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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.
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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. stroke with lower facial palsy - pronator drift despite on aspirin
Tunnel vision - diaphoresis - nausea - pallor
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

2. Tx of bells palsy
Corticosteroid and acyclovir
Myasthenia; due to autoantibodies against acetylecholine receptor;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Difficulty in writing - calculating - distinguishing left and write

3. impaired vibration and increased DTR
Vitamin B12 deficiency
Despite the term neuroma they arise from schwann cells - schwanoma
Corticosteroid and acyclovir
Femoral n lesion

4. How to stop antiepileptic drugs
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
90% of right handed and 60% of left handed persons; speech and language function
Taper gradually to prevent seizure relapse
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

5. cluster headache
20%
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

6. labyrinthitis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
90% of right handed and 60% of left handed persons; speech and language function
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

7. impaired perception of complex sounds
It patient has electrolyte imbalance and hypothermia
Difficulty in writing - calculating - distinguishing left and write
Lesion in nondominant temporal lobe
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

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
20%
Construction apraxia; lesion in non dominant parietal lobe (right)
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

9. What percent of dementia is reversible
Spastic paraparesis
20%
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;
Reduced efficacy of OCP

10. When to give aspirin when patient on tPA after stroke
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Not within 24 hours; give afte 24-48 hours if patient stable
Spastic paraparesis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

11. How to perform apnea test
Spastic paraparesis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Myasthenia; due to autoantibodies against acetylecholine receptor;
Tunnel vision - diaphoresis - nausea - pallor

12. benign essential tremor
Cholinesterase inhibitor; and antiparkinsonism drugs
Vitamin B12 deficiency
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness

13. 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
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;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cholinesterase inhibitor; and antiparkinsonism drugs

14. lesion in dominant parietal lobe
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in writing - calculating - distinguishing left and write
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Gilberts disease

15. 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
Nystagmus on far lateral gaze
Lesion in nondominant temporal lobe
Obturator n lesion

16. medial thigh sensory loss and weakness in addcution
Difficulty in writing - calculating - distinguishing left and write
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia
Obturator n lesion

17. differentiate wenicke and korsakoff
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

18. What is can be used cluster headache prevention
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency
Verapamil

19. Blood transfusion in 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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

20. indication of plasmapheresis in GBS
Femoral n lesion
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
<20; if patient scores >25 benign forgetfulness

21. impaired hepatic conjugation of billirubin
Cerebral palsy; dx mri
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Gilberts disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

22. contraindication of sumatripta
Coronary artery disease
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Propranolol or primidone
Corticosteroid and acyclovir

23. 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
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

24. 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
82% specific for dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

25. MG
Myasthenia; due to autoantibodies against acetylecholine receptor;
MS
Acetylecholinersterase inhibitors
Vitamin B12 deficiency

26. GBS
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 understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
IVIG and plasmapheresis

27. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Not within 24 hours; give afte 24-48 hours if patient stable
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Cerebellar 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

28. at first tingling in toes and feet then weakness in extremities
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Despite the term neuroma they arise from schwann cells - schwanoma
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

29. get up and go test
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma
Get up from chair walk a short distance turn around and sit; screening test for fall
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.

30. infections in GBS
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
EPV - campylobacter - HSV
Despite the term neuroma they arise from schwann cells - schwanoma
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

31. How to tx lewy body dementia
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
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc
Cholinesterase inhibitor; and antiparkinsonism drugs

32. differentiate lewy body dementia and vascular dementia
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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
82% specific for dementia
Obturator n lesion

33. How to tx acute exacerbation of MS
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
High dose IV methyleprednisone;
Cholinesterase inhibitor; and antiparkinsonism drugs
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

34. phenytoin and OCP
Reduced efficacy of OCP
Upright supine position
<20; if patient scores >25 benign forgetfulness
Distal lower motor neuron disease

35. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Propranolol or primidone
82% specific for dementia
Cholinesterase inhibitor; and antiparkinsonism drugs

36. craniopharyngioma
High dose IV methyleprednisone;
MS
Diabetes insipidus
Corticosteroid and acyclovir

37. korsafoff psychosis
Entacapone - COMT inhibitor
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
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

38. women with unilateral eye pain; neurlogic symptoms here there at different times
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis
Nystagmus on far lateral gaze
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

39. dementia plus urinary incontinence
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.
Femoral n lesion
Distal lower motor neuron disease
Normal pressure hydrocephalus

40. best diagnosis for parkinsonim
Entacapone - COMT inhibitor
82% specific for dementia
MS
Autospy gold standard

41. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cerebral palsy; dx mri
Taper gradually to prevent seizure relapse
Femoral n lesion

42. lesion in dominant tempora lobe
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

43. Acute onset of left arm weakness
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

44. How to confirm braindeath?
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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

45. When to use dopamine agonist pramipexol in parkinson
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

46. How to differentiate botulism from tick born paralysis - GBS and MG
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Diabetes insipidus
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Botulism has descending paralysis in contrast othere have ascending paralysis

47. brain stem lesion
Deficit in cranial nerve function
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Antitoxin

48. How to differentiate parkinson and benign essential tremor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Deficit in cranial nerve function
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

49. How to differentiate medial and lateral pontine syndrome
Cerebellar 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
Get up from chair walk a short distance turn around and sit; screening test for fall
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

50. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Distal lower motor neuron disease
Deficit in cranial nerve function

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USMLE Step3 Neurology

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