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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. women with unilateral eye pain; neurlogic symptoms here there at different times
Deficit in cranial nerve function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Reduced efficacy of OCP

2. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cerebellar lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
IVIG and plasmapheresis

3. earliest sign of phenytoin toxicity
Acetylecholinersterase inhibitors
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
Nystagmus on far lateral gaze
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

4. labyrinthitis
Vitamin B12 deficiency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

5. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.
Botulism has descending paralysis in contrast othere have ascending paralysis
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

6. Acute onset of left arm weakness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Deficit in cranial nerve function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

7. Why V12 deficient develop hypokalemia after tx with b12
MS
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Construction apraxia; lesion in non dominant parietal lobe (right)
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

8. Tx of GBS
Diabetes insipidus
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

9. How to differentiate parkinson and benign essential tremor
Corticosteroid and acyclovir
Propranolol or primidone
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

10. acoustic neuroma
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;
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Despite the term neuroma they arise from schwann cells - schwanoma

11. When to suspect traumatic LP
RBC count >6000
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
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

12. at first tingling in toes and feet then weakness in extremities
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
20%
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

13. botulism
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Tunnel vision - diaphoresis - nausea - pallor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin

14. what drug is used to extend effects of levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spastic paraparesis
Entacapone - COMT inhibitor

15. What is can be used cluster headache prevention
Verapamil
90% of right handed and 60% of left handed persons; speech and language function
Aphasia - neglect - agnosia - acalculia etc
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. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
MS
Not within 24 hours; give afte 24-48 hours if patient stable
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

17. MG
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus
Entacapone - COMT inhibitor
Acetylecholinersterase inhibitors

18. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Upright supine position
Get up from chair walk a short distance turn around and sit; screening test for fall
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

19. lesion in dominant parietal lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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

20. prodrome of vasovagal syncope
IVIG and plasmapheresis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor

21. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Taper gradually to prevent seizure relapse
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebral palsy; dx mri
20%

22. What is pronator drift
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

23. How to tx lewy body dementia
Vitamin B12 deficiency
EPV - campylobacter - HSV
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
Cholinesterase inhibitor; and antiparkinsonism drugs

24. oligoclonal band in CSF
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
Tunnel vision - diaphoresis - nausea - pallor
Gilberts disease
MS

25. excessive elevation of legs during walking (toe touch floor earlier than heels)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus
Distal lower motor neuron disease

26. 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
Botulism has descending paralysis in contrast othere have ascending paralysis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Wernicke's encephalopathy; due to thiamine definition; medical emergency

27. When headache is presenting complaint of brain tumor
RBC count >6000
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
IVIG and plasmapheresis
Gilberts disease

28. How to confirm braindeath?
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

29. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spastic paraparesis
82% specific for dementia

30. Should we tx htn in acute ischemic stroke

31. cluster headache
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Entacapone - COMT inhibitor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

32. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

33. get up and go test
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.
MS
IVIG and plasmapheresis
Get up from chair walk a short distance turn around and sit; screening test for fall

34. 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
Verapamil
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus

35. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Upright supine position
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

36. anerior and anteriomedial thigh paresthesia - decreased DTR
Corticosteroid and acyclovir
IVIG and plasmapheresis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Femoral n lesion

37. impaired vibration and increased DTR
Vitamin B12 deficiency
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
Tunnel vision - diaphoresis - nausea - pallor

38. How to tx stroke patient came after 6h
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
Aspirin - control HTN and swallow eval before giving any oral meds
<20; if patient scores >25 benign forgetfulness

39. When to give aspirin when patient on tPA after stroke
Reduced efficacy of OCP
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

40. What mmse score suggest dementia
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;
<20; if patient scores >25 benign forgetfulness
Vitamin B12 deficiency
Corticosteroid and acyclovir

41. brain stem lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Deficit in cranial nerve function
Construction apraxia; lesion in non dominant parietal lobe (right)

42. impaired hepatic conjugation of billirubin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Deficit in cranial nerve function
IVIG and plasmapheresis
Gilberts disease

43. lesion in dominant tempora lobe
Distal lower motor neuron disease
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

44. How to perform apnea test
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Reduced efficacy of OCP
Tunnel vision - diaphoresis - nausea - pallor

45. How to prevent prevent frequency of MS exacerbation
Deficit in cranial nerve function
Entacapone - COMT inhibitor
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

46. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
82% specific for dementia
Diabetes insipidus

47. 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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cholinesterase inhibitor; and antiparkinsonism drugs
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

48. 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
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;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Taper gradually to prevent seizure relapse

49. medial thigh sensory loss and weakness in addcution
Distal lower motor neuron disease
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
Obturator n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

50. How to differentiate traumatic LP and SAH
Cholinesterase inhibitor; and antiparkinsonism drugs
20%
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Gilberts disease