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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. differentiate picks and huntington
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
Difficulty in writing - calculating - distinguishing left and write
Tunnel vision - diaphoresis - nausea - pallor
Upright supine position

2. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Gilberts disease
Deficit in cranial nerve function

3. infections in GBS
EPV - campylobacter - HSV
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Distal lower motor neuron disease

4. phenytoin and OCP
Botulism has descending paralysis in contrast othere have ascending paralysis
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

5. differentiate lewy body dementia and vascular dementia
High dose IV methyleprednisone;
Vitamin B12 deficiency
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

6. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Propranolol or primidone
Autospy gold standard
Aphasia - neglect - agnosia - acalculia etc

7. When to start fibrinolytic therapy in stroke patient?
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS

8. benign essential tremor
Nystagmus on far lateral gaze
EPV - campylobacter - HSV
Propranolol or primidone
Cerebral palsy; dx mri

9. dementia plus urinary incontinence
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Normal pressure hydrocephalus

10. contraindication of sumatripta
Coronary artery disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Despite the term neuroma they arise from schwann cells - schwanoma
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;

11. indication of plasmapheresis in GBS
Antitoxin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis

12. impaired perception of complex sounds
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Lesion in nondominant temporal lobe

13. Tx of bells palsy
Get up from chair walk a short distance turn around and sit; screening test for fall
Antitoxin
Corticosteroid and acyclovir
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

14. Why V12 deficient develop hypokalemia after tx with b12
Obturator n lesion
MS
Nystagmus on far lateral gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

15. what drug is used to extend effects of levodopa
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Entacapone - COMT inhibitor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

16. How to differentiate dementias
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Not within 24 hours; give afte 24-48 hours if patient stable
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

17. brain stem lesion
Diabetes insipidus
Deficit in cranial nerve function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

18. impaired vibration and increased DTR
Coronary artery disease
Vitamin B12 deficiency
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

19. lesion in dominant parietal lobe
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
IVIG and plasmapheresis
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

20. at first tingling in toes and feet then weakness in extremities
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Lesion in nondominant temporal lobe
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

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

22. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

23. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
EPV - campylobacter - HSV
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

24. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
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;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Get up from chair walk a short distance turn around and sit; screening test for fall

25. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Autospy gold standard
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

26. stroke with lower facial palsy - pronator drift despite on aspirin
Entacapone - COMT inhibitor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

27. How to differentiate medial and lateral medullary syndrome
Corticosteroid and acyclovir
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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. botulism
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Antitoxin
Acetylecholinersterase inhibitors
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

29. How to tx stroke patient came after 6h
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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;
MS
Aspirin - control HTN and swallow eval before giving any oral meds

30. Tx of GBS
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

31. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Not within 24 hours; give afte 24-48 hours if patient stable
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

32. When to suspect traumatic LP
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
RBC count >6000
Vitamin B12 deficiency
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

33. What is can be used cluster headache prevention
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Verapamil
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Corticosteroid and acyclovir

34. dominant parietal lobe on the left side
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Obturator n lesion
90% of right handed and 60% of left handed persons; speech and language function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

35. severe headache and high BP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Nystagmus on far lateral gaze

36. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Diabetes insipidus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Difficulty in writing - calculating - distinguishing left and write
Get up from chair walk a short distance turn around and sit; screening test for fall

37. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Spastic paraparesis
Wernicke's encephalopathy; due to thiamine definition; medical emergency

38. MG
Verapamil
Acetylecholinersterase inhibitors
Aphasia - neglect - agnosia - acalculia etc
Propranolol or primidone

39. double vision at the end of day and ptosis
Botulism has descending paralysis in contrast othere have ascending paralysis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Reduced efficacy of OCP
Myasthenia; due to autoantibodies against acetylecholine receptor;

40. cluster headache
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
90% of right handed and 60% of left handed persons; speech and language function
Nystagmus on far lateral gaze
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. MMSE score of less than 24
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Autospy gold standard
Entacapone - COMT inhibitor
82% specific for dementia

42. Unable to copy of matchstick - unable to dress up
Gilberts disease
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Construction apraxia; lesion in non dominant parietal lobe (right)
Antitoxin

43. How to differentiate botulism from tick born paralysis - GBS and MG
82% specific for dementia
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Deficit in cranial nerve function

44. anerior and anteriomedial thigh paresthesia - decreased DTR
Get up from chair walk a short distance turn around and sit; screening test for fall
Spastic paraparesis
Verapamil
Femoral n lesion

45. oligoclonal band in CSF
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
MS
20%
Botulism has descending paralysis in contrast othere have ascending paralysis

46. 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
Difficulty in writing - calculating - distinguishing left and write
Botulism has descending paralysis in contrast othere have ascending paralysis
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

47. How to tx acute exacerbation of MS
Acetylecholinersterase inhibitors
High dose IV methyleprednisone;
RBC count >6000
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

48. How to stop antiepileptic drugs
Nystagmus on far lateral gaze
Coronary artery disease
Taper gradually to prevent seizure relapse
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

49. What percent of dementia is reversible
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Verapamil

50. earliest sign of phenytoin toxicity
Entacapone - COMT inhibitor
It patient has electrolyte imbalance and hypothermia
Antitoxin
Nystagmus on far lateral gaze