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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. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Deficit in cranial nerve function
Taper gradually to prevent seizure relapse
Obturator n lesion

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

3. what drug is used to extend effects of levodopa
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
Spastic paraparesis
Entacapone - COMT inhibitor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

4. When to use dopamine agonist pramipexol in parkinson
Cerebral palsy; dx mri
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aphasia - neglect - agnosia - acalculia etc

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

6. When to suspect traumatic LP
RBC count >6000
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of 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

7. oligoclonal band in CSF
MS
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
Acetylecholinersterase inhibitors

8. differentiate lewy body dementia and vascular dementia
Myasthenia; due to autoantibodies against acetylecholine receptor;
Coronary artery disease
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

9. How to differentiate dementias
Verapamil
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

10. botulism
Lesion in nondominant temporal lobe
MS
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
Antitoxin

11. phenytoin and OCP
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Reduced efficacy of OCP
Diabetes insipidus

12. excessive elevation of legs during walking (toe touch floor earlier than heels)
Diabetes insipidus
Normal pressure hydrocephalus
Distal lower motor neuron disease
Cholinesterase inhibitor; and antiparkinsonism drugs

13. women with unilateral eye pain; neurlogic symptoms here there at different times
Distal lower motor neuron disease
Despite the term neuroma they arise from schwann cells - schwanoma
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
IVIG and plasmapheresis

14. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Coronary artery disease
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

15. When headache is presenting complaint of brain tumor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Clonidine will take care both high bp and withdrawal

16. How to differentiate traumatic LP and SAH
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;
Upright supine position
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

17. lesion in dominant tempora lobe
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 understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Aphasia - neglect - agnosia - acalculia etc

18. dominant parietal lobe on the left side
<20; if patient scores >25 benign forgetfulness
90% of right handed and 60% of left handed persons; speech and language function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Distal lower motor neuron disease

19. When to use brain spect scintigraphy to confirm brain death
Upright supine position
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion
It patient has electrolyte imbalance and hypothermia

20. lesion in dominant parietal lobe
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
Difficulty in writing - calculating - distinguishing left and write
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

21. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Diabetes insipidus

22. medial thigh sensory loss and weakness in addcution
Autospy gold standard
Antitoxin
Obturator n lesion
Verapamil

23. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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.

24. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Autospy gold standard

25. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Myasthenia; due to autoantibodies against acetylecholine receptor;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

26. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
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
RBC count >6000
Coronary artery disease

27. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone
Distal lower motor neuron disease

28. GBS
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Verapamil
IVIG and plasmapheresis

29. impaired perception of complex sounds
Construction apraxia; lesion in non dominant parietal lobe (right)
Lesion in nondominant temporal lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds

30. best diagnosis for parkinsonim
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
It patient has electrolyte imbalance and hypothermia
Botulism has descending paralysis in contrast othere have ascending paralysis
Autospy gold standard

31. How to tx acute exacerbation of MS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
High dose IV methyleprednisone;
<20; if patient scores >25 benign forgetfulness
Clonidine will take care both high bp and withdrawal

32. 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
Obturator n lesion
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

33. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
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
EPV - campylobacter - HSV
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

34. Patient with carbamazepine; What should be advice?
Aspirin - control HTN and swallow eval before giving any oral meds
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Reduced efficacy of OCP

35. prodrome of vasovagal syncope
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor
90% of right handed and 60% of left handed persons; speech and language function

36. Should we tx htn in acute ischemic stroke

37. Tx of bells palsy
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

38. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
EPV - campylobacter - HSV

39. earliest sign of phenytoin toxicity
EPV - campylobacter - HSV
Deficit in cranial nerve function
Nystagmus on far lateral gaze
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

40. impaired vibration and increased DTR
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
90% of right handed and 60% of left handed persons; speech and language function
Vitamin B12 deficiency

41. Blood transfusion in hypothermia
Verapamil
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Femoral n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

42. craniopharyngioma
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Diabetes insipidus
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
Coronary artery disease

43. How to differentiate parkinson and benign essential tremor
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.
Corticosteroid and acyclovir
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
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

44. cluster headache
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

45. How to differentiate medial and lateral pontine syndrome
<20; if patient scores >25 benign forgetfulness
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

46. differentiate wenicke and korsakoff
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
Cerebellar lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

47. How to tx lewy body dementia
EPV - campylobacter - HSV
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
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. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Femoral n lesion
EPV - campylobacter - HSV
<20; if patient scores >25 benign forgetfulness

49. double vision at the end of day and ptosis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
IVIG and plasmapheresis
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;

50. What percent of dementia is reversible
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
<20; if patient scores >25 benign forgetfulness
20%