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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. How to tx stroke patient came after 6h
High dose IV methyleprednisone;
Aspirin - control HTN and swallow eval before giving any oral meds
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

2. How to tx lewy body dementia
Reduced efficacy of OCP
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
IVIG and plasmapheresis
Cholinesterase inhibitor; and antiparkinsonism drugs

3. When to use brain spect scintigraphy to confirm brain death
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
Entacapone - COMT inhibitor

4. Patient with carbamazepine; What should be advice?
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
Despite the term neuroma they arise from schwann cells - schwanoma
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

5. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

6. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive 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
82% specific for dementia
Cerebral palsy; dx mri

7. women with unilateral eye pain; neurlogic symptoms here there at different times
Normal pressure hydrocephalus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Coronary artery disease

8. earliest sign of phenytoin toxicity
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
MS
Nystagmus on far lateral gaze

9. differentiate wenicke and korsakoff
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
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
Acetylecholinersterase inhibitors

10. excessive elevation of legs during walking (toe touch floor earlier than heels)
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Antitoxin
Distal lower motor neuron disease
Get up from chair walk a short distance turn around and sit; screening test for fall

11. stroke with lower facial palsy - pronator drift despite on aspirin
Gilberts disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Botulism has descending paralysis in contrast othere have ascending paralysis
Wernicke's encephalopathy; due to thiamine definition; medical emergency

12. 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
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;
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

13. How to confirm braindeath?
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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.
Aphasia - neglect - agnosia - acalculia etc
Lesion in nondominant temporal lobe

14. How to stop antiepileptic drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Not within 24 hours; give afte 24-48 hours if patient stable

15. lesion in dominant tempora lobe
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Get up from chair walk a short distance turn around and sit; screening test for fall
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

16. dementia plus urinary incontinence
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Normal pressure hydrocephalus
90% of right handed and 60% of left handed persons; speech and language function
<20; if patient scores >25 benign forgetfulness

17. MMSE score of less than 24
Gilberts disease
82% specific for dementia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
RBC count >6000

18. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Diabetes insipidus
Cerebellar lesion

19. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
IVIG and plasmapheresis
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

20. How to differentiate botulism from tick born paralysis - GBS and MG
Corticosteroid and acyclovir
Botulism has descending paralysis in contrast othere have ascending paralysis
Antitoxin
Despite the term neuroma they arise from schwann cells - schwanoma

21. indication of plasmapheresis in GBS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Femoral n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Vitamin B12 deficiency

22. impaired vibration and increased DTR
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Taper gradually to prevent seizure relapse
Vitamin B12 deficiency

23. impaired hepatic conjugation of billirubin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Clonidine will take care both high bp and withdrawal
Gilberts disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

24. best diagnosis for parkinsonim
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Autospy gold standard
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Nystagmus on far lateral gaze

25. differentiate picks and huntington
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Not within 24 hours; give afte 24-48 hours if patient stable
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

26. How to differentiate parkinson and benign essential tremor
Construction apraxia; lesion in non dominant parietal lobe (right)
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
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

27. double vision at the end of day and ptosis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Myasthenia; due to autoantibodies against acetylecholine receptor;

28. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Lesion in nondominant temporal lobe

29. What bp med to be given in a patient with high bp and signs of opioid withdrawal
20%
RBC count >6000
Clonidine will take care both high bp and withdrawal
Corticosteroid and acyclovir

30. medial thigh sensory loss and weakness in addcution
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;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebellar lesion
Obturator n lesion

31. cluster headache
Lesion in nondominant temporal lobe
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

32. Tx of bells palsy
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir
Lesion in nondominant temporal lobe

33. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Propranolol or primidone
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

34. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
RBC count >6000
Spastic paraparesis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

35. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
20%

36. How to differentiate medial and lateral medullary syndrome
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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;

37. Blood transfusion in hypothermia
Coronary artery disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Aspirin - control HTN and swallow eval before giving any oral meds
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

38. Should we tx htn in acute ischemic stroke

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39. phenytoin and OCP
Aspirin - control HTN and swallow eval before giving any oral meds
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
Reduced efficacy of OCP
MS

40. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Upright supine position
Cerebellar lesion
Construction apraxia; lesion in non dominant parietal lobe (right)

41. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spastic paraparesis
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

42. Acute onset of left arm weakness
Taper gradually to prevent seizure relapse
<20; if patient scores >25 benign forgetfulness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

43. When to use dopamine agonist pramipexol in parkinson
EPV - campylobacter - HSV
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Taper gradually to prevent seizure relapse

44. MG
Obturator n lesion
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
Acetylecholinersterase inhibitors
Cholinesterase inhibitor; and antiparkinsonism drugs

45. What mmse score suggest dementia
Spastic paraparesis
90% of right handed and 60% of left handed persons; speech and language function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness

46. How to perform apnea test
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
EPV - campylobacter - HSV

47. impaired perception of complex sounds
Verapamil
Corticosteroid and acyclovir
Lesion in nondominant temporal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

48. prodrome of vasovagal syncope
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Tunnel vision - diaphoresis - nausea - pallor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

49. What is can be used cluster headache prevention
MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Verapamil
Entacapone - COMT inhibitor

50. When to suspect traumatic LP
Autospy gold standard
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
RBC count >6000
Coronary artery disease