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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. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Despite the term neuroma they arise from schwann cells - schwanoma
Antitoxin
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

2. When to start fibrinolytic therapy in stroke patient?
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
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
Diabetes insipidus

3. brain stem lesion
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;
EPV - campylobacter - HSV
Deficit in cranial nerve function
Reduced efficacy of OCP

4. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Normal pressure hydrocephalus
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Reduced efficacy of OCP

5. What percent of dementia is reversible
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
20%
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

6. When to use dopamine agonist pramipexol in parkinson
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Corticosteroid and acyclovir
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Despite the term neuroma they arise from schwann cells - schwanoma

7. When headache is presenting complaint of brain tumor
RBC count >6000
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Botulism has descending paralysis in contrast othere have ascending paralysis

8. How to differentiate dementias
Nystagmus on far lateral gaze
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Distal lower motor neuron disease
Cerebral palsy; dx mri

9. lesion in dominant tempora lobe
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
IVIG and plasmapheresis
Construction apraxia; lesion in non dominant parietal lobe (right)

10. How to differentiate traumatic LP and SAH
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aspirin - control HTN and swallow eval before giving any oral meds
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
90% of right handed and 60% of left handed persons; speech and language function

11. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

12. infections in GBS
Corticosteroid and acyclovir
EPV - campylobacter - HSV
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
20%

13. How to differentiate medial and lateral pontine syndrome
82% specific for dementia
Normal pressure hydrocephalus
Acetylecholinersterase inhibitors
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

14. How to differentiate parkinson and benign essential tremor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

15. How to manage stroke patient came within 4 hours
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Obturator n lesion

16. How to tx acute exacerbation of MS
Nystagmus on far lateral gaze
High dose IV methyleprednisone;
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Deficit in cranial nerve function

17. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
90% of right handed and 60% of left handed persons; speech and language function
Despite the term neuroma they arise from schwann cells - schwanoma
Propranolol or primidone

18. Acute onset of left arm weakness
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.
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Femoral n lesion

19. Blood transfusion in hypothermia
Vitamin B12 deficiency
Corticosteroid and acyclovir
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

20. differentiate wenicke and korsakoff
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
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

21. earliest sign of phenytoin toxicity
Autospy gold standard
Antitoxin
82% specific for dementia
Nystagmus on far lateral gaze

22. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
Upright supine position
Distal lower motor neuron disease

23. MG
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Acetylecholinersterase inhibitors
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease

24. When to give aspirin when patient on tPA after stroke
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
Cerebellar lesion
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

25. Unable to copy of matchstick - unable to dress up
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Get up from chair walk a short distance turn around and sit; screening test for fall
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Construction apraxia; lesion in non dominant parietal lobe (right)

26. impaired hepatic conjugation of billirubin
Entacapone - COMT inhibitor
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Gilberts disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

27. Tx of bells palsy
Corticosteroid and acyclovir
High dose IV methyleprednisone;
It patient has electrolyte imbalance and hypothermia
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. 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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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
Propranolol or primidone

29. impaired vibration and increased DTR
Vitamin B12 deficiency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Get up from chair walk a short distance turn around and sit; screening test for fall
<20; if patient scores >25 benign forgetfulness

30. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Femoral n lesion
Cerebral palsy; dx mri
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;

31. labyrinthitis
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%
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting

32. What is can be used cluster headache prevention
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
Verapamil
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;

33. Tx of GBS
Obturator n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard

34. phenytoin and OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Reduced efficacy of OCP
Obturator n lesion
Upright supine position

35. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Corticosteroid and acyclovir
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
Diabetes insipidus

36. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

37. How to stop antiepileptic drugs
Distal lower motor neuron disease
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
Taper gradually to prevent seizure relapse
Clonidine will take care both high bp and withdrawal

38. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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.
Clonidine will take care both high bp and withdrawal
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

39. MMSE score of less than 24
Upright supine position
Obturator n lesion
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

40. korsafoff psychosis
Spastic paraparesis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

41. oligoclonal band in CSF
MS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Not within 24 hours; give afte 24-48 hours if patient stable
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

42. Patient with carbamazepine; What should be advice?
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
It patient has electrolyte imbalance and hypothermia
Difficulty in writing - calculating - distinguishing left and write

43. How to prevent prevent frequency of MS exacerbation
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spastic paraparesis

44. differentiate lewy body dementia and vascular dementia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Entacapone - COMT inhibitor
Lesion in nondominant temporal lobe

45. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Obturator n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Antitoxin

46. 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
Not within 24 hours; give afte 24-48 hours if patient stable
Autospy gold standard
82% specific for dementia

47. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS
Tunnel vision - diaphoresis - nausea - pallor
Acetylecholinersterase inhibitors

48. Should we tx htn in acute ischemic stroke

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49. What is pronator drift
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
Gilberts disease

50. contraindication of sumatripta
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Coronary artery disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Diabetes insipidus