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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. brain stem lesion
Deficit in cranial nerve function
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Vitamin B12 deficiency
MS

2. What mmse score suggest dementia
Deficit in cranial nerve function
Acetylecholinersterase inhibitors
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
<20; if patient scores >25 benign forgetfulness

3. dementia plus urinary incontinence
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Normal pressure hydrocephalus

4. Acute onset of left arm weakness
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
High dose IV methyleprednisone;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Myasthenia; due to autoantibodies against acetylecholine receptor;

5. How to differentiate dementias
Coronary artery disease
<20; if patient scores >25 benign forgetfulness
Not within 24 hours; give afte 24-48 hours if patient stable
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

6. Tx of bells palsy
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Normal pressure hydrocephalus
Corticosteroid and acyclovir
Aspirin - control HTN and swallow eval before giving any oral meds

7. at first tingling in toes and feet then weakness in extremities
Aphasia - neglect - agnosia - acalculia etc
High dose IV methyleprednisone;
Diabetes insipidus
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

8. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Get up from chair walk a short distance turn around and sit; screening test for fall
Obturator n lesion

9. differentiate picks and huntington
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
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion

10. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Nystagmus on far lateral gaze
Cerebellar lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
High dose IV methyleprednisone;

11. When to use brain spect scintigraphy to confirm brain death
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
It patient has electrolyte imbalance and hypothermia
Not within 24 hours; give afte 24-48 hours if patient stable
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. what drug is used to extend effects of levodopa
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Difficulty in writing - calculating - distinguishing left and write
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor

13. get up and go test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Get up from chair walk a short distance turn around and sit; screening test for fall
Cerebellar lesion
Cholinesterase inhibitor; and antiparkinsonism drugs

14. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Spastic paraparesis
90% of right handed and 60% of left handed persons; speech and language function
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
Upright supine position

15. prodrome of vasovagal syncope
Aphasia - neglect - agnosia - acalculia etc
EPV - campylobacter - HSV
Tunnel vision - diaphoresis - nausea - pallor
Taper gradually to prevent seizure relapse

16. Why V12 deficient develop hypokalemia after tx with b12
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Obturator n lesion

17. korsafoff psychosis
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
RBC count >6000
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

18. anerior and anteriomedial thigh paresthesia - decreased DTR
Lesion in nondominant temporal lobe
Femoral n lesion
Cerebral palsy; dx mri
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

19. When headache is presenting complaint of brain tumor
Entacapone - COMT inhibitor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

20. MMSE score of less than 24
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia
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

21. Unable to copy of matchstick - unable to dress up
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

22. How to differentiate medial and lateral medullary syndrome
Myasthenia; due to autoantibodies against acetylecholine receptor;
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;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

23. impaired vibration and increased DTR
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Vitamin B12 deficiency

24. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

25. severe headache and high BP
Clonidine will take care both high bp and withdrawal
Diabetes insipidus
Cholinesterase inhibitor; and antiparkinsonism drugs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

26. impaired perception of complex sounds
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
Vitamin B12 deficiency
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Lesion in nondominant temporal lobe

27. How to differentiate botulism from tick born paralysis - GBS and MG
Lesion in nondominant temporal lobe
Botulism has descending paralysis in contrast othere have ascending paralysis
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

28. What is can be used cluster headache prevention
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Verapamil

29. impaired hepatic conjugation of billirubin
Cholinesterase inhibitor; and antiparkinsonism drugs
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Gilberts disease
Nystagmus on far lateral gaze

30. How to differentiate medial and lateral pontine syndrome
High dose IV methyleprednisone;
Entacapone - COMT inhibitor
Gilberts disease
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

31. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV
Acetylecholinersterase inhibitors

32. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in writing - calculating - distinguishing left and write
Diabetes insipidus

33. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Cerebellar lesion
Taper gradually to prevent seizure relapse
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

34. benign essential tremor
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Propranolol or primidone
Spastic paraparesis
Clonidine will take care both high bp and withdrawal

35. How to prevent prevent frequency of MS exacerbation
Taper gradually to prevent seizure relapse
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS

36. excessive elevation of legs during walking (toe touch floor earlier than heels)
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Distal lower motor neuron disease
82% specific for dementia

37. Should we tx htn in acute ischemic stroke

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38. How to confirm braindeath?
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor
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.
Deficit in cranial nerve function

39. What percent of dementia is reversible
Antitoxin
20%
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse

40. When to suspect traumatic LP
RBC count >6000
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

41. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Verapamil

42. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Tunnel vision - diaphoresis - nausea - pallor
Entacapone - COMT inhibitor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Vitamin B12 deficiency

43. How to differentiate traumatic LP and SAH
Spastic paraparesis
Aspirin - control HTN and swallow eval before giving any oral meds
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.
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

44. dominant parietal lobe on the left side
Antitoxin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
90% of right handed and 60% of left handed persons; speech and language function
Vitamin B12 deficiency

45. How to differentiate parkinson and benign essential tremor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

46. infections in GBS
IVIG and plasmapheresis
EPV - campylobacter - HSV
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Construction apraxia; lesion in non dominant parietal lobe (right)

47. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Cerebral palsy; dx mri
Entacapone - COMT inhibitor

48. stroke with lower facial palsy - pronator drift despite on aspirin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

49. double vision at the end of day and ptosis
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

50. oligoclonal band in CSF
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
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
MS
Coronary artery disease