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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. contraindication of sumatripta
Taper gradually to prevent seizure relapse
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Coronary artery disease

2. benign essential tremor
Propranolol or primidone
Aspirin - control HTN and swallow eval before giving any oral meds
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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

3. korsafoff psychosis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

4. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MS
Cerebellar lesion
Cerebral palsy; dx mri

5. double vision at the end of day and ptosis
Construction apraxia; lesion in non dominant parietal lobe (right)
Autospy gold standard
Lesion in nondominant temporal lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;

6. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Wernicke's encephalopathy; due to thiamine definition; medical emergency

7. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Aspirin - control HTN and swallow eval before giving any oral meds
Cerebellar lesion
Nystagmus on far lateral gaze
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

8. Why V12 deficient develop hypokalemia after tx with b12
<20; if patient scores >25 benign forgetfulness
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Clonidine will take care both high bp and withdrawal
MS

9. stroke with lower facial palsy - pronator drift despite on aspirin
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor

10. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
<20; if patient scores >25 benign forgetfulness
Upright supine position
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
IVIG and plasmapheresis

11. When to use brain spect scintigraphy to confirm brain death
Gilberts disease
Acetylecholinersterase inhibitors
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
It patient has electrolyte imbalance and hypothermia

12. Unable to copy of matchstick - unable to dress up
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Coronary artery disease
Construction apraxia; lesion in non dominant parietal lobe (right)

13. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
RBC count >6000
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;

14. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Deficit in cranial nerve function
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

15. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Antitoxin

16. differentiate picks and huntington
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
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
EPV - campylobacter - HSV

17. infections in GBS
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;
EPV - campylobacter - HSV
Difficulty in writing - calculating - distinguishing left and write
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

18. Should we tx htn in acute ischemic stroke

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19. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
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.
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

20. botulism
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
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
Antitoxin
EPV - campylobacter - HSV

21. dementia plus urinary incontinence
EPV - campylobacter - HSV
Normal pressure hydrocephalus
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

22. How to perform apnea test
Despite the term neuroma they arise from schwann cells - schwanoma
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

23. How to differentiate medial and lateral medullary syndrome
Normal pressure hydrocephalus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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;

24. What percent of dementia is reversible
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
20%
Gilberts disease

25. What mmse score suggest dementia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
<20; if patient scores >25 benign forgetfulness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

26. impaired hepatic conjugation of billirubin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
It patient has electrolyte imbalance and hypothermia
Spastic paraparesis

27. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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 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.
Aspirin - control HTN and swallow eval before giving any oral meds

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

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29. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
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

30. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Verapamil
Cerebral palsy; dx mri
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

31. How to confirm braindeath?
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
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.
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
Diabetes insipidus

32. What is can be used cluster headache prevention
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Verapamil
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS

33. impaired perception of complex sounds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in writing - calculating - distinguishing left and write
Lesion in nondominant temporal lobe
Not within 24 hours; give afte 24-48 hours if patient stable

34. medial thigh sensory loss and weakness in addcution
Follows viral illness; vertigo - tinnitus - nausea. self limiting
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)

35. Tx of GBS
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

36. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Propranolol or primidone
RBC count >6000

37. get up and go test
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Upright supine position
Get up from chair walk a short distance turn around and sit; screening test for fall
Vitamin B12 deficiency

38. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia
Not within 24 hours; give afte 24-48 hours if patient stable

39. When headache is presenting complaint of brain tumor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Vitamin B12 deficiency
Tunnel vision - diaphoresis - nausea - pallor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

40. 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
High dose IV methyleprednisone;
Nystagmus on far lateral gaze
Coronary artery disease

41. How to prevent prevent frequency of MS exacerbation
Myasthenia; due to autoantibodies against acetylecholine receptor;
Botulism has descending paralysis in contrast othere have ascending paralysis
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.
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

42. best diagnosis for parkinsonim
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil
Autospy gold standard
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

43. phenytoin and OCP
Entacapone - COMT inhibitor
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Deficit in cranial nerve function
Reduced efficacy of OCP

44. How to differentiate medial and lateral pontine syndrome
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
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

45. How to tx lewy body dementia
Femoral n lesion
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cholinesterase inhibitor; and antiparkinsonism drugs

46. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
82% specific for dementia
Entacapone - COMT inhibitor
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

47. acoustic neuroma
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Despite the term neuroma they arise from schwann cells - schwanoma
Taper gradually to prevent seizure relapse

48. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Aspirin - control HTN and swallow eval before giving any oral meds
MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Acetylecholinersterase inhibitors

49. labyrinthitis
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis
Follows viral illness; vertigo - tinnitus - nausea. self limiting

50. 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
Construction apraxia; lesion in non dominant parietal lobe (right)
Deficit in cranial nerve function
Clonidine will take care both high bp and withdrawal