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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. dominant parietal lobe on the left side
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
90% of right handed and 60% of left handed persons; speech and language function
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

2. When to use dopamine agonist pramipexol in parkinson
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

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

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4. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Femoral n lesion
MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebellar lesion

5. dementia plus urinary incontinence
Not within 24 hours; give afte 24-48 hours if patient stable
Normal pressure hydrocephalus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

6. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Normal pressure hydrocephalus
Lesion in nondominant temporal lobe

7. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
20%
Lesion in nondominant temporal lobe

8. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Nystagmus on far lateral gaze
Autospy gold standard

9. Tx of bells palsy
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

10. GBS
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
IVIG and plasmapheresis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

11. double vision at the end of day and ptosis
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

12. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

13. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Corticosteroid and acyclovir
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.
Cerebellar lesion

14. Blood transfusion in hypothermia
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
High dose IV methyleprednisone;
IVIG and plasmapheresis

15. acoustic neuroma
Upright supine position
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

16. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
<20; if patient scores >25 benign forgetfulness
Upright supine position
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

17. How to tx acute exacerbation of MS
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.
Distal lower motor neuron disease
Antitoxin
High dose IV methyleprednisone;

18. When to suspect traumatic LP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
20%
Reduced efficacy of OCP
RBC count >6000

19. impaired vibration and increased DTR
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Vitamin B12 deficiency
Deficit in cranial nerve function

20. lesion in dominant parietal lobe
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Difficulty in writing - calculating - distinguishing left and write
EPV - campylobacter - HSV
Deficit in cranial nerve function

21. benign essential tremor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Autospy gold standard
Clonidine will take care both high bp and withdrawal
Propranolol or primidone

22. Tx of GBS
Vitamin B12 deficiency
Upright supine position
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

23. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Verapamil
Normal pressure hydrocephalus
IVIG and plasmapheresis

24. labyrinthitis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Femoral n lesion

25. differentiate wenicke and korsakoff
Nystagmus on far lateral gaze
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
Corticosteroid and acyclovir
82% specific for dementia

26. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Difficulty in writing - calculating - distinguishing left and write
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

27. prodrome of vasovagal syncope
Upright supine position
Tunnel vision - diaphoresis - nausea - pallor
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

28. How to differentiate traumatic LP and SAH
Difficulty in writing - calculating - distinguishing left and write
Verapamil
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

29. Why V12 deficient develop hypokalemia after tx with b12
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spastic paraparesis
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

30. best diagnosis for parkinsonim
Autospy gold standard
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

31. When headache is presenting complaint of brain tumor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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;

32. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
20%
IVIG and plasmapheresis
RBC count >6000

33. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Upright supine position
Reduced efficacy of OCP

34. When to start fibrinolytic therapy in stroke patient?
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

35. How to differentiate medial and lateral medullary syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Despite the term neuroma they arise from schwann cells - schwanoma
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;

36. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Corticosteroid and acyclovir

37. What mmse score suggest dementia
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
<20; if patient scores >25 benign forgetfulness
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Femoral n lesion

38. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

39. cluster headache
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
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

40. indication of plasmapheresis in GBS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting

41. severe headache and high BP
Cerebral palsy; dx mri
IVIG and plasmapheresis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor

42. differentiate picks and huntington
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Spastic paraparesis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

43. oligoclonal band in CSF
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

44. How to differentiate dementias
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Gilberts disease

45. infections in GBS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
EPV - campylobacter - HSV
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Antitoxin

46. korsafoff psychosis
Tunnel vision - diaphoresis - nausea - pallor
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
Difficulty in writing - calculating - distinguishing left and write

47. phenytoin and OCP
Reduced efficacy of OCP
Antitoxin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

48. How to perform apnea test
Corticosteroid and acyclovir
Coronary artery disease
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

49. Should we tx htn in acute ischemic stroke

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50. Acute onset of left arm weakness
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
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA