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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

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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. lesion in dominant parietal lobe
Corticosteroid and acyclovir
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Difficulty in writing - calculating - distinguishing left and write

2. Should we tx htn in acute ischemic stroke

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3. How to differentiate traumatic LP and SAH
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
82% specific for dementia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

4. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Antitoxin

5. 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
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
Coronary artery disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

6. severe headache and high BP
Deficit in cranial nerve function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Distal lower motor neuron disease

7. Why V12 deficient develop hypokalemia after tx with b12
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Follows viral illness; vertigo - tinnitus - nausea. self limiting
EPV - campylobacter - HSV

8. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Femoral n lesion
Deficit in cranial nerve function

9. How to differentiate botulism from tick born paralysis - GBS and MG
Upright supine position
Acetylecholinersterase inhibitors
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Botulism has descending paralysis in contrast othere have ascending paralysis

10. 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
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
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

11. impaired perception of complex sounds
Lesion in nondominant temporal lobe
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

12. GBS
Get up from chair walk a short distance turn around and sit; screening test for fall
Cerebral palsy; dx mri
Upright supine position
IVIG and plasmapheresis

13. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
RBC count >6000
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

14. infections in GBS
Construction apraxia; lesion in non dominant parietal lobe (right)
EPV - campylobacter - HSV
Gilberts disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

15. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Distal lower motor neuron disease
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
High dose IV methyleprednisone;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

16. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus
RBC count >6000
Clonidine will take care both high bp and withdrawal

17. How to tx stroke patient came after 6h
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
Aspirin - control HTN and swallow eval before giving any oral meds
Propranolol or primidone

18. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Myasthenia; due to autoantibodies against acetylecholine receptor;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Verapamil

19. When to use dopamine agonist pramipexol in parkinson
Corticosteroid and acyclovir
90% of right handed and 60% of left handed persons; speech and language function
IVIG and plasmapheresis
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

20. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

21. How to tx lewy body dementia
Obturator n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Cholinesterase inhibitor; and antiparkinsonism drugs
Despite the term neuroma they arise from schwann cells - schwanoma

22. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
MS
Upright supine position
Vitamin B12 deficiency
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

23. prodrome of vasovagal syncope
Gilberts disease
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Tunnel vision - diaphoresis - nausea - pallor

24. impaired hepatic conjugation of billirubin
Nystagmus on far lateral gaze
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Gilberts disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

25. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Lesion in nondominant temporal lobe
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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.

26. How to stop antiepileptic drugs
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
82% specific for dementia
Botulism has descending paralysis in contrast othere have ascending paralysis
Taper gradually to prevent seizure relapse

27. How to prevent prevent frequency of MS exacerbation
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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.
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease

28. cluster headache
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Upright supine position

29. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Reduced efficacy of OCP
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cerebellar lesion

30. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
82% specific for dementia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Normal pressure hydrocephalus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

31. best diagnosis for parkinsonim
High dose IV methyleprednisone;
Acetylecholinersterase inhibitors
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
Autospy gold standard

32. botulism
Antitoxin
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Obturator n lesion

33. What percent of dementia is reversible
20%
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe
Clonidine will take care both high bp and withdrawal

34. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Nystagmus on far lateral gaze
Clonidine will take care both high bp and withdrawal
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

35. When to use brain spect scintigraphy to confirm brain death
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

36. How to differentiate medial and lateral medullary 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;
Spastic paraparesis
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

37. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Aspirin - control HTN and swallow eval before giving any oral meds
Verapamil
20%
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

38. acoustic neuroma
Myasthenia; due to autoantibodies against acetylecholine receptor;
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
Coronary artery disease

39. MG
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
Acetylecholinersterase inhibitors
Taper gradually to prevent seizure relapse
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.

40. Tx of GBS
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Acetylecholinersterase inhibitors
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

41. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
It patient has electrolyte imbalance and hypothermia
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Corticosteroid and acyclovir

42. 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
Spastic paraparesis
Diabetes insipidus
Upright supine position

43. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Cerebral palsy; dx mri

44. double vision at the end of day and ptosis
Gilberts disease
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus

45. dementia plus urinary incontinence
Normal pressure hydrocephalus
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;
IVIG and plasmapheresis
Upright supine position

46. excessive elevation of legs during walking (toe touch floor earlier than heels)
Corticosteroid and acyclovir
RBC count >6000
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Distal lower motor neuron disease

47. How to confirm braindeath?
Taper gradually to prevent seizure relapse
Aphasia - neglect - agnosia - acalculia etc
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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.

48. at first tingling in toes and feet then weakness in extremities
MS
It patient has electrolyte imbalance and hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor

49. When to suspect traumatic LP
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
RBC count >6000
Antitoxin
Construction apraxia; lesion in non dominant parietal lobe (right)

50. contraindication of sumatripta
Not within 24 hours; give afte 24-48 hours if patient stable
Obturator n lesion
Corticosteroid and acyclovir
Coronary artery disease

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USMLE Step3 Neurology

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