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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. GBS
Cerebral palsy; dx mri
IVIG and plasmapheresis
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
Not within 24 hours; give afte 24-48 hours if patient stable

2. impaired perception of complex sounds
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Lesion in nondominant temporal lobe
Deficit in cranial nerve function

3. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

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

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5. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Reduced efficacy of OCP
Distal lower motor neuron disease

6. korsafoff psychosis
Distal lower motor neuron disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
It patient has electrolyte imbalance and hypothermia

7. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

8. Tx of bells palsy
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Corticosteroid and acyclovir
Coronary artery disease

9. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
MS
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
Upright supine position
Propranolol or primidone

10. anerior and anteriomedial thigh paresthesia - decreased DTR
Normal pressure hydrocephalus
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

11. what drug is used to extend effects of levodopa
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;
Coronary artery disease
Entacapone - COMT inhibitor

12. indication of plasmapheresis in GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

13. women with unilateral eye pain; neurlogic symptoms here there at different times
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

14. How to manage stroke patient came within 4 hours
Corticosteroid and acyclovir
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Not within 24 hours; give afte 24-48 hours if patient stable
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

15. When to use brain spect scintigraphy to confirm brain death
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
It patient has electrolyte imbalance and hypothermia
82% specific for dementia
90% of right handed and 60% of left handed persons; speech and language function

16. infections in GBS
EPV - campylobacter - HSV
Deficit in cranial nerve function
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
Cerebral palsy; dx mri

17. stroke with lower facial palsy - pronator drift despite on aspirin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;

18. Should we tx htn in acute ischemic stroke

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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
Cholinesterase inhibitor; and antiparkinsonism drugs
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

20. earliest sign of phenytoin toxicity
Not within 24 hours; give afte 24-48 hours if patient stable
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

21. MG
20%
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
Diabetes insipidus

22. botulism
Antitoxin
Botulism has descending paralysis in contrast othere have ascending paralysis
Femoral n lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

23. What is can be used cluster headache prevention
Verapamil
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Not within 24 hours; give afte 24-48 hours if patient stable
Cholinesterase inhibitor; and antiparkinsonism drugs

24. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cholinesterase inhibitor; and antiparkinsonism drugs
Distal lower motor neuron disease

25. best diagnosis for parkinsonim
Botulism has descending paralysis in contrast othere have ascending paralysis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Autospy gold standard
Vitamin B12 deficiency

26. 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
Taper gradually to prevent seizure relapse
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion

27. benign essential tremor
Botulism has descending paralysis in contrast othere have ascending paralysis
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
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;

28. differentiate wenicke and korsakoff
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Despite the term neuroma they arise from schwann cells - schwanoma

29. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
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
<20; if patient scores >25 benign forgetfulness
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

30. lesion in dominant tempora lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

31. impaired vibration and increased DTR
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Vitamin B12 deficiency
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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

32. MMSE score of less than 24
Lesion in nondominant temporal lobe
82% specific for dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
<20; if patient scores >25 benign forgetfulness

33. How to confirm braindeath?
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
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.
MS

34. When to start fibrinolytic therapy in stroke patient?
RBC count >6000
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Upright supine position

35. contraindication of sumatripta
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Coronary artery disease
Entacapone - COMT inhibitor

36. Patient with carbamazepine; What should be advice?
Reduced efficacy of OCP
Construction apraxia; lesion in non dominant parietal lobe (right)
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

37. brain stem lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
EPV - campylobacter - HSV
Get up from chair walk a short distance turn around and sit; screening test for fall
Deficit in cranial nerve function

38. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
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;
Clonidine will take care both high bp and withdrawal
Cholinesterase inhibitor; and antiparkinsonism drugs

39. How to stop antiepileptic drugs
Get up from chair walk a short distance turn around and sit; screening test for fall
Taper gradually to prevent seizure relapse
EPV - campylobacter - HSV
Aspirin - control HTN and swallow eval before giving any oral meds

40. What mmse score suggest dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
High dose IV methyleprednisone;
Vitamin B12 deficiency
<20; if patient scores >25 benign forgetfulness

41. How to perform apnea test
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Despite the term neuroma they arise from schwann cells - schwanoma
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

42. When headache is presenting complaint of brain tumor
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
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

43. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Clonidine will take care both high bp and withdrawal

44. craniopharyngioma
Diabetes insipidus
Not within 24 hours; give afte 24-48 hours if patient stable
Taper gradually to prevent seizure relapse
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

45. Acute onset of left arm weakness
Get up from chair walk a short distance turn around and sit; screening test for fall
Distal lower motor neuron 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;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

46. What percent of dementia is reversible
Aphasia - neglect - agnosia - acalculia etc
20%
Entacapone - COMT inhibitor
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

47. medial thigh sensory loss and weakness in addcution
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
Lesion in nondominant temporal lobe
Obturator n lesion
Not within 24 hours; give afte 24-48 hours if patient stable

48. dominant parietal lobe on the left side
Difficulty in writing - calculating - distinguishing left and write
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
90% of right handed and 60% of left handed persons; speech and language function

49. oligoclonal band in CSF
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable
MS

50. get up and go test
Not within 24 hours; give afte 24-48 hours if patient stable
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS
Get up from chair walk a short distance turn around and sit; screening test for fall