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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. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Gilberts disease
Upright supine position
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

2. How to differentiate traumatic LP and SAH
EPV - campylobacter - HSV
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aphasia - neglect - agnosia - acalculia etc
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

3. dominant parietal lobe on the left side
82% specific for dementia
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Construction apraxia; lesion in non dominant parietal lobe (right)

4. 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
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis
Construction apraxia; lesion in non dominant parietal lobe (right)

5. Tx of GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting

6. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Lesion in nondominant temporal lobe

7. MMSE score of less than 24
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
It patient has electrolyte imbalance and hypothermia
82% specific for dementia
Myasthenia; due to autoantibodies against acetylecholine receptor;

8. Should we tx htn in acute ischemic stroke

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9. How to differentiate medial and lateral medullary syndrome
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
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;
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

10. How to confirm braindeath?
Not within 24 hours; give afte 24-48 hours if patient stable
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease
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. impaired vibration and increased DTR
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor
Entacapone - COMT inhibitor
Vitamin B12 deficiency

12. Tx of bells palsy
Corticosteroid and acyclovir
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

13. How to tx stroke patient came after 6h
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds
Entacapone - COMT inhibitor

14. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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
MS

15. impaired hepatic conjugation of billirubin
Obturator n lesion
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
Tunnel vision - diaphoresis - nausea - pallor

16. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Diabetes insipidus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
RBC count >6000

17. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

18. indication of plasmapheresis in GBS
Reduced efficacy of OCP
82% specific for dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion

19. When to start fibrinolytic therapy in stroke patient?
Deficit in cranial nerve function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebral palsy; dx mri
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

20. differentiate wenicke and korsakoff
It patient has electrolyte imbalance and hypothermia
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

21. lesion in dominant tempora lobe
Reduced efficacy of OCP
Antitoxin
20%
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

22. contraindication of sumatripta
Reduced efficacy of OCP
Coronary artery disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

23. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Entacapone - COMT inhibitor
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

24. 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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Wernicke's encephalopathy; due to thiamine definition; medical emergency

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

26. Unable to copy of matchstick - unable to dress up
High dose IV methyleprednisone;
Construction apraxia; lesion in non dominant parietal lobe (right)
Distal lower motor neuron disease
Acetylecholinersterase inhibitors

27. double vision at the end of day and ptosis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Myasthenia; due to autoantibodies against acetylecholine receptor;
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.
Spastic paraparesis

28. craniopharyngioma
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Construction apraxia; lesion in non dominant parietal lobe (right)
Diabetes insipidus

29. How to prevent prevent frequency of MS exacerbation
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

30. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
<20; if patient scores >25 benign forgetfulness
90% of right handed and 60% of left handed persons; speech and language function

31. severe headache and high BP
MS
Cerebellar lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

32. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Aspirin - control HTN and swallow eval before giving any oral meds
Normal pressure hydrocephalus
Femoral n lesion
Cerebral palsy; dx mri

33. How to perform apnea test
Distal lower motor neuron disease
<20; if patient scores >25 benign forgetfulness
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

34. benign essential tremor
Propranolol or primidone
90% of right handed and 60% of left handed persons; speech and language function
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Entacapone - COMT inhibitor

35. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Corticosteroid and acyclovir
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

36. Patient with carbamazepine; What should be advice?
Myasthenia; due to autoantibodies against acetylecholine receptor;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Acetylecholinersterase inhibitors
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

37. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Clonidine will take care both high bp and withdrawal
Acetylecholinersterase inhibitors
It patient has electrolyte imbalance and hypothermia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

38. When to use brain spect scintigraphy to confirm brain death
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

39. Blood transfusion in hypothermia
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
Reduced efficacy of OCP
IVIG and plasmapheresis

40. anerior and anteriomedial thigh paresthesia - decreased DTR
Entacapone - COMT inhibitor
Diabetes insipidus
Femoral n lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

41. oligoclonal band in CSF
Myasthenia; due to autoantibodies against acetylecholine receptor;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS
Nystagmus on far lateral gaze

42. botulism
Antitoxin
Aphasia - neglect - agnosia - acalculia etc
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Nystagmus on far lateral gaze

43. How to tx acute exacerbation of MS
Clonidine will take care both high bp and withdrawal
High dose IV methyleprednisone;
RBC count >6000
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

44. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
RBC count >6000
Follows viral illness; vertigo - tinnitus - nausea. self limiting
82% specific for dementia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

45. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Verapamil
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

46. differentiate lewy body dementia and vascular dementia
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
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
EPV - campylobacter - HSV
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

47. When to suspect traumatic LP
EPV - campylobacter - HSV
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

48. phenytoin and 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Reduced efficacy of OCP
Cerebral palsy; dx mri

49. dementia plus urinary incontinence
Distal lower motor neuron disease
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

50. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Nystagmus on far lateral gaze
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal