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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 perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
High dose IV methyleprednisone;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

3. When to suspect traumatic LP
RBC count >6000
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
Gilberts disease
Myasthenia; due to autoantibodies against acetylecholine receptor;

4. What is can be used cluster headache prevention
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Verapamil
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Obturator n lesion

5. What mmse score suggest dementia
Lesion in nondominant temporal lobe
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis
<20; if patient scores >25 benign forgetfulness

6. Tx of bells palsy
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Corticosteroid and acyclovir

7. botulism
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
Antitoxin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

8. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Tunnel vision - diaphoresis - nausea - pallor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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

9. dementia plus urinary incontinence
Normal pressure hydrocephalus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

10. How to differentiate parkinson and benign essential tremor
Coronary artery 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
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
Entacapone - COMT inhibitor

11. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Cerebellar lesion
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

12. infections in GBS
EPV - campylobacter - HSV
Get up from chair walk a short distance turn around and sit; screening test for fall
Botulism has descending paralysis in contrast othere have ascending paralysis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

13. Blood transfusion in hypothermia
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

14. MG
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors

15. best diagnosis for parkinsonim
Antitoxin
It patient has electrolyte imbalance and hypothermia
Autospy gold standard
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

16. get up and go test
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Coronary artery disease
Gilberts disease
Get up from chair walk a short distance turn around and sit; screening test for fall

17. How to differentiate traumatic LP and SAH
Diabetes insipidus
Vitamin B12 deficiency
Coronary artery disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

18. lesion in dominant tempora lobe
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS

20. How to differentiate botulism from tick born paralysis - GBS and MG
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Autospy gold standard

21. What percent of dementia is reversible
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
20%

22. 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia

23. Unable to copy of matchstick - unable to dress up
Lesion in nondominant temporal lobe
Aphasia - neglect - agnosia - acalculia etc
Construction apraxia; lesion in non dominant parietal lobe (right)
90% of right handed and 60% of left handed persons; speech and language function

24. How to manage stroke patient came within 4 hours
Femoral n lesion
Deficit in cranial nerve function
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

25. differentiate lewy body dementia and vascular dementia
82% specific for dementia
EPV - campylobacter - HSV
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
Aphasia - neglect - agnosia - acalculia etc

26. impaired perception of complex sounds
Difficulty in writing - calculating - distinguishing left and write
Lesion in nondominant temporal lobe
<20; if patient scores >25 benign forgetfulness
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

27. korsafoff psychosis
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Obturator n lesion
Deficit in cranial nerve function

28. oligoclonal band in CSF
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cerebellar lesion
Clonidine will take care both high bp and withdrawal
MS

29. How to confirm braindeath?
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
Lesion in nondominant temporal lobe
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; if patient scores >25 benign forgetfulness

30. What is pronator drift
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
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
Distal lower motor neuron disease

31. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

32. phenytoin and OCP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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.
Aphasia - neglect - agnosia - acalculia etc
Reduced efficacy of OCP

33. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Corticosteroid and acyclovir
Get up from chair walk a short distance turn around and sit; screening test for fall
Coronary artery disease

34. Patient with carbamazepine; What should be advice?
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;
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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

35. How to differentiate medial and lateral medullary syndrome
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease
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;
20%

36. How to prevent prevent frequency of MS exacerbation
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

37. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

38. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Coronary artery disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

39. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
IVIG and plasmapheresis
Cerebellar lesion
It patient has electrolyte imbalance and hypothermia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

40. GBS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
20%
IVIG and plasmapheresis
Verapamil

41. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
High dose IV methyleprednisone;
Autospy gold standard

42. prodrome of vasovagal syncope
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Deficit in cranial nerve function
Tunnel vision - diaphoresis - nausea - pallor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

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

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44. excessive elevation of legs during walking (toe touch floor earlier than heels)
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease

45. How to stop antiepileptic drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Deficit in cranial nerve function
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Taper gradually to prevent seizure relapse

46. impaired hepatic conjugation of billirubin
Taper gradually to prevent seizure relapse
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

47. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Obturator n lesion

48. contraindication of sumatripta
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
90% of right handed and 60% of left handed persons; speech and language function
Coronary artery disease
Lesion in nondominant temporal lobe

49. 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
Tunnel vision - diaphoresis - nausea - pallor
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
Aspirin - control HTN and swallow eval before giving any oral meds

50. what drug is used to extend effects of levodopa
Distal lower motor neuron disease
EPV - campylobacter - HSV
Aspirin - control HTN and swallow eval before giving any oral meds
Entacapone - COMT inhibitor