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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 diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Cerebral palsy; dx mri
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

2. impaired perception of complex sounds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Lesion in nondominant temporal lobe
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

3. Unable to copy of matchstick - unable to dress up
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Construction apraxia; lesion in non dominant parietal lobe (right)
High dose IV methyleprednisone;

4. differentiate picks and huntington
Spastic paraparesis
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
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
Despite the term neuroma they arise from schwann cells - schwanoma

5. GBS
Cerebral palsy; dx mri
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
IVIG and plasmapheresis

6. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

7. Blood transfusion in hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
EPV - campylobacter - HSV
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

8. When to use brain spect scintigraphy to confirm brain death
Gilberts disease
Deficit in cranial nerve function
It patient has electrolyte imbalance and hypothermia
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

9. benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Botulism has descending paralysis in contrast othere have ascending paralysis
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

10. How to differentiate botulism from tick born paralysis - GBS and MG
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds
Gilberts disease
Botulism has descending paralysis in contrast othere have ascending paralysis

11. What percent of dementia is reversible
Clonidine will take care both high bp and withdrawal
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
20%

12. at first tingling in toes and feet then weakness in extremities
Antitoxin
Myasthenia; due to autoantibodies against acetylecholine receptor;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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

13. contraindication of sumatripta
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebellar lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease

14. 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
Not within 24 hours; give afte 24-48 hours if patient stable
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

15. brain stem lesion
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Clonidine will take care both high bp and withdrawal
Corticosteroid and acyclovir
Deficit in cranial nerve function

16. How to differentiate dementias
EPV - campylobacter - HSV
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
82% specific for dementia

17. impaired vibration and increased DTR
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

18. How to manage stroke patient came within 4 hours
EPV - campylobacter - HSV
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

19. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS
Normal pressure hydrocephalus

20. 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
Distal lower motor neuron disease
90% of right handed and 60% of left handed persons; speech and language function
Aspirin - control HTN and swallow eval before giving any oral meds

21. When to suspect traumatic LP
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;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Despite the term neuroma they arise from schwann cells - schwanoma
RBC count >6000

22. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
<20; if patient scores >25 benign forgetfulness
20%
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;

23. lesion in dominant parietal lobe
Coronary artery disease
Get up from chair walk a short distance turn around and sit; screening test for fall
Difficulty in writing - calculating - distinguishing left and write
MS

24. indication of plasmapheresis in GBS
Taper gradually to prevent seizure relapse
Propranolol or primidone
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe

25. When to start fibrinolytic therapy in stroke patient?
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Nystagmus on far lateral gaze
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;

26. impaired hepatic conjugation of billirubin
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Normal pressure hydrocephalus
Gilberts disease
Cerebellar lesion

27. How to stop antiepileptic drugs
<20; if patient scores >25 benign forgetfulness
Distal lower motor neuron disease
Taper gradually to prevent seizure relapse
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.

28. MG
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Acetylecholinersterase inhibitors
Normal pressure hydrocephalus
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

29. When headache is presenting complaint of brain tumor
Aphasia - neglect - agnosia - acalculia etc
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Antitoxin

30. cluster headache
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Diabetes insipidus
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
Aphasia - neglect - agnosia - acalculia etc

31. acoustic neuroma
Nystagmus on far lateral gaze
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Despite the term neuroma they arise from schwann cells - schwanoma
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

32. lesion in dominant tempora lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
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.

33. Should we tx htn in acute ischemic stroke

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34. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Corticosteroid and acyclovir
Difficulty in writing - calculating - distinguishing left and write
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

35. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Despite the term neuroma they arise from schwann cells - schwanoma
Deficit in cranial nerve function

36. How to differentiate medial and lateral medullary syndrome
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;
Aphasia - neglect - agnosia - acalculia etc
Gilberts disease
MS

37. How to tx stroke patient came after 6h
Diabetes insipidus
Aspirin - control HTN and swallow eval before giving any oral meds
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Normal pressure hydrocephalus

38. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
82% specific for dementia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Reduced efficacy of OCP

39. best diagnosis for parkinsonim
Verapamil
82% specific for dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Autospy gold standard

40. Why V12 deficient develop hypokalemia after tx with b12
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

41. korsafoff psychosis
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then 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

42. What is pronator drift
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

43. How to differentiate medial and lateral pontine syndrome
Corticosteroid and acyclovir
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
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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

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

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

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46. When to give aspirin when patient on tPA after stroke
It patient has electrolyte imbalance and hypothermia
Distal lower motor neuron disease
Not within 24 hours; give afte 24-48 hours if patient stable
Acetylecholinersterase inhibitors

47. prodrome of vasovagal syncope
Construction apraxia; lesion in non dominant parietal lobe (right)
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Tunnel vision - diaphoresis - nausea - pallor

48. Acute onset of left arm weakness
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
Cerebral palsy; dx mri
Construction apraxia; lesion in non dominant parietal lobe (right)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

49. differentiate wenicke and korsakoff
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Reduced efficacy of OCP
Nystagmus on far lateral gaze

50. How to confirm braindeath?
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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 understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Myasthenia; due to autoantibodies against acetylecholine receptor;