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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. differentiate lewy body dementia and vascular dementia
Autospy gold standard
Antitoxin
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

2. double vision at the end of day and ptosis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aspirin - control HTN and swallow eval before giving any oral meds
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

3. When to suspect traumatic LP
Femoral n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Spastic paraparesis
RBC count >6000

4. Should we tx htn in acute ischemic stroke

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5. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Clonidine will take care both high bp and withdrawal
Spastic paraparesis
Reduced efficacy of OCP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

6. How to differentiate parkinson and benign essential tremor
Entacapone - COMT inhibitor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

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

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8. How to confirm braindeath?
Myasthenia; due to autoantibodies against acetylecholine receptor;
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Acetylecholinersterase inhibitors

9. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Botulism has descending paralysis in contrast othere have ascending paralysis
Lesion in nondominant temporal lobe
Nystagmus on far lateral gaze

10. women with unilateral eye pain; neurlogic symptoms here there at different times
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
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

11. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Coronary artery disease
Cerebellar lesion
Clonidine will take care both high bp and withdrawal
Vitamin B12 deficiency

12. contraindication of sumatripta
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
Coronary artery disease
Taper gradually to prevent seizure relapse

13. What percent of dementia is reversible
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
20%
RBC count >6000
Deficit in cranial nerve function

14. cortical lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aphasia - neglect - agnosia - acalculia etc
82% specific for dementia
Despite the term neuroma they arise from schwann cells - schwanoma

15. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
It patient has electrolyte imbalance and hypothermia
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

16. How to differentiate dementias
EPV - campylobacter - HSV
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
Get up from chair walk a short distance turn around and sit; screening test for fall

17. What is pronator drift
Entacapone - COMT inhibitor
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
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
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

18. botulism
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting
<20; if patient scores >25 benign forgetfulness
Antitoxin

19. at first tingling in toes and feet then weakness in extremities
MS
Obturator n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in writing - calculating - distinguishing left and write

20. acoustic neuroma
Obturator n lesion
Despite the term neuroma they arise from schwann cells - schwanoma
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
Spastic paraparesis

21. What mmse score suggest dementia
Cerebellar lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
<20; if patient scores >25 benign forgetfulness

22. How to manage stroke patient came within 4 hours
Autospy gold standard
Normal pressure hydrocephalus
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

23. labyrinthitis
MS
Distal lower motor neuron disease
High dose IV methyleprednisone;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

24. When to give aspirin when patient on tPA after stroke
Nystagmus on far lateral gaze
Cholinesterase inhibitor; and antiparkinsonism drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Not within 24 hours; give afte 24-48 hours if patient stable

25. Why V12 deficient develop hypokalemia after tx with b12
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Deficit in cranial nerve function

26. impaired hepatic conjugation of billirubin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Gilberts disease
EPV - campylobacter - HSV

27. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Gilberts disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

28. Unable to copy of matchstick - unable to dress up
Autospy gold standard
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)

29. phenytoin and OCP
Reduced efficacy of OCP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Corticosteroid and acyclovir
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

30. lesion in dominant tempora lobe
Lesion in nondominant temporal lobe
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
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

31. How to tx lewy body dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
20%
Cholinesterase inhibitor; and antiparkinsonism drugs
Distal lower motor neuron disease

32. prodrome of vasovagal syncope
Normal pressure hydrocephalus
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
Femoral n lesion
Tunnel vision - diaphoresis - nausea - pallor

33. How to differentiate medial and lateral pontine syndrome
Antitoxin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
MS

34. When to use brain spect scintigraphy to confirm brain death
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
20%

35. 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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Lesion in nondominant temporal lobe
Femoral n lesion

36. GBS
Acetylecholinersterase inhibitors
Aphasia - neglect - agnosia - acalculia etc
IVIG and plasmapheresis
82% specific for dementia

37. indication of plasmapheresis in GBS
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

38. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

39. lesion in dominant parietal lobe
Verapamil
Difficulty in writing - calculating - distinguishing left and write
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Coronary artery disease

40. brain stem lesion
Get up from chair walk a short distance turn around and sit; screening test for fall
Deficit in cranial nerve function
Femoral n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency

41. benign essential tremor
Propranolol or primidone
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

42. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

43. 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
Taper gradually to prevent seizure relapse
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

44. medial thigh sensory loss and weakness in addcution
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
Femoral n lesion
Obturator n lesion
Clonidine will take care both high bp and withdrawal

45. Tx of bells palsy
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Despite the term neuroma they arise from schwann cells - schwanoma
Corticosteroid and acyclovir

46. impaired perception of complex sounds
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
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

47. How to perform apnea test
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion
Verapamil
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

48. When headache is presenting complaint of brain tumor
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

49. oligoclonal band in CSF
Verapamil
MS
Corticosteroid and acyclovir
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

50. korsafoff psychosis
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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