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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 parkinson and benign essential tremor
Corticosteroid and acyclovir
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
Nystagmus on far lateral gaze
Difficulty in writing - calculating - distinguishing left and write

2. How to differentiate botulism from tick born paralysis - GBS and MG
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Botulism has descending paralysis in contrast othere have ascending paralysis
MS

3. at first tingling in toes and feet then weakness in extremities
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Construction apraxia; lesion in non dominant parietal lobe (right)
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

4. differentiate lewy body dementia and vascular dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Difficulty in writing - calculating - distinguishing left and write

5. cluster headache
Nystagmus on far lateral gaze
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
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
Vitamin B12 deficiency

6. When to suspect traumatic LP
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
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

7. Should we tx htn in acute ischemic stroke

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8. How to differentiate medial and lateral pontine syndrome
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Coronary artery disease
IVIG and plasmapheresis

9. lesion in dominant parietal lobe
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Difficulty in writing - calculating - distinguishing left and write
Cerebral palsy; dx mri

10. brain stem lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Deficit in cranial nerve function

11. lesion in dominant tempora lobe
Verapamil
Entacapone - COMT inhibitor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

12. cortical lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Aphasia - neglect - agnosia - acalculia etc
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir

13. How to tx stroke patient came after 6h
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Verapamil
Aspirin - control HTN and swallow eval before giving any oral meds

14. GBS
Cerebral palsy; dx mri
IVIG and plasmapheresis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Corticosteroid and acyclovir

15. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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;

16. 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
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
Normal pressure hydrocephalus

17. severe headache and high BP
Cerebral palsy; dx mri
Botulism has descending paralysis in contrast othere have ascending paralysis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
It patient has electrolyte imbalance and hypothermia

18. How to differentiate traumatic LP and SAH
Coronary artery disease
It patient has electrolyte imbalance and hypothermia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

19. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
20%
Coronary artery disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

20. craniopharyngioma
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
Diabetes insipidus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cerebellar lesion

21. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

22. When to start fibrinolytic therapy in stroke patient?
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
82% specific for dementia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

23. Blood transfusion in hypothermia
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Entacapone - COMT inhibitor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

24. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
<20; if patient scores >25 benign forgetfulness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Despite the term neuroma they arise from schwann cells - schwanoma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

25. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spastic paraparesis
Verapamil

26. When to use dopamine agonist pramipexol in parkinson
20%
90% of right handed and 60% of left handed persons; speech and language function
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

27. women with unilateral eye pain; neurlogic symptoms here there at different times
Cerebral palsy; dx mri
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acetylecholinersterase inhibitors

28. What is can be used cluster headache prevention
Verapamil
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

29. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Antitoxin
Acetylecholinersterase inhibitors
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

30. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Tunnel vision - diaphoresis - nausea - pallor
Cerebral palsy; dx mri

31. 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;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spastic paraparesis
Reduced efficacy of OCP

32. When to give aspirin when patient on tPA after stroke
Botulism has descending paralysis in contrast othere have ascending paralysis
Not within 24 hours; give afte 24-48 hours if patient stable
High dose IV methyleprednisone;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

33. MMSE score of less than 24
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Follows viral illness; vertigo - tinnitus - nausea. self limiting
82% specific for dementia
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

34. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
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
Cerebellar lesion
Distal lower motor neuron disease

35. impaired perception of complex sounds
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness
Lesion in nondominant temporal lobe
Cerebellar lesion

36. What mmse score suggest dementia
Cerebellar lesion
Clonidine will take care both high bp and withdrawal
<20; if patient scores >25 benign forgetfulness
Myasthenia; due to autoantibodies against acetylecholine receptor;

37. prodrome of vasovagal syncope
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis

38. stroke with lower facial palsy - pronator drift despite on aspirin
Upright supine position
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

39. phenytoin and OCP
RBC count >6000
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Reduced efficacy of OCP
It patient has electrolyte imbalance and hypothermia

40. Tx of GBS
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
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

41. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

42. impaired hepatic conjugation of billirubin
Vitamin B12 deficiency
Gilberts disease
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in writing - calculating - distinguishing left and write

43. How to tx lewy body dementia
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
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

44. contraindication of sumatripta
Coronary artery disease
Cerebral palsy; dx mri
Entacapone - COMT inhibitor
Vitamin B12 deficiency

45. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Deficit in cranial nerve function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

46. labyrinthitis
90% of right handed and 60% of left handed persons; speech and language function
Despite the term neuroma they arise from schwann cells - schwanoma
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

47. 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
Antitoxin
Cerebral palsy; dx mri
Deficit in cranial nerve function

48. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Botulism has descending paralysis in contrast othere have ascending paralysis
High dose IV methyleprednisone;
Not within 24 hours; give afte 24-48 hours if patient stable

49. 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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion

50. earliest sign of phenytoin toxicity
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Nystagmus on far lateral gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty