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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 medial and lateral medullary syndrome
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Botulism has descending paralysis in contrast othere have ascending paralysis
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;

2. anerior and anteriomedial thigh paresthesia - decreased DTR
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Clonidine will take care both high bp and withdrawal
Femoral n lesion

3. stroke with lower facial palsy - pronator drift despite on aspirin
Entacapone - COMT inhibitor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
RBC count >6000
82% specific for dementia

4. When headache is presenting complaint of brain tumor
Obturator n lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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

5. What is pronator drift
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
High dose IV methyleprednisone;
Cerebellar lesion
Entacapone - COMT inhibitor

6. What is can be used cluster headache prevention
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Construction apraxia; lesion in non dominant parietal lobe (right)
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Verapamil

7. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Autospy gold standard
Verapamil

8. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

9. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Corticosteroid and acyclovir
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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;
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

10. excessive elevation of legs during walking (toe touch floor earlier than heels)
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Distal lower motor neuron disease

11. Tx of GBS
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.
Corticosteroid and acyclovir
Nystagmus on far lateral gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

12. How to manage stroke patient came within 4 hours
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Follows viral illness; vertigo - tinnitus - nausea. self limiting
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Femoral n lesion

13. When to give aspirin when patient on tPA after stroke
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Lesion in nondominant temporal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Normal pressure hydrocephalus

14. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Coronary artery disease
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

15. differentiate lewy body dementia and vascular dementia
Obturator n lesion
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
Distal lower motor neuron disease
Gilberts disease

16. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Botulism has descending paralysis in contrast othere have ascending paralysis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc

17. What mmse score suggest dementia
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;
RBC count >6000
<20; if patient scores >25 benign forgetfulness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

18. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Corticosteroid and acyclovir
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acetylecholinersterase inhibitors

19. impaired hepatic conjugation of billirubin
90% of right handed and 60% of left handed persons; speech and language function
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.
Gilberts disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

20. brain stem lesion
Deficit in cranial nerve function
RBC count >6000
High dose IV methyleprednisone;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

21. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
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
Autospy gold standard

22. dementia plus urinary incontinence
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
IVIG and plasmapheresis
Get up from chair walk a short distance turn around and sit; screening test for fall
Normal pressure hydrocephalus

23. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
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.
<20; if patient scores >25 benign forgetfulness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

24. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor
Wernicke's encephalopathy; due to thiamine definition; medical emergency

25. How to differentiate botulism from tick born paralysis - GBS and MG
90% of right handed and 60% of left handed persons; speech and language function
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Botulism has descending paralysis in contrast othere have ascending paralysis

26. How to differentiate traumatic LP and SAH
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cholinesterase inhibitor; and antiparkinsonism drugs

27. Why V12 deficient develop hypokalemia after tx with b12
Lesion in nondominant temporal lobe
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Taper gradually to prevent seizure relapse
Acetylecholinersterase inhibitors

28. contraindication of sumatripta
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
Acetylecholinersterase inhibitors
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Coronary artery disease

29. double vision at the end of day and ptosis
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Myasthenia; due to autoantibodies against acetylecholine receptor;

30. korsafoff psychosis
Cholinesterase inhibitor; and antiparkinsonism drugs
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
Coronary artery disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

31. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Cerebral palsy; dx mri
Obturator n lesion
Not within 24 hours; give afte 24-48 hours if patient stable

32. best diagnosis for parkinsonim
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Autospy gold standard

33. oligoclonal band in CSF
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Coronary artery disease
MS
Despite the term neuroma they arise from schwann cells - schwanoma

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

35. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Femoral n lesion
Propranolol or primidone
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall

36. dominant parietal lobe on the left side
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
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
It patient has electrolyte imbalance and hypothermia
90% of right handed and 60% of left handed persons; speech and language function

37. MMSE score of less than 24
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
20%
82% specific for dementia
Cerebral palsy; dx mri

38. How to perform apnea test
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Clonidine will take care both high bp and withdrawal
Vitamin B12 deficiency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

39. How to tx acute exacerbation of MS
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;
High dose IV methyleprednisone;
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.
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. infections in GBS
EPV - campylobacter - HSV
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;
Verapamil
Autospy gold standard

41. labyrinthitis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
20%
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aspirin - control HTN and swallow eval before giving any oral meds

42. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebral palsy; dx mri
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
IVIG and plasmapheresis

43. differentiate picks and huntington
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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

44. lesion in dominant parietal lobe
Clonidine will take care both high bp and withdrawal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Difficulty in writing - calculating - distinguishing left and write
Upright supine position

45. differentiate wenicke and korsakoff
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS
Gilberts 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

46. cluster headache
Diabetes insipidus
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
EPV - campylobacter - HSV

47. MG
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acetylecholinersterase inhibitors
RBC count >6000
Coronary artery disease

48. botulism
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Antitoxin
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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

49. How to differentiate parkinson and benign essential tremor
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
Diabetes insipidus
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

50. phenytoin and OCP
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Get up from chair walk a short distance turn around and sit; screening test for fall
Entacapone - COMT inhibitor
Reduced efficacy of OCP