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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. earliest sign of phenytoin toxicity
Propranolol or primidone
Nystagmus on far lateral gaze
Cerebral palsy; dx mri
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

2. How to perform apnea test
Entacapone - COMT inhibitor
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

3. indication of plasmapheresis in GBS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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
Vitamin B12 deficiency
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

4. When to use brain spect scintigraphy to confirm brain death
Cerebellar lesion
It patient has electrolyte imbalance and hypothermia
Difficulty in writing - calculating - distinguishing left and write
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

5. best diagnosis for parkinsonim
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
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
MS
Autospy gold standard

6. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Corticosteroid and acyclovir
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

7. 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
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.
Reduced efficacy of OCP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

8. differentiate lewy body dementia and vascular dementia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Corticosteroid and acyclovir
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

9. When to start fibrinolytic therapy in stroke patient?
Antitoxin
Distal lower motor neuron disease
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 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

10. Acute onset of left arm weakness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Construction apraxia; lesion in non dominant parietal lobe (right)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

11. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

12. anerior and anteriomedial thigh paresthesia - decreased DTR
Corticosteroid and acyclovir
Femoral n lesion
Botulism has descending paralysis in contrast othere have ascending paralysis
Lesion in nondominant temporal lobe

13. get up and go test
Wernicke's encephalopathy; due to thiamine definition; medical emergency
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Get up from chair walk a short distance turn around and sit; screening test for fall
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

14. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
EPV - campylobacter - HSV
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spastic paraparesis

15. lesion in dominant tempora lobe
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

16. oligoclonal band in CSF
Construction apraxia; lesion in non dominant parietal lobe (right)
Aphasia - neglect - agnosia - acalculia etc
Spastic paraparesis
MS

17. Why V12 deficient develop hypokalemia after tx with b12
Acetylecholinersterase inhibitors
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Propranolol or primidone

18. GBS
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
IVIG and plasmapheresis
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Femoral n lesion

19. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Aspirin - control HTN and swallow eval before giving any oral meds
Clonidine will take care both high bp and withdrawal
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
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

20. 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
Vitamin B12 deficiency
Cholinesterase inhibitor; and antiparkinsonism drugs
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;

21. brain stem 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
Deficit in cranial nerve function
Difficulty in writing - calculating - distinguishing left and write
Autospy gold standard

22. 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
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; 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
It patient has electrolyte imbalance and hypothermia

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

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24. impaired perception of complex sounds
Coronary artery disease
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Lesion in nondominant temporal lobe
It patient has electrolyte imbalance and hypothermia

25. How to differentiate medial and lateral medullary syndrome
Get up from chair walk a short distance turn around and sit; screening test for fall
High dose IV methyleprednisone;
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;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

26. MMSE score of less than 24
Tunnel vision - diaphoresis - nausea - pallor
Get up from chair walk a short distance turn around and sit; screening test for fall
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
82% specific for dementia

27. How to differentiate dementias
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Gilberts disease
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Follows viral illness; vertigo - tinnitus - nausea. self limiting

28. What is can be used cluster headache prevention
Verapamil
Gilberts disease
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

29. botulism
MS
Clonidine will take care both high bp and withdrawal
Antitoxin
Diabetes insipidus

30. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
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
MS
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

31. at first tingling in toes and feet then weakness in extremities
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

32. How to stop antiepileptic drugs
Deficit in cranial nerve function
Corticosteroid and acyclovir
Nystagmus on far lateral gaze
Taper gradually to prevent seizure relapse

33. benign essential tremor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone
82% specific for dementia
Diabetes insipidus

34. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
Coronary artery disease
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

35. What is pronator drift
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

36. What mmse score suggest dementia
Upright supine position
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
<20; if patient scores >25 benign forgetfulness

37. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Diabetes insipidus
Spastic paraparesis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

38. severe headache and high BP
Entacapone - COMT inhibitor
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Vitamin B12 deficiency
Reduced efficacy of OCP

39. infections in GBS
82% specific for dementia
Wernicke's encephalopathy; due to thiamine definition; medical emergency
IVIG and plasmapheresis
EPV - campylobacter - HSV

40. Tx of GBS
Construction apraxia; lesion in non dominant parietal lobe (right)
Upright supine position
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Verapamil

41. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Cerebellar lesion

42. Should we tx htn in acute ischemic stroke

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43. What percent of dementia is reversible
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Coronary artery disease
20%
Distal lower motor neuron disease

44. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Taper gradually to prevent seizure relapse
Myasthenia; due to autoantibodies against acetylecholine receptor;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

45. How to prevent prevent frequency of MS exacerbation
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
High dose IV methyleprednisone;
Clonidine will take care both high bp and withdrawal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

46. impaired hepatic conjugation of billirubin
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
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

47. When to suspect traumatic LP
RBC count >6000
IVIG and plasmapheresis
Reduced efficacy of OCP
Verapamil

48. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Construction apraxia; lesion in non dominant parietal lobe (right)
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

49. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
High dose IV methyleprednisone;
Vitamin B12 deficiency
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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

50. prodrome of vasovagal syncope
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Tunnel vision - diaphoresis - nausea - pallor

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USMLE Step3 Neurology

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