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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. How to differentiate medial and lateral pontine syndrome
Obturator n lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
<20; if patient scores >25 benign forgetfulness
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

2. When to suspect traumatic LP
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
RBC count >6000
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

3. When to use dopamine agonist pramipexol in parkinson
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
Clonidine will take care both high bp and withdrawal
Verapamil

4. severe headache and high BP
Deficit in cranial nerve function
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.
Upright supine position
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

5. women with unilateral eye pain; neurlogic symptoms here there at different times
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

6. How to tx lewy body dementia
Acetylecholinersterase inhibitors
Cholinesterase inhibitor; and antiparkinsonism drugs
Spastic paraparesis
Femoral n lesion

7. indication of plasmapheresis in GBS
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS
Cholinesterase inhibitor; and antiparkinsonism drugs

8. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MS

9. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function
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

10. How to tx stroke patient came after 6h
Normal pressure hydrocephalus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Aspirin - control HTN and swallow eval before giving any oral meds
20%

11. 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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease

12. When to start fibrinolytic therapy in stroke patient?
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

13. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Spastic paraparesis
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

14. How to differentiate botulism from tick born paralysis - GBS and MG
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
Diabetes insipidus
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Botulism has descending paralysis in contrast othere have ascending paralysis

15. Should we tx htn in acute ischemic stroke

16. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Antitoxin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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.

17. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Autospy gold standard

18. GBS
Upright supine position
Diabetes insipidus
IVIG and plasmapheresis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

19. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
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;
Deficit in cranial nerve function
Normal pressure hydrocephalus

20. brain stem lesion
Deficit in cranial nerve function
Distal lower motor neuron disease
Clonidine will take care both high bp and withdrawal
Difficulty in writing - calculating - distinguishing left and write

21. How to stop antiepileptic drugs
MS
Propranolol or primidone
Lesion in nondominant temporal lobe
Taper gradually to prevent seizure relapse

22. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Construction apraxia; lesion in non dominant parietal lobe (right)
Spastic paraparesis
Reduced efficacy of OCP

23. 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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Lesion in nondominant temporal lobe
It patient has electrolyte imbalance and hypothermia

24. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Cerebellar lesion
Coronary artery disease
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

25. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

26. dementia plus urinary incontinence
Cerebellar lesion
Normal pressure hydrocephalus
Nystagmus on far lateral gaze
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

27. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion
Botulism has descending paralysis in contrast othere have ascending paralysis

28. anerior and anteriomedial thigh paresthesia - decreased DTR
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Femoral n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Verapamil

29. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Autospy gold standard
Femoral n lesion
It patient has electrolyte imbalance and hypothermia

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

31. craniopharyngioma
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Diabetes insipidus
<20; if patient scores >25 benign forgetfulness

32. What percent of dementia is reversible
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
20%
Aspirin - control HTN and swallow eval before giving any oral meds
Taper gradually to prevent seizure relapse

33. infections in GBS
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
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

34. Tx of GBS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
<20; if patient scores >25 benign forgetfulness
Distal lower motor neuron disease
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

35. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Diabetes insipidus
Myasthenia; due to autoantibodies against acetylecholine receptor;
It patient has electrolyte imbalance and hypothermia

36. phenytoin and OCP
Antitoxin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

37. How to differentiate parkinson and benign essential tremor
RBC count >6000
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

38. prodrome of vasovagal syncope
Diabetes insipidus
Tunnel vision - diaphoresis - nausea - pallor
EPV - campylobacter - HSV
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

39. 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.
Gilberts disease
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

40. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

41. How to manage stroke patient came within 4 hours
Not within 24 hours; give afte 24-48 hours if patient stable
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Construction apraxia; lesion in non dominant parietal lobe (right)
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

42. What is can be used cluster headache prevention
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;
Verapamil
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cholinesterase inhibitor; and antiparkinsonism drugs

43. benign essential tremor
Propranolol or primidone
90% of right handed and 60% of left handed persons; speech and language function
Myasthenia; due to autoantibodies against acetylecholine receptor;
<20; if patient scores >25 benign forgetfulness

44. Why V12 deficient develop hypokalemia after tx with b12
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Upright supine position
EPV - campylobacter - HSV

45. What mmse score suggest dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
<20; if patient scores >25 benign forgetfulness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
90% of right handed and 60% of left handed persons; speech and language function

46. oligoclonal band in CSF
20%
Reduced efficacy of OCP
MS
It patient has electrolyte imbalance and hypothermia

47. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Cerebellar lesion
Taper gradually to prevent seizure relapse
Upright supine position
Distal lower motor neuron disease

48. differentiate wenicke and korsakoff
Gilberts disease
Clonidine will take care both high bp and withdrawal
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

49. earliest sign of phenytoin toxicity
Reduced efficacy of OCP
Nystagmus on far lateral gaze
Cholinesterase inhibitor; and antiparkinsonism drugs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

50. How to differentiate medial and lateral medullary syndrome
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
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
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;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel