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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. oligoclonal band in CSF
Not within 24 hours; give afte 24-48 hours if patient stable
MS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cerebral palsy; dx mri

2. When headache is presenting complaint of brain tumor
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard
Propranolol or primidone

3. impaired hepatic conjugation of billirubin
Gilberts disease
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebral palsy; dx mri
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

4. cluster headache
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
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
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

5. earliest sign of phenytoin toxicity
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in writing - calculating - distinguishing left and write
Nystagmus on far lateral gaze

6. How to tx lewy body dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

7. What percent of dementia is reversible
Botulism has descending paralysis in contrast othere have ascending paralysis
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors
20%

8. contraindication of sumatripta
Cholinesterase inhibitor; and antiparkinsonism drugs
It patient has electrolyte imbalance and hypothermia
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.
Coronary artery disease

9. at first tingling in toes and feet then weakness in extremities
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

10. benign essential tremor
Botulism has descending paralysis in contrast othere have ascending paralysis
82% specific for dementia
Propranolol or primidone
Antitoxin

11. dementia plus urinary incontinence
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

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

13. prodrome of vasovagal syncope
Corticosteroid and acyclovir
Taper gradually to prevent seizure relapse
Tunnel vision - diaphoresis - nausea - pallor
Acetylecholinersterase inhibitors

14. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
It patient has electrolyte imbalance and hypothermia
Clonidine will take care both high bp and withdrawal
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.

15. How to stop antiepileptic drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Taper gradually to prevent seizure relapse
Reduced efficacy of OCP

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

17. differentiate lewy body dementia and vascular dementia
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Entacapone - COMT inhibitor
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

18. what drug is used to extend effects of levodopa
Difficulty in writing - calculating - distinguishing left and write
Entacapone - COMT inhibitor
Cerebral palsy; dx mri
Normal pressure hydrocephalus

19. impaired vibration and increased DTR
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
20%
Vitamin B12 deficiency
Propranolol or primidone

20. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
It patient has electrolyte imbalance and hypothermia
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

21. 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.
Difficulty in writing - calculating - distinguishing left and write
Aspirin - control HTN and swallow eval before giving any oral meds

22. Tx of GBS
IVIG and plasmapheresis
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

23. How to differentiate botulism from tick born paralysis - GBS and MG
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Botulism has descending paralysis in contrast othere have ascending paralysis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

24. medial thigh sensory loss and weakness in addcution
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
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Obturator n lesion

25. When to use brain spect scintigraphy to confirm brain death
Clonidine will take care both high bp and withdrawal
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
It patient has electrolyte imbalance and hypothermia
Construction apraxia; lesion in non dominant parietal lobe (right)

26. Tx of bells palsy
Corticosteroid and acyclovir
Lesion in nondominant temporal lobe
Difficulty in writing - calculating - distinguishing left and write
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

27. How to tx acute exacerbation of MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
High dose IV methyleprednisone;
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

28. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

29. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Coronary artery disease
Nystagmus on far lateral gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spastic paraparesis

30. lesion in dominant parietal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position
Aphasia - neglect - agnosia - acalculia etc
Difficulty in writing - calculating - distinguishing left and write

31. acoustic neuroma
Myasthenia; due to autoantibodies against acetylecholine receptor;
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Femoral n lesion

32. dominant parietal lobe on the left side
Normal pressure hydrocephalus
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Deficit in cranial nerve function
90% of right handed and 60% of left handed persons; speech and language function

33. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Myasthenia; due to autoantibodies against acetylecholine receptor;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Antitoxin

34. lesion in dominant tempora lobe
EPV - campylobacter - HSV
Difficulty in writing - calculating - distinguishing left and write
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Upright supine position

35. Why V12 deficient develop hypokalemia after tx with b12
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

36. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spastic paraparesis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
EPV - campylobacter - HSV

37. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Cholinesterase inhibitor; and antiparkinsonism drugs
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Aphasia - neglect - agnosia - acalculia etc

38. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
It patient has electrolyte imbalance and hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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.
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

39. Unable to copy of matchstick - unable to dress up
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Construction apraxia; lesion in non dominant parietal lobe (right)
Coronary artery 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

40. When to suspect traumatic LP
Myasthenia; due to autoantibodies against acetylecholine receptor;
Corticosteroid and acyclovir
RBC count >6000
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

41. What is pronator drift
90% of right handed and 60% of left handed persons; speech and language function
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
Aspirin - control HTN and swallow eval before giving any oral meds
Aphasia - neglect - agnosia - acalculia etc

42. infections in GBS
Myasthenia; due to autoantibodies against acetylecholine receptor;
EPV - campylobacter - HSV
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

43. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
IVIG and plasmapheresis
Verapamil
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

44. What is can be used cluster headache prevention
RBC count >6000
Tunnel vision - diaphoresis - nausea - pallor
Coronary artery disease
Verapamil

45. Should we tx htn in acute ischemic stroke

46. anerior and anteriomedial thigh paresthesia - decreased DTR
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Femoral n lesion
Tunnel vision - diaphoresis - nausea - pallor

47. How to differentiate dementias
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
Get up from chair walk a short distance turn around and sit; screening test for fall
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
RBC count >6000

48. Acute onset of left arm weakness
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Myasthenia; due to autoantibodies against acetylecholine receptor;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Taper gradually to prevent seizure relapse

49. best diagnosis for parkinsonim
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

50. How to perform apnea test
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
Acetylecholinersterase inhibitors
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