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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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Propranolol or primidone
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

2. benign essential tremor
It patient has electrolyte imbalance and hypothermia
Not within 24 hours; give afte 24-48 hours if patient stable
20%
Propranolol or primidone

3. infections in GBS
EPV - campylobacter - HSV
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease

4. MG
Get up from chair walk a short distance turn around and sit; screening test for fall
Acetylecholinersterase inhibitors
Cerebellar lesion
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;

5. When to suspect traumatic LP
Cerebellar lesion
RBC count >6000
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

6. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

7. lesion in dominant tempora lobe
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
It patient has electrolyte imbalance and hypothermia
Nystagmus on far lateral gaze

8. differentiate wenicke and korsakoff
MS
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
Aspirin - control HTN and swallow eval before giving any oral meds

9. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
High dose IV methyleprednisone;
Diabetes insipidus

10. Blood transfusion in hypothermia
Upright supine position
Reduced efficacy of OCP
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

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

12. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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.
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Taper gradually to prevent seizure relapse

13. How to differentiate medial and lateral pontine syndrome
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

14. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Antitoxin

15. phenytoin and OCP
Distal lower motor neuron disease
Reduced efficacy of OCP
IVIG and plasmapheresis
Coronary artery disease

16. brain stem lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in writing - calculating - distinguishing left and write
Deficit in cranial nerve function
It patient has electrolyte imbalance and hypothermia

17. How to differentiate traumatic LP and SAH
Entacapone - COMT inhibitor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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.
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

18. botulism
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV
Antitoxin
Tunnel vision - diaphoresis - nausea - pallor

19. Unable to copy of matchstick - unable to dress up
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Construction apraxia; lesion in non dominant parietal lobe (right)

20. What percent of dementia is reversible
20%
Propranolol or primidone
Entacapone - COMT inhibitor
Antitoxin

21. How to confirm braindeath?
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
82% specific for dementia
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.

22. When headache is presenting complaint of brain tumor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Gilberts disease

23. When to use dopamine agonist pramipexol in parkinson
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
IVIG and plasmapheresis

24. How to differentiate dementias
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Entacapone - COMT inhibitor

25. excessive elevation of legs during walking (toe touch floor earlier than heels)
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard
Distal lower motor neuron disease
Clonidine will take care both high bp and withdrawal

26. contraindication of sumatripta
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
Aphasia - neglect - agnosia - acalculia etc
Coronary artery disease

27. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tunnel vision - diaphoresis - nausea - pallor
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;

28. How to differentiate parkinson and benign essential tremor
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
Cerebral palsy; dx mri
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Aspirin - control HTN and swallow eval before giving any oral meds

29. indication of plasmapheresis in GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Despite the term neuroma they arise from schwann cells - schwanoma
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

30. dementia plus urinary incontinence
Antitoxin
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs
Normal pressure hydrocephalus

31. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebral palsy; dx mri
Acetylecholinersterase inhibitors
Vitamin B12 deficiency

32. What bp med to be given in a patient with high bp and signs of opioid withdrawal
82% specific for dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Upright supine position
Clonidine will take care both high bp and withdrawal

33. impaired perception of complex sounds
Reduced efficacy of OCP
Entacapone - COMT inhibitor
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe

34. lesion in dominant parietal lobe
Corticosteroid and acyclovir
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Difficulty in writing - calculating - distinguishing left and write
MS

35. When to give aspirin when patient on tPA after stroke
Obturator n lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable

36. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
90% of right handed and 60% of left handed persons; speech and language function
Cerebellar lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cerebral palsy; dx mri

37. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Aspirin - control HTN and swallow eval before giving any oral meds
RBC count >6000
<20; if patient scores >25 benign forgetfulness
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

38. earliest sign of phenytoin toxicity
It patient has electrolyte imbalance and hypothermia
Despite the term neuroma they arise from schwann cells - schwanoma
Lesion in nondominant temporal lobe
Nystagmus on far lateral gaze

39. Should we tx htn in acute ischemic stroke

40. Tx of bells palsy
MS
Despite the term neuroma they arise from schwann cells - schwanoma
Corticosteroid and acyclovir
Wernicke's encephalopathy; due to thiamine definition; medical emergency

41. anerior and anteriomedial thigh paresthesia - decreased DTR
Not within 24 hours; give afte 24-48 hours if patient stable
Verapamil
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

42. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

43. what drug is used to extend effects of levodopa
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Entacapone - COMT inhibitor
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
Verapamil

44. severe headache and high BP
Coronary artery disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Corticosteroid and acyclovir
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

45. dominant parietal lobe on the left side
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
90% of right handed and 60% of left handed persons; speech and language function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable

46. How to prevent prevent frequency of MS exacerbation
Aphasia - neglect - agnosia - acalculia etc
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Entacapone - COMT inhibitor

47. Acute onset of left arm weakness
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
EPV - campylobacter - HSV

48. medial thigh sensory loss and weakness in addcution
Corticosteroid and acyclovir
Obturator n lesion
Cerebral palsy; dx mri
Upright supine position

49. craniopharyngioma
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Distal lower motor neuron disease
It patient has electrolyte imbalance and hypothermia
Diabetes insipidus

50. best diagnosis for parkinsonim
Lesion in nondominant temporal lobe
Autospy gold standard
Aphasia - neglect - agnosia - acalculia etc
Gilberts disease