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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. When headache is presenting complaint of brain tumor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
It patient has electrolyte imbalance and hypothermia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Get up from chair walk a short distance turn around and sit; screening test for fall

2. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Wernicke's encephalopathy; due to thiamine definition; medical emergency
MS

3. medial thigh sensory loss and weakness in addcution
Normal pressure hydrocephalus
Obturator n lesion
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor

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

5. indication of plasmapheresis in GBS
Difficulty in writing - calculating - distinguishing left and write
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Propranolol or primidone

6. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Obturator n lesion
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

7. contraindication of sumatripta
Coronary artery disease
Difficulty in writing - calculating - distinguishing left and write
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion

8. How to confirm braindeath?
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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.
Clonidine will take care both high bp and withdrawal
Not within 24 hours; give afte 24-48 hours if patient stable

9. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
90% of right handed and 60% of left handed persons; speech and language function

10. what drug is used to extend effects of levodopa
Spastic paraparesis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Entacapone - COMT inhibitor

11. How to differentiate medial and lateral pontine syndrome
Upright supine position
Propranolol or primidone
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

12. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Lesion in nondominant temporal lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
Obturator n lesion
Cerebellar lesion

13. acoustic neuroma
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Despite the term neuroma they arise from schwann cells - schwanoma
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
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;

14. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Lesion in nondominant temporal lobe
MS
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

15. earliest sign of phenytoin toxicity
Deficit in cranial nerve function
Difficulty in writing - calculating - distinguishing left and write
Nystagmus on far lateral gaze
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

16. GBS
IVIG and plasmapheresis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Verapamil
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

17. How to stop antiepileptic drugs
Deficit in cranial nerve function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Taper gradually to prevent seizure relapse
Not within 24 hours; give afte 24-48 hours if patient stable

18. 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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Deficit in cranial nerve function
IVIG and plasmapheresis

19. lesion in dominant tempora lobe
Autospy gold standard
MS
Entacapone - COMT inhibitor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

20. dementia plus urinary incontinence
Coronary artery disease
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Normal pressure hydrocephalus

21. How to manage stroke patient came within 4 hours
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
82% specific for dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

22. 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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Despite the term neuroma they arise from schwann cells - schwanoma
Spastic paraparesis

23. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Despite the term neuroma they arise from schwann cells - schwanoma
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
Upright supine position

24. infections in GBS
EPV - campylobacter - HSV
Antitoxin
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

25. oligoclonal band in CSF
Cerebral palsy; dx mri
MS
EPV - campylobacter - HSV
Reduced efficacy of OCP

26. cluster headache
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

27. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
High dose IV methyleprednisone;
IVIG and plasmapheresis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

28. brain stem lesion
Lesion in nondominant temporal lobe
Get up from chair walk a short distance turn around and sit; screening test for fall
Deficit in cranial nerve function
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. at first tingling in toes and feet then weakness in extremities
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Gilberts disease
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

30. 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
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc
Not within 24 hours; give afte 24-48 hours if patient stable

31. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Antitoxin

32. prodrome of vasovagal syncope
Taper gradually to prevent seizure relapse
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
Tunnel vision - diaphoresis - nausea - pallor

33. Why V12 deficient develop hypokalemia after tx with b12
Aspirin - control HTN and swallow eval before giving any oral meds
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in writing - calculating - distinguishing left and write

34. How to tx lewy body dementia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

35. 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
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
Normal pressure hydrocephalus
Verapamil

36. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
High dose IV methyleprednisone;
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

37. What percent of dementia is reversible
Femoral n lesion
20%
<20; if patient scores >25 benign forgetfulness
IVIG and plasmapheresis

38. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Diabetes insipidus

39. When to suspect traumatic LP
Deficit in cranial nerve function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
RBC count >6000
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

40. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Diabetes insipidus
Clonidine will take care both high bp and withdrawal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Autospy gold standard

41. How to differentiate medial and lateral medullary syndrome
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
Autospy gold standard
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;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

42. impaired vibration and increased DTR
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Acetylecholinersterase inhibitors

43. MG
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;
Acetylecholinersterase inhibitors
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

44. differentiate picks and huntington
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Distal lower motor neuron disease
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
20%

45. phenytoin and OCP
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
Acetylecholinersterase inhibitors
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Reduced efficacy of OCP

46. get up and go test
82% specific for dementia
Get up from chair walk a short distance turn around and sit; screening test for fall
MS
Entacapone - COMT inhibitor

47. What is can be used cluster headache prevention
Verapamil
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebral palsy; dx mri
Spastic paraparesis

48. How to differentiate parkinson and benign essential tremor
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
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
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.
Cerebellar lesion

49. Blood transfusion in hypothermia
Acetylecholinersterase inhibitors
Deficit in cranial nerve function
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

50. differentiate wenicke and korsakoff
MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA