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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. cluster headache
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
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
Lesion in nondominant temporal lobe

2. When headache is presenting complaint of brain tumor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Femoral n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

3. When to give aspirin when patient on tPA after stroke
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Botulism has descending paralysis in contrast othere have ascending paralysis
Not within 24 hours; give afte 24-48 hours if patient stable

4. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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

5. acoustic neuroma
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;
Deficit in cranial nerve function
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Despite the term neuroma they arise from schwann cells - schwanoma

6. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Upright supine position
Construction apraxia; lesion in non dominant parietal lobe (right)
IVIG and plasmapheresis

7. What is pronator drift
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Spastic paraparesis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

8. medial thigh sensory loss and weakness in addcution
Obturator n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Distal lower motor neuron 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

9. Unable to copy of matchstick - unable to dress up
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Construction apraxia; lesion in non dominant parietal lobe (right)
Lesion in nondominant temporal lobe
Antitoxin

10. When to suspect traumatic LP
RBC count >6000
Diabetes insipidus
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

11. impaired vibration and increased DTR
Lesion in nondominant temporal lobe
Vitamin B12 deficiency
Diabetes insipidus
Normal pressure hydrocephalus

12. MG
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
90% of right handed and 60% of left handed persons; speech and language function
Acetylecholinersterase inhibitors

13. GBS
Upright supine position
Not within 24 hours; give afte 24-48 hours if patient stable
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
IVIG and plasmapheresis

14. What mmse score suggest dementia
Spastic paraparesis
Tunnel vision - diaphoresis - nausea - pallor
<20; if patient scores >25 benign forgetfulness
Deficit in cranial nerve function

15. earliest sign of phenytoin toxicity
Corticosteroid and acyclovir
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion
Nystagmus on far lateral gaze

16. contraindication of sumatripta
Acetylecholinersterase inhibitors
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis
Coronary artery disease

17. oligoclonal band in CSF
Diabetes insipidus
Propranolol or primidone
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
MS

18. How to prevent prevent frequency of MS exacerbation
Upright supine position
Normal pressure hydrocephalus
Botulism has descending paralysis in contrast othere have ascending paralysis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

19. labyrinthitis
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

20. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Upright supine position
Normal pressure hydrocephalus

21. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Difficulty in writing - calculating - distinguishing left and write
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
Spastic paraparesis

22. dementia plus urinary incontinence
Verapamil
Obturator n lesion
It patient has electrolyte imbalance and hypothermia
Normal pressure hydrocephalus

23. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in writing - calculating - distinguishing left and write

24. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Nystagmus on far lateral gaze
Cerebellar lesion
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

25. Patient with carbamazepine; What should be advice?
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
Femoral 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

26. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
EPV - campylobacter - HSV
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
RBC count >6000

27. severe headache and high BP
Not within 24 hours; give afte 24-48 hours if patient stable
Diabetes insipidus
Coronary artery disease
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

28. How to tx stroke patient came after 6h
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Aspirin - control HTN and swallow eval before giving any oral meds
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
Clonidine will take care both high bp and withdrawal

29. benign essential tremor
Propranolol or primidone
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

30. How to differentiate traumatic LP and SAH
Propranolol or primidone
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebral palsy; dx mri
Follows viral illness; vertigo - tinnitus - nausea. self limiting

31. How to differentiate botulism from tick born paralysis - GBS and MG
Cerebral palsy; dx mri
Tunnel vision - diaphoresis - nausea - pallor
Botulism has descending paralysis in contrast othere have ascending paralysis
Gilberts disease

32. impaired perception of complex sounds
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
RBC count >6000
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Lesion in nondominant temporal lobe

33. How to tx lewy body dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
RBC count >6000
Despite the term neuroma they arise from schwann cells - schwanoma
Cholinesterase inhibitor; and antiparkinsonism drugs

34. When to use brain spect scintigraphy to confirm brain death
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
It patient has electrolyte imbalance and hypothermia
Botulism has descending paralysis in contrast othere have ascending paralysis

35. botulism
Antitoxin
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
Deficit in cranial nerve function

36. craniopharyngioma
Autospy gold standard
Obturator n lesion
Diabetes insipidus
Acetylecholinersterase inhibitors

37. Why V12 deficient develop hypokalemia after tx with b12
Vitamin B12 deficiency
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Clonidine will take care both high bp and withdrawal

38. How to stop antiepileptic drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acetylecholinersterase inhibitors
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
Taper gradually to prevent seizure relapse

39. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Normal pressure hydrocephalus
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

40. How to tx acute exacerbation of MS
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
High dose IV methyleprednisone;
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Autospy gold standard

41. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Nystagmus on far lateral gaze
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;
Clonidine will take care both high bp and withdrawal
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

42. stroke with lower facial palsy - pronator drift despite on aspirin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
It patient has electrolyte imbalance and hypothermia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

43. How to differentiate medial and lateral medullary syndrome
Entacapone - COMT inhibitor
Aphasia - neglect - agnosia - acalculia etc
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;
Acetylecholinersterase inhibitors

44. get up and go test
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor
Get up from chair walk a short distance turn around and sit; screening test for fall
90% of right handed and 60% of left handed persons; speech and language function

45. anerior and anteriomedial thigh paresthesia - decreased DTR
Construction apraxia; lesion in non dominant parietal lobe (right)
Femoral n lesion
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor

46. dominant parietal lobe on the left side
Clonidine will take care both high bp and withdrawal
90% of right handed and 60% of left handed persons; speech and language function
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Lesion in nondominant temporal lobe

47. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
Upright supine position
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
IVIG and plasmapheresis

48. differentiate picks and huntington
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Reduced efficacy of OCP

49. What percent of dementia is reversible
Wernicke's encephalopathy; due to thiamine definition; medical emergency
20%
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Antitoxin

50. How to manage stroke patient came within 4 hours
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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
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;

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USMLE Step3 Neurology

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