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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. Acute onset of left arm weakness
Cerebral palsy; dx mri
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

2. dementia plus urinary incontinence
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Normal pressure hydrocephalus
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

3. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Myasthenia; due to autoantibodies against acetylecholine receptor;
Deficit in cranial nerve function
Acetylecholinersterase inhibitors

4. How to differentiate medial and lateral pontine syndrome
Get up from chair walk a short distance turn around and sit; screening test for fall
Nystagmus on far lateral gaze
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
Aspirin - control HTN and swallow eval before giving any oral meds

5. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc
Reduced efficacy of OCP
Nystagmus on far lateral gaze

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

7. craniopharyngioma
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
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Diabetes insipidus

8. botulism
Antitoxin
Cerebral palsy; dx mri
Corticosteroid and acyclovir
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

9. 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
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
Cerebral palsy; dx mri
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

10. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Coronary artery disease
MS

11. Should we tx htn in acute ischemic stroke

12. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Cerebellar lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Taper gradually to prevent seizure relapse

13. indication of plasmapheresis in GBS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebral palsy; dx mri
Normal pressure hydrocephalus

14. impaired perception of complex sounds
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Lesion in nondominant temporal lobe
Wernicke's encephalopathy; due to thiamine definition; medical emergency

15. How to differentiate parkinson and benign essential tremor
Tunnel vision - diaphoresis - nausea - pallor
IVIG and plasmapheresis
MS
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

16. lesion in dominant tempora 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
EPV - campylobacter - HSV
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

17. MMSE score of less than 24
20%
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
82% specific for dementia
Difficulty in writing - calculating - distinguishing left and write

18. MG
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Deficit in cranial nerve function
IVIG and plasmapheresis
Acetylecholinersterase inhibitors

19. When to suspect traumatic LP
Deficit in cranial nerve function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
RBC count >6000
Entacapone - COMT inhibitor

20. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Distal lower motor neuron disease
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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Lesion in nondominant temporal lobe

21. When to use brain spect scintigraphy to confirm brain death
Acetylecholinersterase inhibitors
90% of right handed and 60% of left handed persons; speech and language function
It patient has electrolyte imbalance and hypothermia
Diabetes insipidus

22. How to differentiate dementias
Upright supine position
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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.

23. oligoclonal band in CSF
Not within 24 hours; give afte 24-48 hours if patient stable
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
MS

24. How to differentiate medial and lateral medullary syndrome
Obturator n lesion
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
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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

25. earliest sign of phenytoin toxicity
Propranolol or primidone
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
Nystagmus on far lateral gaze

26. What bp med to be given in a patient with high bp and signs of opioid withdrawal
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spastic paraparesis
Clonidine will take care both high bp and withdrawal

27. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
MS
Cerebral palsy; dx mri
Not within 24 hours; give afte 24-48 hours if patient stable
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

28. phenytoin and OCP
Reduced efficacy of OCP
Gilberts disease
82% specific for dementia
Femoral n lesion

29. double vision at the end of day and ptosis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Antitoxin

30. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Construction apraxia; lesion in non dominant parietal lobe (right)
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
90% of right handed and 60% of left handed persons; speech and language function
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

31. anerior and anteriomedial thigh paresthesia - decreased DTR
Reduced efficacy of OCP
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion
Deficit in cranial nerve function

32. differentiate lewy body dementia and vascular dementia
Antitoxin
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
Acetylecholinersterase inhibitors
Upright supine position

33. impaired vibration and increased DTR
Spastic paraparesis
Vitamin B12 deficiency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Distal lower motor neuron disease

34. cortical lesion
IVIG and plasmapheresis
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Aphasia - neglect - agnosia - acalculia etc

35. prodrome of vasovagal syncope
RBC count >6000
EPV - campylobacter - HSV
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Tunnel vision - diaphoresis - nausea - pallor

36. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
High dose IV methyleprednisone;
Verapamil
Spastic paraparesis
Obturator n lesion

37. When headache is presenting complaint of brain tumor
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

38. Patient with carbamazepine; What should be advice?
Verapamil
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
Corticosteroid and acyclovir
MS

39. infections in GBS
Myasthenia; due to autoantibodies against acetylecholine receptor;
EPV - campylobacter - HSV
Nystagmus on far lateral gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

40. contraindication of sumatripta
Difficulty in writing - calculating - distinguishing left and write
Gilberts disease
Coronary artery disease
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

41. How to differentiate traumatic LP and SAH
Diabetes insipidus
RBC count >6000
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor

42. acoustic neuroma
Construction apraxia; lesion in non dominant parietal lobe (right)
Normal pressure hydrocephalus
Autospy gold standard
Despite the term neuroma they arise from schwann cells - schwanoma

43. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Construction apraxia; lesion in non dominant parietal lobe (right)
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

44. korsafoff psychosis
Tunnel vision - diaphoresis - nausea - pallor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Cerebral palsy; dx mri
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

45. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Get up from chair walk a short distance turn around and sit; screening test for fall
Gilberts disease

46. labyrinthitis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
IVIG and plasmapheresis
Construction apraxia; lesion in non dominant parietal lobe (right)

47. cluster headache
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
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
It patient has electrolyte imbalance and hypothermia

48. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Clonidine will take care both high bp and withdrawal

49. brain stem lesion
Acetylecholinersterase inhibitors
Cerebral palsy; dx mri
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Deficit in cranial nerve function

50. Tx of bells palsy
Corticosteroid and acyclovir
Myasthenia; due to autoantibodies against acetylecholine receptor;
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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