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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. Acute onset of left arm weakness
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Clonidine will take care both high bp and withdrawal
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

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

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3. best diagnosis for parkinsonim
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Autospy gold standard
82% specific for dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

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

5. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
<20; if patient scores >25 benign forgetfulness
Aphasia - neglect - agnosia - acalculia etc
Deficit in cranial nerve function

6. contraindication of sumatripta
Coronary artery disease
High dose IV methyleprednisone;
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion

7. indication of plasmapheresis in GBS
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
RBC count >6000
Difficulty in writing - calculating - distinguishing left and write
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

8. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

9. What is pronator drift
Construction apraxia; lesion in non dominant parietal lobe (right)
IVIG and plasmapheresis
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

10. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Despite the term neuroma they arise from schwann cells - schwanoma
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Normal pressure hydrocephalus

11. 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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

12. brain stem lesion
Deficit in cranial nerve function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Obturator n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

13. When to use brain spect scintigraphy to confirm brain death
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
It patient has electrolyte imbalance and hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

14. Should we tx htn in acute ischemic stroke

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15. dominant parietal lobe on the left side
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

16. labyrinthitis
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

17. anerior and anteriomedial thigh paresthesia - decreased DTR
Deficit in cranial nerve function
Autospy gold standard
Femoral n lesion
Not within 24 hours; give afte 24-48 hours if patient stable

18. How to confirm braindeath?
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.
Aspirin - control HTN and swallow eval before giving any oral meds
Follows viral illness; vertigo - tinnitus - nausea. self limiting
20%

19. phenytoin and OCP
Reduced efficacy of OCP
Upright supine position
IVIG and plasmapheresis
RBC count >6000

20. impaired hepatic conjugation of billirubin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts 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.
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;

21. women with unilateral eye pain; neurlogic symptoms here there at different times
Verapamil
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
<20; if patient scores >25 benign forgetfulness

22. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
High dose IV methyleprednisone;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

23. What is can be used cluster headache prevention
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Verapamil
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

24. prodrome of vasovagal syncope
Normal pressure hydrocephalus
High dose IV methyleprednisone;
Tunnel vision - diaphoresis - nausea - pallor
Deficit in cranial nerve function

25. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Diabetes insipidus
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
Upright supine position
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

26. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Clonidine will take care both high bp and withdrawal
Deficit in cranial nerve function

27. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Despite the term neuroma they arise from schwann cells - schwanoma
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
Obturator n lesion

28. what drug is used to extend effects of levodopa
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Reduced efficacy of OCP
Entacapone - COMT inhibitor

29. How to differentiate traumatic LP and SAH
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

30. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. korsafoff psychosis
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
Upright supine position
EPV - campylobacter - HSV

32. How to differentiate parkinson and benign essential tremor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Femoral n lesion
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

33. How to manage stroke patient came within 4 hours
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
82% specific for dementia
High dose IV methyleprednisone;

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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

35. What mmse score suggest dementia
It patient has electrolyte imbalance and hypothermia
<20; if patient scores >25 benign forgetfulness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease

36. Patient with carbamazepine; What should be advice?
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
Femoral n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus

37. benign essential tremor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Propranolol or primidone
Nystagmus on far lateral gaze
Myasthenia; due to autoantibodies against acetylecholine receptor;

38. What percent of dementia is reversible
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Antitoxin
20%
Vitamin B12 deficiency

39. How to stop antiepileptic drugs
Normal pressure hydrocephalus
Obturator n lesion
Cholinesterase inhibitor; and antiparkinsonism drugs
Taper gradually to prevent seizure relapse

40. GBS
Aphasia - neglect - agnosia - acalculia etc
Cholinesterase inhibitor; and antiparkinsonism drugs
82% specific for dementia
IVIG and plasmapheresis

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

42. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Construction apraxia; lesion in non dominant parietal lobe (right)
Spastic paraparesis

43. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs

44. dementia plus urinary incontinence
Propranolol or primidone
It patient has electrolyte imbalance and hypothermia
Antitoxin
Normal pressure hydrocephalus

45. impaired perception of complex sounds
Autospy gold standard
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Acetylecholinersterase inhibitors
Lesion in nondominant temporal lobe

46. When headache is presenting complaint of brain tumor
RBC count >6000
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Coronary artery disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

47. How to perform apnea test
Aspirin - control HTN and swallow eval before giving any oral meds
EPV - campylobacter - HSV
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

48. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Construction apraxia; lesion in non dominant parietal lobe (right)

49. acoustic neuroma
Construction apraxia; lesion in non dominant parietal lobe (right)
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.
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP

50. MMSE score of less than 24
High dose IV methyleprednisone;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Despite the term neuroma they arise from schwann cells - schwanoma
82% specific for dementia