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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 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
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
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

2. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Obturator n lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
Upright supine position
20%

3. double vision at the end of day and ptosis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Clonidine will take care both high bp and withdrawal
Myasthenia; due to autoantibodies against acetylecholine receptor;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

4. Acute onset of left arm weakness
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Aphasia - neglect - agnosia - acalculia etc

5. How to tx stroke patient came after 6h
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cerebral palsy; dx mri
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Aspirin - control HTN and swallow eval before giving any oral meds

6. How to differentiate medial and lateral pontine syndrome
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;
It patient has electrolyte imbalance and hypothermia
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
Verapamil

7. best diagnosis for parkinsonim
Autospy gold standard
Deficit in cranial nerve function
Gilberts disease
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.

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

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9. at first tingling in toes and feet then weakness in extremities
Aphasia - neglect - agnosia - acalculia etc
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acetylecholinersterase inhibitors
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

10. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
High dose IV methyleprednisone;
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Antitoxin

11. differentiate wenicke and korsakoff
Vitamin B12 deficiency
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

12. dominant parietal lobe on the left side
20%
Clonidine will take care both high bp and withdrawal
90% of right handed and 60% of left handed persons; speech and language function
82% specific for dementia

13. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Get up from chair walk a short distance turn around and sit; screening test for fall
Nystagmus on far lateral gaze
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

14. How to tx lewy body dementia
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;
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs

15. benign essential tremor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Propranolol or primidone
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

16. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Reduced efficacy of OCP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
82% specific for dementia

17. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

18. lesion in dominant parietal lobe
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Difficulty in writing - calculating - distinguishing left and write
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position

19. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Propranolol or primidone
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

20. cluster headache
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
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
Autospy gold standard

21. 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
Obturator n lesion
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

22. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Corticosteroid and acyclovir

23. korsafoff psychosis
Reduced efficacy of OCP
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Aphasia - neglect - agnosia - acalculia etc
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

24. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
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.
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

25. oligoclonal band in CSF
Acetylecholinersterase inhibitors
IVIG and plasmapheresis
Spastic paraparesis
MS

26. differentiate picks and huntington
90% of right handed and 60% of left handed persons; speech and language function
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
Deficit in cranial nerve function

27. MMSE score of less than 24
Spastic paraparesis
It patient has electrolyte imbalance and hypothermia
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

28. How to confirm braindeath?
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
90% of right handed and 60% of left handed persons; speech and language function
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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.

29. Tx of bells palsy
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. How to differentiate traumatic LP and SAH
Spastic paraparesis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Distal lower motor neuron disease

31. infections in GBS
Coronary artery disease
EPV - campylobacter - HSV
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

32. Tx of GBS
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
IVIG and plasmapheresis

33. earliest sign of phenytoin toxicity
Difficulty in writing - calculating - distinguishing left and write
Not within 24 hours; give afte 24-48 hours if patient stable
Despite the term neuroma they arise from schwann cells - schwanoma
Nystagmus on far lateral gaze

34. What percent of dementia is reversible
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Cerebellar lesion
20%
Deficit in cranial nerve function

35. Why V12 deficient develop hypokalemia after tx with b12
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Femoral n lesion
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

36. 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
Nystagmus on far lateral gaze
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Distal lower motor neuron disease

37. brain stem lesion
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Deficit in cranial nerve function
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

38. Should we tx htn in acute ischemic stroke

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39. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
IVIG and plasmapheresis
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

40. What is pronator drift
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

41. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
High dose IV methyleprednisone;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

42. Unable to copy of matchstick - unable to dress up
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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.
Autospy gold standard
Construction apraxia; lesion in non dominant parietal lobe (right)

43. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Vitamin B12 deficiency
Cerebral palsy; dx mri
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

44. How to perform apnea test
Autospy gold standard
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
It patient has electrolyte imbalance and hypothermia
Spastic paraparesis

45. acoustic neuroma
IVIG and plasmapheresis
Despite the term neuroma they arise from schwann cells - schwanoma
Vitamin B12 deficiency
Femoral n lesion

46. What bp med to be given in a patient with high bp and signs of opioid withdrawal
EPV - campylobacter - HSV
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
Clonidine will take care both high bp and withdrawal

47. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
RBC count >6000
82% specific for dementia

48. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Entacapone - COMT inhibitor

49. What mmse score suggest dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
<20; if patient scores >25 benign forgetfulness
Entacapone - COMT inhibitor
RBC count >6000

50. When to give aspirin when patient on tPA after stroke
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Vitamin B12 deficiency
Not within 24 hours; give afte 24-48 hours if patient stable
20%