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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 picks and huntington
Nystagmus on far lateral gaze
90% of right handed and 60% of left handed persons; speech and language function
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
MS

2. How to confirm braindeath?
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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.
Taper gradually to prevent seizure relapse

3. 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
MS: CSF increased IgG -IgM and IgA also increased. not specific to 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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

4. GBS
Aphasia - neglect - agnosia - acalculia etc
Gilberts disease
IVIG and plasmapheresis
20%

5. Patient with carbamazepine; What should be advice?
High dose IV methyleprednisone;
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
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

6. at first tingling in toes and feet then weakness in extremities
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Obturator n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

7. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Nystagmus on far lateral gaze
Antitoxin
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness

8. What is pronator drift
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

9. How to differentiate botulism from tick born paralysis - GBS and MG
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
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis
90% of right handed and 60% of left handed persons; speech and language function

10. When to give aspirin when patient on tPA after stroke
EPV - campylobacter - HSV
Not within 24 hours; give afte 24-48 hours if patient stable
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

11. best diagnosis for parkinsonim
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Autospy gold standard

12. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Cholinesterase inhibitor; and antiparkinsonism drugs
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Propranolol or primidone
20%

13. What percent of dementia is reversible
Difficulty in writing - calculating - distinguishing left and write
Not within 24 hours; give afte 24-48 hours if patient stable
20%
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;

14. How to manage stroke patient came within 4 hours
Get up from chair walk a short distance turn around and sit; screening test for fall
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Deficit in cranial nerve function
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

15. excessive elevation of legs during walking (toe touch floor earlier than heels)
Nystagmus on far lateral gaze
Distal lower motor neuron disease
Cerebellar lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

16. When to use dopamine agonist pramipexol in parkinson
EPV - campylobacter - HSV
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
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

17. When to use brain spect scintigraphy to confirm brain death
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion
Taper gradually to prevent seizure relapse
It patient has electrolyte imbalance and hypothermia

18. differentiate wenicke and korsakoff
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
Vitamin B12 deficiency
Construction apraxia; lesion in non dominant parietal lobe (right)
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

19. When to suspect traumatic LP
Cerebral palsy; dx mri
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
RBC count >6000
Gilberts disease

20. cortical lesion
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aphasia - neglect - agnosia - acalculia etc
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

21. cluster headache
90% of right handed and 60% of left handed persons; speech and language function
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil

22. 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
Autospy gold standard
High dose IV methyleprednisone;
Spastic paraparesis

23. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Coronary artery disease
Clonidine will take care both high bp and withdrawal
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

24. What is can be used cluster headache prevention
Verapamil
Aphasia - neglect - agnosia - acalculia etc
Femoral n 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;

25. How to differentiate medial and lateral pontine syndrome
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
Distal lower motor neuron disease
Reduced efficacy of OCP
It patient has electrolyte imbalance and hypothermia

26. Tx of bells palsy
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
90% of right handed and 60% of left handed persons; speech and language function
Cerebellar lesion

27. indication of plasmapheresis in GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Clonidine will take care both high bp and withdrawal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion

28. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
20%
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Taper gradually to prevent seizure relapse

29. severe headache and high BP
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebellar lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

30. Blood transfusion in hypothermia
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
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

31. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
Distal lower motor neuron disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

32. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

33. How to differentiate dementias
Obturator n lesion
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
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

34. How to differentiate medial and lateral medullary syndrome
Coronary artery disease
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;
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
Entacapone - COMT inhibitor

35. lesion in dominant parietal lobe
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in writing - calculating - distinguishing left and write
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

36. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
RBC count >6000
Difficulty in writing - calculating - distinguishing left and write
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

37. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
<20; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

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

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39. benign essential tremor
Propranolol or primidone
Corticosteroid and acyclovir
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor

40. prodrome of vasovagal syncope
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Tunnel vision - diaphoresis - nausea - pallor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Wernicke's encephalopathy; due to thiamine definition; medical emergency

41. How to perform apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

42. impaired vibration and increased DTR
Cholinesterase inhibitor; and antiparkinsonism drugs
Aspirin - control HTN and swallow eval before giving any oral meds
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

43. labyrinthitis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Follows viral illness; vertigo - tinnitus - nausea. self limiting

44. How to stop antiepileptic drugs
MS
Taper gradually to prevent seizure relapse
Deficit in cranial nerve function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

45. women with unilateral eye pain; neurlogic symptoms here there at different times
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Lesion in nondominant temporal lobe
Femoral n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

46. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Myasthenia; due to autoantibodies against acetylecholine receptor;
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

47. impaired perception of complex sounds
Nystagmus on far lateral gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe

48. How to differentiate parkinson and benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Distal lower motor neuron disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

49. MMSE score of less than 24
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
82% specific for dementia
EPV - campylobacter - HSV
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

50. botulism
Not within 24 hours; give afte 24-48 hours if patient stable
Antitoxin
Cerebellar lesion
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