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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. at first tingling in toes and feet then weakness in extremities
MS
Obturator n lesion
Aphasia - neglect - agnosia - acalculia etc
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

2. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in writing - calculating - distinguishing left and write
Cholinesterase inhibitor; and antiparkinsonism drugs

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

4. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

5. Patient with carbamazepine; What should be advice?
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
82% specific for dementia

6. How to tx stroke patient came after 6h
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

7. Should we tx htn in acute ischemic stroke

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8. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Tunnel vision - diaphoresis - nausea - pallor
Cerebral palsy; dx mri
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

9. Unable to copy of matchstick - unable to dress up
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
90% of right handed and 60% of left handed persons; speech and language function
Construction apraxia; lesion in non dominant parietal lobe (right)

10. When to start fibrinolytic therapy in stroke patient?
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS
Botulism has descending paralysis in contrast othere have ascending paralysis

11. When to use brain spect scintigraphy to confirm brain death
Autospy gold standard
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
It patient has electrolyte imbalance and hypothermia

12. How to differentiate dementias
Nystagmus on far lateral gaze
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

13. women with unilateral eye pain; neurlogic symptoms here there at different times
Acetylecholinersterase inhibitors
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Despite the term neuroma they arise from schwann cells - schwanoma

14. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
82% specific for dementia
Upright supine position
Difficulty in writing - calculating - distinguishing left and write

15. What is can be used cluster headache prevention
Verapamil
Not within 24 hours; give afte 24-48 hours if patient stable
EPV - campylobacter - HSV
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

16. oligoclonal band in CSF
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

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

18. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
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;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
<20; if patient scores >25 benign forgetfulness
Normal pressure hydrocephalus

19. How to differentiate medial and lateral medullary syndrome
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;
RBC count >6000
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Wernicke's encephalopathy; due to thiamine definition; medical emergency

20. How to manage stroke patient came within 4 hours
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)
Cerebellar lesion
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

21. impaired perception of complex sounds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
<20; if patient scores >25 benign forgetfulness

22. Blood transfusion in hypothermia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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;
Cerebral palsy; dx mri
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

23. what drug is used to extend effects of levodopa
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Entacapone - COMT inhibitor
It patient has electrolyte imbalance and hypothermia

24. get up and go test
Myasthenia; due to autoantibodies against acetylecholine receptor;
Get up from chair walk a short distance turn around and sit; screening test for fall
MS
Verapamil

25. differentiate wenicke and korsakoff
Wernicke's encephalopathy; due to thiamine definition; medical emergency
<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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

26. differentiate lewy body dementia and vascular dementia
MS
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
Nystagmus on far lateral gaze

27. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Reduced efficacy of OCP
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors

28. When to suspect traumatic LP
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.
RBC count >6000
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

29. How to confirm braindeath?
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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.
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

30. How to prevent prevent frequency of MS exacerbation
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
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

31. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
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
Cholinesterase inhibitor; and antiparkinsonism drugs

32. botulism
82% specific for dementia
Antitoxin
Autospy gold standard
RBC count >6000

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

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34. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Aspirin - control HTN and swallow eval before giving any oral meds
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

35. When to use dopamine agonist pramipexol in parkinson
Diabetes insipidus
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Distal lower motor neuron disease

36. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Nystagmus on far lateral gaze
Acetylecholinersterase inhibitors
Taper gradually to prevent seizure relapse

37. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

38. lesion in dominant tempora lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Entacapone - COMT inhibitor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Acetylecholinersterase inhibitors

39. 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
EPV - campylobacter - HSV
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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;

40. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
RBC count >6000
Taper gradually to prevent seizure relapse
Diabetes insipidus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

41. MMSE score of less than 24
20%
82% specific for dementia
Coronary artery disease
Obturator n lesion

42. 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
Aspirin - control HTN and swallow eval before giving any oral meds
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

43. When to give aspirin when patient on tPA after stroke
Gilberts disease
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable

44. benign essential tremor
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
High dose IV methyleprednisone;
IVIG and plasmapheresis
Propranolol or primidone

45. phenytoin and OCP
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Reduced efficacy of OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

46. impaired vibration and increased DTR
Vitamin B12 deficiency
Diabetes insipidus
Acetylecholinersterase inhibitors
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

47. MG
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Clonidine will take care both high bp and withdrawal

48. Tx of GBS
Tunnel vision - diaphoresis - nausea - pallor
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

49. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency

50. excessive elevation of legs during walking (toe touch floor earlier than heels)
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Distal lower motor neuron disease