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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 differentiate dementias
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

2. How to perform apnea test
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;
Nystagmus on far lateral gaze

3. impaired hepatic conjugation of billirubin
Gilberts disease
Corticosteroid and acyclovir
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse

4. How to differentiate parkinson and benign essential tremor
<20; if patient scores >25 benign forgetfulness
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
Antitoxin
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

5. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Autospy gold standard
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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;

6. How to tx stroke patient came after 6h
Obturator n lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Aspirin - control HTN and swallow eval before giving any oral meds

7. MG
Acetylecholinersterase inhibitors
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis
Reduced efficacy of OCP

8. How to differentiate botulism from tick born paralysis - GBS and MG
Coronary artery disease
Botulism has descending paralysis in contrast othere have ascending paralysis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Corticosteroid and acyclovir

9. dementia plus urinary incontinence
Tunnel vision - diaphoresis - nausea - pallor
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Normal pressure hydrocephalus

10. oligoclonal band in CSF
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc
MS

11. How to differentiate medial and lateral pontine syndrome
Tunnel vision - diaphoresis - nausea - pallor
Normal pressure hydrocephalus
Taper gradually to prevent seizure relapse
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. impaired vibration and increased DTR
IVIG and plasmapheresis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Vitamin B12 deficiency

13. brain stem lesion
Deficit in cranial nerve function
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
It patient has electrolyte imbalance and hypothermia

14. earliest sign of phenytoin toxicity
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MS
Nystagmus on far lateral gaze

15. lesion in dominant tempora lobe
Upright supine position
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

16. prodrome of vasovagal syncope
Botulism has descending paralysis in contrast othere have ascending paralysis
Tunnel vision - diaphoresis - nausea - pallor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Verapamil

17. Tx of bells palsy
Corticosteroid and acyclovir
Tunnel vision - diaphoresis - nausea - pallor
It patient has electrolyte imbalance and hypothermia
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

18. How to confirm braindeath?
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.
Not within 24 hours; give afte 24-48 hours if patient stable
Diabetes insipidus
Verapamil

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

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20. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
90% of right handed and 60% of left handed persons; speech and language function
Cerebral palsy; dx mri
Spastic paraparesis

21. What is can be used cluster headache prevention
Verapamil
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Construction apraxia; lesion in non dominant parietal lobe (right)
Entacapone - COMT inhibitor

22. double vision at the end of day and ptosis
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
High dose IV methyleprednisone;
Myasthenia; due to autoantibodies against acetylecholine receptor;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

23. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Lesion in nondominant temporal lobe
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Upright supine position
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Entacapone - COMT inhibitor

25. korsafoff psychosis
Reduced efficacy of OCP
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

26. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
RBC count >6000
20%
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

27. How to differentiate traumatic LP and SAH
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
RBC count >6000
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

28. craniopharyngioma
Diabetes insipidus
Deficit in cranial nerve function
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

29. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

30. best diagnosis for parkinsonim
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Gilberts disease
Autospy gold standard
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

31. differentiate lewy body dementia and vascular dementia
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Aspirin - control HTN and swallow eval before giving any oral meds
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;

32. When to use dopamine agonist pramipexol in parkinson
<20; if patient scores >25 benign forgetfulness
High dose IV methyleprednisone;
Normal pressure hydrocephalus
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

33. What mmse score suggest dementia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Distal lower motor neuron disease
<20; if patient scores >25 benign forgetfulness
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

34. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

35. get up and go test
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Coronary artery disease
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
Get up from chair walk a short distance turn around and sit; screening test for fall

36. cluster headache
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
High dose IV methyleprednisone;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

37. 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
Nystagmus on far lateral gaze
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

38. Acute onset of left arm weakness
Coronary artery disease
Antitoxin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

39. dominant parietal lobe on the left side
Distal lower motor neuron disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Tunnel vision - diaphoresis - nausea - pallor
90% of right handed and 60% of left handed persons; speech and language function

40. at first tingling in toes and feet then weakness in extremities
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;

41. lesion in dominant parietal lobe
Entacapone - COMT inhibitor
Normal pressure hydrocephalus
Difficulty in writing - calculating - distinguishing left and write
Tunnel vision - diaphoresis - nausea - pallor

42. What percent of dementia is reversible
Distal lower motor neuron disease
20%
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
Femoral n lesion

43. Why V12 deficient develop hypokalemia after tx with b12
Distal lower motor neuron disease
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
Vitamin B12 deficiency

44. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Taper gradually to prevent seizure relapse

45. How to tx lewy body dementia
Cerebral palsy; dx mri
Cholinesterase inhibitor; and antiparkinsonism drugs
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

46. impaired perception of complex sounds
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

47. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
<20; if patient scores >25 benign forgetfulness
Cerebellar lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
High dose IV methyleprednisone;

48. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Propranolol or primidone
Corticosteroid and acyclovir
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Despite the term neuroma they arise from schwann cells - schwanoma

49. How to differentiate medial and lateral medullary syndrome
Corticosteroid and acyclovir
Coronary artery disease
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;
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

50. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Distal lower motor neuron disease
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Spastic paraparesis
Gilberts disease