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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. labyrinthitis
Corticosteroid and acyclovir
Not within 24 hours; give afte 24-48 hours if patient stable
Follows viral illness; vertigo - tinnitus - nausea. self limiting
It patient has electrolyte imbalance and hypothermia

2. What percent of dementia is reversible
20%
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
MS

3. oligoclonal band in CSF
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Aspirin - control HTN and swallow eval before giving any oral meds
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MS

4. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

5. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
Entacapone - COMT inhibitor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Clonidine will take care both high bp and withdrawal

6. differentiate wenicke and korsakoff
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
82% specific for dementia

7. cluster headache
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Autospy gold standard
Gilberts disease

8. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
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
Taper gradually to prevent seizure relapse
Distal lower motor neuron disease

9. How to differentiate medial and lateral pontine syndrome
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

10. dementia plus urinary incontinence
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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.

11. earliest sign of phenytoin toxicity
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
Femoral n lesion
Acetylecholinersterase inhibitors

12. How to differentiate traumatic LP and SAH
82% specific for dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
IVIG and plasmapheresis
Aspirin - control HTN and swallow eval before giving any oral meds

13. Unable to copy of matchstick - unable to dress up
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis
Construction apraxia; lesion in non dominant parietal lobe (right)
Acetylecholinersterase inhibitors

14. infections in GBS
Propranolol or primidone
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
EPV - campylobacter - HSV
Antitoxin

15. korsafoff psychosis
Not within 24 hours; give afte 24-48 hours if patient stable
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

16. How to differentiate botulism from tick born paralysis - GBS and MG
Propranolol or primidone
Obturator n lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
Construction apraxia; lesion in non dominant parietal lobe (right)

17. contraindication of sumatripta
Reduced efficacy of OCP
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Coronary artery disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

18. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

19. dominant parietal lobe on the left side
Deficit in cranial nerve function
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

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

21. impaired hepatic conjugation of billirubin
Deficit in cranial nerve function
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
It patient has electrolyte imbalance and hypothermia
Gilberts disease

22. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
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
20%
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

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

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24. 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
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
<20; if patient scores >25 benign forgetfulness
Lesion in nondominant temporal lobe

25. When to start fibrinolytic therapy in stroke patient?
Autospy gold standard
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebellar lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

26. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Spastic paraparesis
82% specific for dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

27. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Corticosteroid and acyclovir

28. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Deficit in cranial nerve function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

29. 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
Corticosteroid and acyclovir
Nystagmus on far lateral gaze
Difficulty in writing - calculating - distinguishing left and write

30. Acute onset of left arm weakness
EPV - campylobacter - HSV
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MS

31. women with unilateral eye pain; neurlogic symptoms here there at different times
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
IVIG and plasmapheresis

32. Tx of GBS
Cerebral palsy; dx mri
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

33. best diagnosis for parkinsonim
Not within 24 hours; give afte 24-48 hours if patient stable
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
<20; if patient scores >25 benign forgetfulness
Autospy gold standard

34. When headache is presenting complaint of brain 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Not within 24 hours; give afte 24-48 hours if patient stable
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

35. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
<20; if patient scores >25 benign forgetfulness
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
MS

36. How to perform apnea test
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Despite the term neuroma they arise from schwann cells - schwanoma
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

37. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

38. phenytoin and OCP
Reduced efficacy of OCP
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Femoral n lesion

39. at first tingling in toes and feet then weakness in extremities
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Get up from chair walk a short distance turn around and sit; screening test for fall
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

40. impaired vibration and increased DTR
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Autospy gold standard
<20; if patient scores >25 benign forgetfulness
Vitamin B12 deficiency

41. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;

42. stroke with lower facial palsy - pronator drift despite on aspirin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
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.

43. anerior and anteriomedial thigh paresthesia - decreased DTR
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Femoral n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Coronary artery disease

44. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Aspirin - control HTN and swallow eval before giving any oral meds
Cerebellar lesion
Deficit in cranial nerve function

45. medial thigh sensory loss and weakness in addcution
Coronary artery disease
Obturator n lesion
90% of right handed and 60% of left handed persons; speech and language function
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

46. What mmse score suggest dementia
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
82% specific for dementia
<20; if patient scores >25 benign forgetfulness

47. How to tx lewy body dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
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
Cholinesterase inhibitor; and antiparkinsonism drugs

48. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor

49. benign essential tremor
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
Autospy gold standard
Propranolol or primidone

50. Blood transfusion in hypothermia
High dose IV methyleprednisone;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin