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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. best diagnosis for parkinsonim
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard
Diabetes insipidus

2. Acute onset of left arm weakness
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Distal lower motor neuron disease
Entacapone - COMT inhibitor

3. When to use dopamine agonist pramipexol in parkinson
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs
Aspirin - control HTN and swallow eval before giving any oral meds

4. Should we tx htn in acute ischemic stroke

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5. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Gilberts disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

6. infections in GBS
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
Entacapone - COMT inhibitor
Gilberts disease

7. When to suspect traumatic LP
Cholinesterase inhibitor; and antiparkinsonism drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
RBC count >6000
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

8. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Entacapone - COMT inhibitor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

9. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Femoral n lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

10. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Obturator n lesion
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

11. What is can be used cluster headache prevention
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Verapamil
RBC count >6000

12. contraindication of sumatripta
20%
Coronary artery disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

13. brain stem lesion
Deficit in cranial nerve function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

14. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Upright supine position

15. phenytoin and OCP
Reduced efficacy of OCP
Femoral n lesion
Gilberts disease
High dose IV methyleprednisone;

16. impaired hepatic conjugation of billirubin
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
EPV - campylobacter - HSV
Gilberts disease
20%

17. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Construction apraxia; lesion in non dominant parietal lobe (right)

18. at first tingling in toes and feet then weakness in extremities
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
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
Vitamin B12 deficiency
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

19. what drug is used to extend effects of levodopa
Spastic paraparesis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor

20. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Construction apraxia; lesion in non dominant parietal lobe (right)
Get up from chair walk a short distance turn around and sit; screening test for fall
Gilberts disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

21. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
It patient has electrolyte imbalance and hypothermia
Not within 24 hours; give afte 24-48 hours if patient stable

22. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS
Propranolol or primidone

23. benign essential tremor
Entacapone - COMT inhibitor
Propranolol or primidone
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;
90% of right handed and 60% of left handed persons; speech and language function

24. Tx of bells palsy
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

25. Unable to copy of matchstick - unable to dress up
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Despite the term neuroma they arise from schwann cells - schwanoma

26. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Reduced efficacy of OCP
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

27. oligoclonal band in CSF
Diabetes insipidus
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
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
MS

28. prodrome of vasovagal syncope
Despite the term neuroma they arise from schwann cells - schwanoma
Tunnel vision - diaphoresis - nausea - pallor
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
Clonidine will take care both high bp and withdrawal

29. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
20%
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

30. Why V12 deficient develop hypokalemia after tx with b12
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

31. severe headache and high BP
Propranolol or primidone
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

32. botulism
RBC count >6000
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.
20%
Antitoxin

33. What percent of dementia is reversible
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
20%
<20; if patient scores >25 benign forgetfulness

34. When headache is presenting complaint of brain tumor
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

35. How to differentiate parkinson and benign essential tremor
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

36. How to differentiate dementias
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
90% of right handed and 60% of left handed persons; speech and language function

37. How to differentiate medial and lateral pontine syndrome
90% of right handed and 60% of left handed persons; speech and language function
Cerebral palsy; dx mri
Despite the term neuroma they arise from schwann cells - schwanoma
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

38. How to perform apnea test
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

39. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Normal pressure hydrocephalus
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

40. 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
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
Propranolol or primidone
Cerebellar lesion

41. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spastic paraparesis
Myasthenia; due to autoantibodies against acetylecholine receptor;

42. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebellar lesion
Upright supine position

43. cluster headache
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
High dose IV methyleprednisone;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

44. 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.
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Nystagmus on far lateral gaze
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

45. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position
Normal pressure hydrocephalus
RBC count >6000

46. 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
Entacapone - COMT inhibitor
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
Nystagmus on far lateral gaze

47. How to differentiate traumatic LP and SAH
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Normal pressure hydrocephalus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

48. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Deficit in cranial nerve function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

49. dementia plus urinary incontinence
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 develop fever - mouth ulcer - easy brusing - petechie - see a doc ; the drug cause neutropenia - and bone marrow suppression; elderly are at risk of SIADH
It patient has electrolyte imbalance and hypothermia
Normal pressure hydrocephalus

50. medial thigh sensory loss and weakness in addcution
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Aphasia - neglect - agnosia - acalculia etc
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