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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. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

2. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Botulism has descending paralysis in contrast othere have ascending paralysis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

3. infections in GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Normal pressure hydrocephalus
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

4. stroke with lower facial palsy - pronator drift despite on aspirin
IVIG and plasmapheresis
High dose IV methyleprednisone;
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Clonidine will take care both high bp and withdrawal

5. contraindication of sumatripta
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Spastic paraparesis
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
Coronary artery disease

6. craniopharyngioma
Diabetes insipidus
Aspirin - control HTN and swallow eval before giving any oral meds
Coronary artery disease
Spastic paraparesis

7. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in writing - calculating - distinguishing left and write
20%

8. impaired vibration and increased DTR
Coronary artery disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

9. best diagnosis for parkinsonim
Despite the term neuroma they arise from schwann cells - schwanoma
Autospy gold standard
Cerebral palsy; dx mri
Clonidine will take care both high bp and withdrawal

10. oligoclonal band in CSF
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
MS
It patient has electrolyte imbalance and hypothermia
High dose IV methyleprednisone;

11. acoustic neuroma
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

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

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13. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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;

14. When to use dopamine agonist pramipexol in parkinson
Normal pressure hydrocephalus
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency
Not within 24 hours; give afte 24-48 hours if patient stable

15. severe headache and high BP
Obturator n lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency

16. How to differentiate medial and lateral pontine syndrome
MS
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
Reduced efficacy of OCP
It patient has electrolyte imbalance and hypothermia

17. botulism
Propranolol or primidone
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Antitoxin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

18. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone
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

19. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
<20; if patient scores >25 benign forgetfulness
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Clonidine will take care both high bp and withdrawal

20. When to give aspirin when patient on tPA after stroke
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

21. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
82% specific for dementia
Upright supine position
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

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

23. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
Upright supine position
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

24. lesion in dominant parietal lobe
Spastic paraparesis
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
Clonidine will take care both high bp and withdrawal

25. What percent of dementia is reversible
Verapamil
20%
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

26. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
<20; if patient scores >25 benign forgetfulness
Antitoxin

27. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors

28. labyrinthitis
Despite the term neuroma they arise from schwann cells - schwanoma
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
82% specific for dementia

29. How to tx lewy body dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cholinesterase inhibitor; and antiparkinsonism drugs
Antitoxin

30. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MS
Obturator n lesion
Antitoxin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

31. brain stem lesion
Deficit in cranial nerve function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Aphasia - neglect - agnosia - acalculia etc
Upright supine position

32. 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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
High dose IV methyleprednisone;
Aspirin - control HTN and swallow eval before giving any oral meds

33. How to differentiate medial and lateral medullary syndrome
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
It patient has electrolyte imbalance and hypothermia
20%
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;

34. impaired hepatic conjugation of billirubin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Cerebral palsy; dx mri

35. How to differentiate traumatic LP and SAH
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

36. double vision at the end of day and ptosis
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Get up from chair walk a short distance turn around and sit; screening test for fall

37. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Corticosteroid and acyclovir
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

38. benign essential tremor
Entacapone - COMT inhibitor
Propranolol or primidone
Spastic paraparesis
Taper gradually to prevent seizure relapse

39. 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
Femoral n lesion
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs

40. MMSE score of less than 24
82% specific for dementia
Autospy gold standard
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
90% of right handed and 60% of left handed persons; speech and language function

41. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Lesion in nondominant temporal lobe
90% of right handed and 60% of left handed persons; speech and language function

42. 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.
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
Tunnel vision - diaphoresis - nausea - pallor
Verapamil

43. 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;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
It patient has electrolyte imbalance and hypothermia

44. Tx of bells palsy
Reduced efficacy of OCP
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Corticosteroid and acyclovir
IVIG and plasmapheresis

45. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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.
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

46. at first tingling in toes and feet then weakness in extremities
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor

47. How to differentiate parkinson and benign essential tremor
Verapamil
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.
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;

48. earliest sign of phenytoin toxicity
Obturator n lesion
Aphasia - neglect - agnosia - acalculia etc
Nystagmus on far lateral gaze
Reduced efficacy of OCP

49. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Cerebellar lesion
Aphasia - neglect - agnosia - acalculia etc
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

50. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Entacapone - COMT inhibitor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aspirin - control HTN and swallow eval before giving any oral meds