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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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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. Tx of GBS
Cerebellar lesion
IVIG and plasmapheresis
Diabetes insipidus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

2. When to use dopamine agonist pramipexol in parkinson
Normal pressure hydrocephalus
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
EPV - campylobacter - HSV

3. best diagnosis for parkinsonim
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
EPV - campylobacter - HSV
Obturator n lesion
Autospy gold standard

4. prodrome of vasovagal syncope
High dose IV methyleprednisone;
Cholinesterase inhibitor; and antiparkinsonism drugs
Tunnel vision - diaphoresis - nausea - pallor
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

5. phenytoin and OCP
Reduced efficacy of OCP
Corticosteroid and acyclovir
Propranolol or primidone
20%

6. What is pronator drift
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Deficit in cranial nerve function
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

7. korsafoff psychosis
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
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
Distal lower motor neuron disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

8. Acute onset of left arm weakness
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
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

9. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Normal pressure hydrocephalus
Propranolol or primidone
20%

10. women with unilateral eye pain; neurlogic symptoms here there at different times
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
Aspirin - control HTN and swallow eval before giving any oral meds
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

11. severe headache and high BP
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

12. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Distal lower motor neuron disease

13. How to tx stroke patient came after 6h
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Aspirin - control HTN and swallow eval before giving any oral meds
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

14. What is can be used cluster headache prevention
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
90% of right handed and 60% of left handed persons; speech and language function

15. Should we tx htn in acute ischemic stroke

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16. contraindication of sumatripta
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Coronary artery disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Get up from chair walk a short distance turn around and sit; screening test for fall

17. impaired vibration and increased DTR
Upright supine position
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion
Vitamin B12 deficiency

18. Tx of bells palsy
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Botulism has descending paralysis in contrast othere have ascending paralysis
Corticosteroid and acyclovir
Taper gradually to prevent seizure relapse

19. When to suspect traumatic LP
RBC count >6000
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Distal lower motor neuron disease
MS

20. impaired hepatic conjugation of billirubin
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Gilberts disease
Reduced efficacy of OCP
Cholinesterase inhibitor; and antiparkinsonism drugs

21. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
MS
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
Construction apraxia; lesion in non dominant parietal lobe (right)

22. indication of plasmapheresis in GBS
RBC count >6000
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
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

23. How to differentiate medial and lateral medullary syndrome
Spastic paraparesis
Clonidine will take care both high bp and withdrawal
Botulism has descending paralysis in contrast othere have ascending paralysis
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;

24. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Reduced efficacy of OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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
Cerebral palsy; dx mri

25. oligoclonal band in CSF
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS
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
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

26. How to differentiate botulism from tick born paralysis - GBS and MG
Cholinesterase inhibitor; and antiparkinsonism drugs
IVIG and plasmapheresis
Botulism has descending paralysis in contrast othere have ascending paralysis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

27. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position

28. How to tx lewy body dementia
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Verapamil
Spastic paraparesis

29. GBS
Entacapone - COMT inhibitor
IVIG and plasmapheresis
Myasthenia; due to autoantibodies against acetylecholine receptor;
Follows viral illness; vertigo - tinnitus - nausea. self limiting

30. anerior and anteriomedial thigh paresthesia - decreased DTR
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Femoral 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
Lesion in nondominant temporal lobe

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

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32. How to confirm braindeath?
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.
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Upright supine position
Acetylecholinersterase inhibitors

33. botulism
Antitoxin
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
Tunnel vision - diaphoresis - nausea - pallor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

34. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Autospy gold standard
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

35. Blood transfusion in hypothermia
Propranolol or primidone
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Myasthenia; due to autoantibodies against acetylecholine receptor;
IVIG and plasmapheresis

36. What percent of dementia is reversible
Vitamin B12 deficiency
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
20%
Upright supine position

37. differentiate picks and huntington
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
Aphasia - neglect - agnosia - acalculia etc
Despite the term neuroma they arise from schwann cells - schwanoma

38. brain stem lesion
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
Deficit in cranial nerve function
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

39. medial thigh sensory loss and weakness in addcution
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Reduced efficacy of OCP
Obturator n lesion
Coronary artery disease

40. stroke with lower facial palsy - pronator drift despite on aspirin
Femoral n lesion
RBC count >6000
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Myasthenia; due to autoantibodies against acetylecholine receptor;

41. What mmse score suggest dementia
<20; if patient scores >25 benign forgetfulness
Verapamil
High dose IV methyleprednisone;
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

42. Why V12 deficient develop hypokalemia after tx with b12
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

43. 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
It patient has electrolyte imbalance and hypothermia
Acetylecholinersterase inhibitors
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

44. at first tingling in toes and feet then weakness in extremities
Upright supine position
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard

45. labyrinthitis
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;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Follows viral illness; vertigo - tinnitus - nausea. self limiting

46. When to start fibrinolytic therapy in stroke patient?
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Coronary artery disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

47. How to manage stroke patient came within 4 hours
Autospy gold standard
Cerebellar lesion
Tunnel vision - diaphoresis - nausea - pallor
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

48. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Get up from chair walk a short distance turn around and sit; screening test for fall
Upright supine position
Despite the term neuroma they arise from schwann cells - schwanoma

49. excessive elevation of legs during walking (toe touch floor earlier than heels)
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Deficit in cranial nerve function
Femoral n lesion
Distal lower motor neuron disease

50. craniopharyngioma
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
Obturator n lesion
Diabetes insipidus
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

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USMLE Step3 Neurology

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