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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 botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
IVIG and plasmapheresis
Spastic paraparesis

2. Tx of bells palsy
Corticosteroid and acyclovir
90% of right handed and 60% of left handed persons; speech and language function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

3. what drug is used to extend effects of levodopa
Obturator n lesion
Entacapone - COMT inhibitor
Propranolol or primidone
MS

4. How to differentiate traumatic LP and SAH
Upright supine position
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
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

5. severe headache and high BP
Antitoxin
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
High dose IV methyleprednisone;

6. How to confirm braindeath?
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
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.

7. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Aphasia - neglect - agnosia - acalculia etc
Propranolol or primidone
Cerebellar lesion
20%

8. When to use brain spect scintigraphy to confirm brain death
Construction apraxia; lesion in non dominant parietal lobe (right)
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
It patient has electrolyte imbalance and hypothermia
Clonidine will take care both high bp and withdrawal

9. 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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
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

10. What is can be used cluster headache prevention
Not within 24 hours; give afte 24-48 hours if patient stable
Verapamil
Obturator n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

11. impaired hepatic conjugation of billirubin
Gilberts disease
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

12. medial thigh sensory loss and weakness in addcution
<20; if patient scores >25 benign forgetfulness
Deficit in cranial nerve function
Cerebral palsy; dx mri
Obturator n lesion

13. get up and go test
Cholinesterase inhibitor; and antiparkinsonism drugs
Aspirin - control HTN and swallow eval before giving any oral meds
Corticosteroid and acyclovir
Get up from chair walk a short distance turn around and sit; screening test for fall

14. impaired perception of complex sounds
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;
Lesion in nondominant temporal lobe
Acetylecholinersterase inhibitors

15. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
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
EPV - campylobacter - HSV

16. prodrome of vasovagal syncope
Botulism has descending paralysis in contrast othere have ascending paralysis
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

17. Tx of GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

18. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Taper gradually to prevent seizure relapse
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

19. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Diabetes insipidus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

20. When headache is presenting complaint of brain tumor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tunnel vision - diaphoresis - nausea - pallor
IVIG and plasmapheresis

21. When to suspect traumatic LP
Verapamil
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
RBC count >6000
Distal lower motor neuron disease

22. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
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
Normal pressure hydrocephalus
82% specific for dementia

23. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Autospy gold standard
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

24. botulism
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
90% of right handed and 60% of left handed persons; speech and language function
Antitoxin

25. How to perform apnea test
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
Autospy gold standard
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Cerebellar lesion

26. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Clonidine will take care both high bp and withdrawal

27. phenytoin and OCP
EPV - campylobacter - HSV
Reduced efficacy of OCP
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

28. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;

29. dominant parietal lobe on the left side
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
90% of right handed and 60% of left handed persons; speech and language function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

30. labyrinthitis
Taper gradually to prevent seizure relapse
Follows viral illness; vertigo - tinnitus - nausea. self limiting
High dose IV methyleprednisone;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

31. What is pronator drift
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
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

32. Why V12 deficient develop hypokalemia after tx with b12
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Autospy gold standard
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

33. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
RBC count >6000
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Botulism has descending paralysis in contrast othere have ascending paralysis

34. 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
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
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

35. infections in GBS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Normal pressure hydrocephalus
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV

36. benign essential tremor
Propranolol or primidone
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
IVIG and plasmapheresis

37. MMSE score of less than 24
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion
Reduced efficacy of OCP
82% specific for dementia

38. cluster headache
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
Distal lower motor neuron disease
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

39. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Propranolol or primidone
Aphasia - neglect - agnosia - acalculia etc
Corticosteroid and acyclovir
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

40. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
EPV - campylobacter - HSV
Autospy gold standard

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

42. differentiate picks and huntington
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
Deficit in cranial nerve function
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
IVIG and plasmapheresis

43. craniopharyngioma
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Diabetes insipidus
RBC count >6000

44. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis
Vitamin B12 deficiency
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

45. How to differentiate dementias
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Get up from chair walk a short distance turn around and sit; screening test for fall

46. brain stem lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Deficit in cranial nerve function
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

47. anerior and anteriomedial thigh paresthesia - decreased DTR
Get up from chair walk a short distance turn around and sit; screening test for fall
Aspirin - control HTN and swallow eval before giving any oral meds
Femoral n lesion
Normal pressure hydrocephalus

48. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Obturator n lesion
Spastic paraparesis
Coronary artery disease
Wernicke's encephalopathy; due to thiamine definition; medical emergency

49. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Upright supine position
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Cerebral palsy; dx mri

50. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Despite the term neuroma they arise from schwann cells - schwanoma
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
Upright supine position