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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. Unable to copy of matchstick - unable to dress up
Despite the term neuroma they arise from schwann cells - schwanoma
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Construction apraxia; lesion in non dominant parietal lobe (right)

2. phenytoin and OCP
Vitamin B12 deficiency
Reduced efficacy of OCP
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

3. medial thigh sensory loss and weakness in addcution
Deficit in cranial nerve function
Cerebral palsy; dx mri
Obturator n lesion
20%

4. Tx of bells palsy
IVIG and plasmapheresis
Corticosteroid and acyclovir
Upright supine position
High dose IV methyleprednisone;

5. differentiate picks and huntington
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Vitamin B12 deficiency
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;

6. benign essential tremor
82% specific for 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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Propranolol or primidone

7. differentiate wenicke and korsakoff
Aphasia - neglect - agnosia - acalculia etc
EPV - campylobacter - HSV
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
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

8. women with unilateral eye pain; neurlogic symptoms here there at different times
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

9. Should we tx htn in acute ischemic stroke

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10. lesion in dominant parietal lobe
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)
Difficulty in writing - calculating - distinguishing left and write
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

11. infections in GBS
Lesion in nondominant temporal lobe
EPV - campylobacter - HSV
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Cholinesterase inhibitor; and antiparkinsonism drugs

12. botulism
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Antitoxin

13. How to prevent prevent frequency of MS exacerbation
Corticosteroid and acyclovir
Acetylecholinersterase inhibitors
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Deficit in cranial nerve function

14. When to give aspirin when patient on tPA after stroke
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cholinesterase inhibitor; and antiparkinsonism drugs
Not within 24 hours; give afte 24-48 hours if patient stable
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.

15. differentiate lewy body dementia and vascular dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

16. cortical lesion
<20; if patient scores >25 benign forgetfulness
90% of right handed and 60% of left handed persons; speech and language function
Obturator n lesion
Aphasia - neglect - agnosia - acalculia etc

17. 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;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus

18. stroke with lower facial palsy - pronator drift despite on aspirin
IVIG and plasmapheresis
Not within 24 hours; give afte 24-48 hours if patient stable
82% specific for dementia
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

19. oligoclonal band in CSF
Tunnel vision - diaphoresis - nausea - pallor
Vitamin B12 deficiency
MS
Entacapone - COMT inhibitor

20. Blood transfusion in hypothermia
Taper gradually to prevent seizure relapse
Femoral n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Acetylecholinersterase inhibitors

21. MG
Cerebral palsy; dx mri
Acetylecholinersterase inhibitors
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
90% of right handed and 60% of left handed persons; speech and language function

22. dementia plus urinary incontinence
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Normal pressure hydrocephalus

23. what drug is used to extend effects of levodopa
Vitamin B12 deficiency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
82% specific for dementia
Entacapone - COMT inhibitor

24. When to use dopamine agonist pramipexol in parkinson
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Aspirin - control HTN and swallow eval before giving any oral meds
Corticosteroid and acyclovir
Deficit in cranial nerve function

25. When headache is presenting complaint of brain tumor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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;
Coronary artery disease
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

26. What percent of dementia is reversible
Verapamil
20%
<20; if patient scores >25 benign forgetfulness
Despite the term neuroma they arise from schwann cells - schwanoma

27. GBS
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
IVIG and plasmapheresis
Antitoxin
82% specific for dementia

28. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Spastic paraparesis

29. Patient with carbamazepine; What should be advice?
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
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Nystagmus on far lateral gaze

30. indication of plasmapheresis in GBS
Antitoxin
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
Acetylecholinersterase inhibitors
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

31. How to differentiate parkinson and benign essential tremor
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
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
20%
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

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

33. Tx of GBS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Propranolol or primidone
Spontaneous remission; admit if suspected and monitor pulse ox for 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

34. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cholinesterase inhibitor; and antiparkinsonism drugs
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

35. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;

36. contraindication of sumatripta
Coronary artery disease
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
RBC count >6000

37. craniopharyngioma
Antitoxin
Clonidine will take care both high bp and withdrawal
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Diabetes insipidus

38. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Vitamin B12 deficiency
Coronary artery disease
Upright supine position
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

39. How to tx acute exacerbation of MS
Cerebellar lesion
High dose IV methyleprednisone;
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

40. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
EPV - campylobacter - HSV
Spastic paraparesis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

41. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
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;
Cholinesterase inhibitor; and antiparkinsonism drugs
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

42. How to stop antiepileptic drugs
Despite the term neuroma they arise from schwann cells - schwanoma
Not within 24 hours; give afte 24-48 hours if patient stable
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

43. 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
Obturator n lesion
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Difficulty in writing - calculating - distinguishing left and write

44. excessive elevation of legs during walking (toe touch floor earlier than heels)
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.
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Distal lower motor neuron disease
RBC count >6000

45. MMSE score of less than 24
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;
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.
82% specific for dementia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

46. How to differentiate dementias
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

47. 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
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
High dose IV methyleprednisone;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

48. How to differentiate medial and lateral pontine syndrome
Construction apraxia; lesion in non dominant parietal lobe (right)
90% of right handed and 60% of left handed persons; speech and language function
Deficit in cranial nerve function
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

49. impaired vibration and increased DTR
Vitamin B12 deficiency
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.
Myasthenia; due to autoantibodies against acetylecholine receptor;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

50. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Gilberts disease
Construction apraxia; lesion in non dominant parietal lobe (right)
Nystagmus on far lateral gaze

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USMLE Step3 Neurology

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