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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 tx acute exacerbation of MS
RBC count >6000
Distal lower motor neuron disease
Vitamin B12 deficiency
High dose IV methyleprednisone;

2. differentiate lewy body dementia and vascular dementia
Not within 24 hours; give afte 24-48 hours if patient stable
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

3. contraindication of sumatripta
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease
Coronary artery disease
90% of right handed and 60% of left handed persons; speech and language function

4. lesion in dominant tempora lobe
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
20%
It patient has electrolyte imbalance and hypothermia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

5. botulism
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Despite the term neuroma they arise from schwann cells - schwanoma
Antitoxin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

6. What is can be used cluster headache prevention
Verapamil
Construction apraxia; lesion in non dominant parietal lobe (right)
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Wernicke's encephalopathy; due to thiamine definition; medical emergency

7. earliest sign of phenytoin toxicity
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Nystagmus on far lateral gaze

8. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Difficulty in writing - calculating - distinguishing left and write
Diabetes insipidus
Cerebellar lesion

9. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
<20; if patient scores >25 benign forgetfulness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

10. GBS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
IVIG and plasmapheresis
Upright supine position
90% of right handed and 60% of left handed persons; speech and language function

11. What mmse score suggest dementia
Reduced efficacy of OCP
Taper gradually to prevent seizure relapse
<20; if patient scores >25 benign forgetfulness
Wernicke's encephalopathy; due to thiamine definition; medical emergency

12. dementia plus urinary incontinence
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
Normal pressure hydrocephalus
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

13. How to differentiate parkinson and benign essential tremor
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
Antitoxin
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

14. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Lesion in nondominant temporal lobe
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Wernicke's encephalopathy; due to thiamine definition; medical emergency

15. Tx of GBS
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
Vitamin B12 deficiency
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

16. How to differentiate medial and lateral medullary syndrome
Follows viral illness; vertigo - tinnitus - nausea. self limiting
90% of right handed and 60% of left handed persons; speech and language function
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

17. at first tingling in toes and feet then weakness in extremities
Despite the term neuroma they arise from schwann cells - schwanoma
Difficulty in writing - calculating - distinguishing left and write
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Vitamin B12 deficiency

18. Patient with carbamazepine; What should be advice?
Lesion in nondominant temporal lobe
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;

19. What percent of dementia is reversible
It patient has electrolyte imbalance and hypothermia
High dose IV methyleprednisone;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
20%

20. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

21. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Entacapone - COMT inhibitor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Get up from chair walk a short distance turn around and sit; screening test for fall
Clonidine will take care both high bp and withdrawal

22. How to tx stroke patient came after 6h
Cholinesterase inhibitor; and antiparkinsonism drugs
Tunnel vision - diaphoresis - nausea - pallor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Aspirin - control HTN and swallow eval before giving any oral meds

23. benign essential tremor
Propranolol or primidone
Not within 24 hours; give afte 24-48 hours if patient stable
Femoral n lesion
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

24. Should we tx htn in acute ischemic stroke

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25. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Spastic paraparesis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

26. How to differentiate botulism from tick born paralysis - GBS and MG
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
Spastic paraparesis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

27. dominant parietal lobe on the left side
Aphasia - neglect - agnosia - acalculia etc
Taper gradually to prevent seizure relapse
Difficulty in writing - calculating - distinguishing left and write
90% of right handed and 60% of left handed persons; speech and language function

28. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
<20; if patient scores >25 benign forgetfulness
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

29. MG
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Acetylecholinersterase inhibitors
82% specific for dementia
Obturator n lesion

30. How to prevent prevent frequency of MS exacerbation
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Verapamil
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

31. get up and go test
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Get up from chair walk a short distance turn around and sit; screening test for fall

32. How to manage stroke patient came within 4 hours
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

33. How to differentiate traumatic LP and SAH
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

34. stroke with lower facial palsy - pronator drift despite on aspirin
Propranolol or primidone
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

35. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Coronary artery disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Spastic paraparesis

36. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Coronary artery disease
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Botulism has descending paralysis in contrast othere have ascending paralysis

37. 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
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

38. cluster headache
RBC count >6000
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Aspirin - control HTN and swallow eval before giving any oral meds

39. cortical lesion
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.
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Aphasia - neglect - agnosia - acalculia etc
Upright supine position

40. medial thigh sensory loss and weakness in addcution
Cerebral palsy; dx mri
Obturator n lesion
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
Femoral n lesion

41. severe headache and high BP
Tunnel vision - diaphoresis - nausea - pallor
Distal lower motor neuron disease
IVIG and plasmapheresis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

42. When to use brain spect scintigraphy to confirm brain death
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
20%
It patient has electrolyte imbalance and hypothermia

43. korsafoff psychosis
Aphasia - neglect - agnosia - acalculia etc
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; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

44. best diagnosis for parkinsonim
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Autospy gold standard
Tunnel vision - diaphoresis - nausea - pallor
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

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

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46. How to confirm braindeath?
Deficit in cranial nerve function
MS
Upright supine position
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.

47. How to differentiate medial and lateral pontine syndrome
Propranolol or primidone
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
Cerebral palsy; dx mri
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

48. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Entacapone - COMT inhibitor
Not within 24 hours; give afte 24-48 hours if patient stable
IVIG and plasmapheresis

49. craniopharyngioma
82% specific for dementia
Clonidine will take care both high bp and withdrawal
Diabetes insipidus
It patient has electrolyte imbalance and hypothermia

50. How to stop antiepileptic drugs
Upright supine position
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse
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