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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. What bp med to be given in a patient with high bp and signs of opioid withdrawal
82% specific for dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Clonidine will take care both high bp and withdrawal

2. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acetylecholinersterase inhibitors
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Reduced efficacy of OCP

3. cortical 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
Aphasia - neglect - agnosia - acalculia etc
90% of right handed and 60% of left handed persons; speech and language function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

4. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Autospy gold standard

5. botulism
Spastic paraparesis
MS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Antitoxin

6. GBS
IVIG and plasmapheresis
Corticosteroid and acyclovir
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

7. women with unilateral eye pain; neurlogic symptoms here there at different times
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Cerebellar lesion

8. When to give aspirin when patient on tPA after stroke
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function
Not within 24 hours; give afte 24-48 hours if patient stable

9. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Diabetes insipidus
Cerebral palsy; dx mri
Upright supine position

10. impaired perception of complex sounds
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
Lesion in nondominant temporal lobe
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acetylecholinersterase inhibitors

11. How to differentiate parkinson and benign essential tremor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

12. labyrinthitis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Verapamil
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

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

14. earliest sign of phenytoin toxicity
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
Nystagmus on far lateral gaze
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

15. phenytoin and OCP
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
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
Cerebellar lesion

16. What percent of dementia is reversible
Clonidine will take care both high bp and withdrawal
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%
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

17. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Obturator n lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Femoral n lesion

18. 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
Construction apraxia; lesion in non dominant parietal lobe (right)
Obturator n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

19. lesion in dominant tempora lobe
Femoral n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Vitamin B12 deficiency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

20. dementia plus urinary incontinence
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
90% of right handed and 60% of left handed persons; speech and language function
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus

21. Why V12 deficient develop hypokalemia after tx with b12
Entacapone - COMT inhibitor
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
<20; if patient scores >25 benign forgetfulness

22. at first tingling in toes and feet then weakness in extremities
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
Despite the term neuroma they arise from schwann cells - schwanoma
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

23. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Not within 24 hours; give afte 24-48 hours if patient stable
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

24. MG
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acetylecholinersterase inhibitors
Normal pressure hydrocephalus
Botulism has descending paralysis in contrast othere have ascending paralysis

25. benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Propranolol or primidone

26. lesion in dominant parietal lobe
Difficulty in writing - calculating - distinguishing left and write
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Obturator n lesion

27. When to suspect traumatic LP
RBC count >6000
Vitamin B12 deficiency
Normal pressure hydrocephalus
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

28. differentiate wenicke and korsakoff
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
Construction apraxia; lesion in non dominant parietal lobe (right)
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

29. oligoclonal band in CSF
Diabetes insipidus
MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

30. How to differentiate traumatic LP and 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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acetylecholinersterase inhibitors
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;

31. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Despite the term neuroma they arise from schwann cells - schwanoma
High dose IV methyleprednisone;

32. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Tunnel vision - diaphoresis - nausea - pallor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion
Acetylecholinersterase inhibitors

33. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

34. best diagnosis for parkinsonim
Autospy gold standard
Diabetes insipidus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

35. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Deficit in cranial nerve function

36. craniopharyngioma
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Diabetes insipidus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

37. How to prevent prevent frequency of MS exacerbation
Reduced efficacy of OCP
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
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

38. impaired vibration and increased DTR
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Vitamin B12 deficiency
<20; if patient scores >25 benign forgetfulness

39. How to tx lewy body dementia
Aspirin - control HTN and swallow eval before giving any oral meds
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Normal pressure hydrocephalus
Cholinesterase inhibitor; and antiparkinsonism drugs

40. prodrome of vasovagal syncope
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
Despite the term neuroma they arise from schwann cells - schwanoma
Construction apraxia; lesion in non dominant parietal lobe (right)

41. excessive elevation of legs during walking (toe touch floor earlier than heels)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Distal lower motor neuron disease
Vitamin B12 deficiency

42. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor
Gilberts disease
Obturator n lesion

43. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Upright supine position
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds

44. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Spastic paraparesis
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
Corticosteroid and acyclovir

45. What is can be used cluster headache prevention
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Verapamil
Cerebral palsy; dx mri
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

46. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia
Gilberts disease

47. contraindication of sumatripta
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
Obturator n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Coronary artery disease

48. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cerebellar lesion
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

49. Patient with carbamazepine; What should be advice?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Coronary artery disease
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
Verapamil

50. infections in GBS
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor
Femoral n lesion
Diabetes insipidus