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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. When headache is presenting complaint of brain tumor
90% of right handed and 60% of left handed persons; speech and language function
Gilberts disease
Propranolol or primidone
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

2. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
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.
Antitoxin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

3. anerior and anteriomedial thigh paresthesia - decreased DTR
<20; if patient scores >25 benign forgetfulness
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

4. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Botulism has descending paralysis in contrast othere have ascending paralysis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Normal pressure hydrocephalus

5. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Construction apraxia; lesion in non dominant parietal lobe (right)
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

6. How to differentiate dementias
Vitamin B12 deficiency
It patient has electrolyte imbalance and hypothermia
Difficulty in writing - calculating - distinguishing left and write
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

7. differentiate picks and huntington
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
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

8. How to prevent prevent frequency of MS exacerbation
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Distal lower motor neuron disease

9. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

10. dementia plus urinary incontinence
Corticosteroid and acyclovir
Spastic paraparesis
Normal pressure hydrocephalus
Deficit in cranial nerve function

11. oligoclonal band in CSF
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
RBC count >6000
MS
Autospy gold standard

12. differentiate wenicke and korsakoff
Tunnel vision - diaphoresis - nausea - pallor
Not within 24 hours; give afte 24-48 hours if patient stable
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
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

13. severe headache and high BP
Myasthenia; due to autoantibodies against acetylecholine receptor;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

14. How to differentiate medial and lateral medullary syndrome
Autospy gold standard
Acetylecholinersterase inhibitors
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;
Aspirin - control HTN and swallow eval before giving any oral meds

15. Acute onset of left arm weakness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Normal pressure hydrocephalus

16. women with unilateral eye pain; neurlogic symptoms here there at different times
Entacapone - COMT inhibitor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis

17. What is can be used cluster headache prevention
Verapamil
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
82% specific for dementia

18. What is pronator drift
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Acetylecholinersterase inhibitors
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
Verapamil

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

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

21. Patient with carbamazepine; What should be advice?
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
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Distal lower motor neuron disease

22. When to give aspirin when patient on tPA after stroke
Difficulty in writing - calculating - distinguishing left and write
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis
Tunnel vision - diaphoresis - nausea - pallor

23. double vision at the end of day and ptosis
Verapamil
Botulism has descending paralysis in contrast othere have ascending paralysis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;

24. contraindication of sumatripta
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Coronary artery disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

25. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Tunnel vision - diaphoresis - nausea - pallor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil

26. Unable to copy of matchstick - unable to dress up
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
Diabetes insipidus
Construction apraxia; lesion in non dominant parietal lobe (right)
Deficit in cranial nerve function

27. impaired hepatic conjugation of billirubin
<20; if patient scores >25 benign forgetfulness
Gilberts disease
Taper gradually to prevent seizure relapse
Normal pressure hydrocephalus

28. get up and go test
Nystagmus on far lateral gaze
High dose IV methyleprednisone;
Get up from chair walk a short distance turn around and sit; screening test for fall
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

29. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Distal lower motor neuron disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Clonidine will take care both high bp and withdrawal

30. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
MS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Autospy gold standard

31. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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;
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

32. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function
Cerebellar lesion

33. How to tx lewy body dementia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
It patient has electrolyte imbalance and hypothermia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cholinesterase inhibitor; and antiparkinsonism drugs

34. How to perform apnea test
Acetylecholinersterase inhibitors
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
EPV - campylobacter - HSV
Distal lower motor neuron disease

35. indication of plasmapheresis in GBS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
EPV - campylobacter - HSV
Not within 24 hours; give afte 24-48 hours if patient stable

36. medial thigh sensory loss and weakness in addcution
Obturator n lesion
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Despite the term neuroma they arise from schwann cells - schwanoma

37. Tx of bells palsy
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Gilberts disease

38. MG
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Acetylecholinersterase inhibitors
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
Despite the term neuroma they arise from schwann cells - schwanoma

39. cortical lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aphasia - neglect - agnosia - acalculia etc
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Obturator n lesion

40. How to tx stroke patient came after 6h
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
High dose IV methyleprednisone;

41. How to differentiate botulism from tick born paralysis - GBS and MG
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis

42. GBS
IVIG and plasmapheresis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

43. How to differentiate medial and lateral pontine syndrome
Diabetes insipidus
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease

44. How to differentiate traumatic LP and SAH
It patient has electrolyte imbalance and hypothermia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

45. benign essential tremor
Cerebral palsy; dx mri
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.
Aphasia - neglect - agnosia - acalculia etc
Propranolol or primidone

46. MMSE score of less than 24
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
82% specific for dementia
Femoral n lesion

47. at first tingling in toes and feet then weakness in extremities
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

48. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Gilberts disease
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

49. differentiate lewy body dementia and vascular dementia
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Cerebellar lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

50. When to start fibrinolytic therapy in stroke patient?
Obturator n lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Do CT scan at first to r/o SAH - if ct neg lumbar puncture