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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 manage stroke patient came within 4 hours
Deficit in cranial nerve function
<20; if patient scores >25 benign forgetfulness
Corticosteroid and acyclovir
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

2. What percent of dementia is reversible
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
20%
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

3. prodrome of vasovagal syncope
Botulism has descending paralysis in contrast othere have ascending paralysis
Reduced efficacy of OCP
Tunnel vision - diaphoresis - nausea - pallor
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

4. oligoclonal band in CSF
Reduced efficacy of OCP
MS
Clonidine will take care both high bp and withdrawal
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

5. When to use brain spect scintigraphy to confirm brain death
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
It patient has electrolyte imbalance and hypothermia
Propranolol or primidone

6. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Cerebellar lesion
Normal pressure hydrocephalus

7. How to prevent prevent frequency of MS exacerbation
Despite the term neuroma they arise from schwann cells - schwanoma
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
20%
Diabetes insipidus

8. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

9. anerior and anteriomedial thigh paresthesia - decreased DTR
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Femoral n lesion
Not within 24 hours; give afte 24-48 hours if patient stable
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. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
It patient has electrolyte imbalance and hypothermia
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

11. medial thigh sensory loss and weakness in addcution
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Obturator n lesion

12. What is pronator drift
It patient has electrolyte imbalance and hypothermia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Nystagmus on far lateral gaze
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. When headache is presenting complaint of brain tumor
Corticosteroid and acyclovir
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;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

14. Tx of bells palsy
Tunnel vision - diaphoresis - nausea - pallor
Corticosteroid and acyclovir
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
Aphasia - neglect - agnosia - acalculia etc

15. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

16. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
82% specific for dementia
Autospy gold standard
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

17. How to differentiate medial and lateral pontine syndrome
Femoral n lesion
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cholinesterase inhibitor; and antiparkinsonism drugs

18. Patient with carbamazepine; What should be advice?
RBC count >6000
Deficit in cranial nerve function
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
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;

19. contraindication of sumatripta
Coronary artery disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
IVIG and plasmapheresis
Spastic paraparesis

20. How to differentiate parkinson and benign essential tremor
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Aspirin - control HTN and swallow eval before giving any oral meds
Botulism has descending paralysis in contrast othere have ascending paralysis

21. infections in GBS
Femoral n lesion
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Autospy gold standard
EPV - campylobacter - HSV

22. How to differentiate traumatic LP and SAH
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Verapamil

23. lesion in dominant parietal lobe
<20; if patient scores >25 benign forgetfulness
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in writing - calculating - distinguishing left and write

24. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acetylecholinersterase inhibitors

25. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Not within 24 hours; give afte 24-48 hours if patient stable
Entacapone - COMT inhibitor
90% of right handed and 60% of left handed persons; speech and language function

26. impaired perception of complex sounds
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

27. phenytoin and OCP
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
MS

28. How to perform apnea test
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Gilberts disease
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
<20; if patient scores >25 benign forgetfulness

29. dominant parietal lobe on the left side
EPV - campylobacter - HSV
90% of right handed and 60% of left handed persons; speech and language function
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Diabetes insipidus

30. When to give aspirin when patient on tPA after stroke
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Not within 24 hours; give afte 24-48 hours if patient stable
RBC count >6000
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

31. differentiate picks and huntington
Gilberts disease
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
IVIG and plasmapheresis

32. best diagnosis for parkinsonim
Autospy gold standard
Distal lower motor neuron disease
Cholinesterase inhibitor; and antiparkinsonism drugs
Construction apraxia; lesion in non dominant parietal lobe (right)

33. differentiate wenicke and korsakoff
Coronary artery disease
Cerebral palsy; dx mri
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
Acetylecholinersterase inhibitors

34. dementia plus urinary incontinence
Gilberts disease
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Normal pressure hydrocephalus

35. MG
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
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
Vitamin B12 deficiency

36. benign essential tremor
Coronary artery 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
Propranolol or primidone
Acetylecholinersterase inhibitors

37. brain stem lesion
Deficit in cranial nerve function
Obturator n lesion
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; if patient scores >25 benign forgetfulness

38. When to suspect traumatic LP
Antitoxin
Aphasia - neglect - agnosia - acalculia etc
RBC count >6000
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

39. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
EPV - campylobacter - HSV
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
82% specific for dementia
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

40. impaired vibration and increased DTR
Vitamin B12 deficiency
20%
Acetylecholinersterase inhibitors
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

41. Tx of GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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.
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

42. lesion in dominant tempora lobe
Autospy gold standard
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

43. cluster headache
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
Reduced efficacy of OCP
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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. double vision at the end of day and ptosis
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.
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Gilberts disease

45. How to tx lewy body dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

46. How to confirm braindeath?
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
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.
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Gilberts disease

47. 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
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
EPV - campylobacter - HSV
Clonidine will take care both high bp and withdrawal

48. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Botulism has descending paralysis in contrast othere have ascending paralysis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

49. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Cholinesterase inhibitor; and antiparkinsonism drugs
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

50. How to stop antiepileptic drugs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Taper gradually to prevent seizure relapse
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA