibitors

27. How to differentiate medial and lateral pontine syndrome
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
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

28. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion
Entacapone - COMT inhibitor
20%

29. Tx of bells palsy
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Corticosteroid and acyclovir
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

30. differentiate picks and huntington
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Lesion in nondominant temporal lobe
Difficulty in writing - calculating - distinguishing left and write

31. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

32. infections in GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Lesion in nondominant temporal lobe
EPV - campylobacter - HSV

33. oligoclonal band in CSF
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
It patient has electrolyte imbalance and hypothermia

34. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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
Antitoxin

35. Acute onset of left arm weakness
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

36. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
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
Vitamin B12 deficiency
Corticosteroid and acyclovir
Cerebral palsy; dx mri

37. lesion in dominant parietal lobe
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;
Difficulty in writing - calculating - distinguishing left and write
Cerebral palsy; dx mri
Aspirin - control HTN and swallow eval before giving any oral meds

38. How to differentiate traumatic LP and SAH
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

39. Tx of GBS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Taper gradually to prevent seizure relapse
Verapamil

40. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Corticosteroid and acyclovir
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

41. acoustic neuroma
Reduced efficacy of OCP
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Despite the term neuroma they arise from schwann cells - schwanoma
Aphasia - neglect - agnosia - acalculia etc

42. korsafoff psychosis
Cerebellar lesion
Coronary artery disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Clonidine will take care both high bp and withdrawal

43. GBS
IVIG and plasmapheresis
Difficulty in writing - calculating - distinguishing left and write
Normal pressure hydrocephalus
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

44. What percent of dementia is reversible
Verapamil
20%
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;
Spastic paraparesis

45. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Verapamil
Not within 24 hours; give afte 24-48 hours if patient stable
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

46. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Acetylecholinersterase inhibitors
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

47. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
<20; if patient scores >25 benign forgetfulness
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

48. When to suspect traumatic LP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
EPV - campylobacter - HSV
RBC count >6000
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

49. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Verapamil
Vitamin B12 deficiency
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Obturator n lesion

50. double vision at the end of day and ptosis
Botulism has descending paralysis in contrast othere have ascending paralysis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Myasthenia; due to autoantibodies against acetylecholine receptor;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin