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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. women with unilateral eye pain; neurlogic symptoms here there at different times
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
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

2. contraindication of sumatripta
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Coronary artery disease

3. excessive elevation of legs during walking (toe touch floor earlier than heels)
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

4. How to stop antiepileptic drugs
90% of right handed and 60% of left handed persons; speech and language function
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Taper gradually to prevent seizure relapse

5. GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
EPV - campylobacter - HSV
IVIG and plasmapheresis
Nystagmus on far lateral gaze

6. medial thigh sensory loss and weakness in addcution
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Taper gradually to prevent seizure relapse
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Obturator n lesion

7. How to differentiate parkinson and benign essential tremor
Aphasia - neglect - agnosia - acalculia etc
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
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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. How to differentiate medial and lateral pontine syndrome
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
20%
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Taper gradually to prevent seizure relapse

9. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
82% specific for dementia
Normal pressure hydrocephalus

10. stroke with lower facial palsy - pronator drift despite on aspirin
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

11. best diagnosis for parkinsonim
Obturator n lesion
20%
Propranolol or primidone
Autospy gold standard

12. Unable to copy of matchstick - unable to dress up
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Construction apraxia; lesion in non dominant parietal lobe (right)
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

13. How to confirm braindeath?
Spastic paraparesis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
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.
Cerebellar lesion

14. lesion in dominant parietal lobe
Myasthenia; due to autoantibodies against acetylecholine receptor;
Difficulty in writing - calculating - distinguishing left and write
Distal lower motor neuron disease
EPV - campylobacter - HSV

15. prodrome of vasovagal syncope
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
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

16. Blood transfusion in hypothermia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spastic paraparesis
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.

17. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Vitamin B12 deficiency

18. What bp med to be given in a patient with high bp and signs of opioid withdrawal
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
Normal pressure hydrocephalus
Cholinesterase inhibitor; and antiparkinsonism drugs
Clonidine will take care both high bp and withdrawal

19. brain stem lesion
Vitamin B12 deficiency
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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
Deficit in cranial nerve function

20. MMSE score of less than 24
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
Normal pressure hydrocephalus
Not within 24 hours; give afte 24-48 hours if patient stable

21. impaired hepatic conjugation of billirubin
Taper gradually to prevent seizure relapse
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Gilberts disease

22. dementia plus urinary incontinence
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
Normal pressure hydrocephalus
Aspirin - control HTN and swallow eval before giving any oral meds
Distal lower motor neuron disease

23. How to prevent prevent frequency of MS exacerbation
Spastic paraparesis
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

24. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
High dose IV methyleprednisone;
Cerebral palsy; dx mri
Spastic paraparesis
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

25. korsafoff psychosis
Nystagmus on far lateral gaze
Cholinesterase inhibitor; and antiparkinsonism drugs
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

26. Patient with carbamazepine; What should be advice?
Gilberts disease
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
Obturator n lesion
Vitamin B12 deficiency

27. benign essential tremor
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
Propranolol or primidone
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

28. How to manage stroke patient came within 4 hours
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

29. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
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
Reduced efficacy of OCP
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.
Spastic paraparesis

30. Why V12 deficient develop hypokalemia after tx with b12
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus
<20; if patient scores >25 benign forgetfulness
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

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

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32. How to differentiate botulism from tick born paralysis - GBS and MG
Taper gradually to prevent seizure relapse
Upright supine position
Botulism has descending paralysis in contrast othere have ascending paralysis
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

33. When to suspect traumatic LP
Get up from chair walk a short distance turn around and sit; screening test for fall
Verapamil
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
RBC count >6000

34. MG
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Difficulty in writing - calculating - distinguishing left and write
Acetylecholinersterase inhibitors
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

35. impaired vibration and increased DTR
Vitamin B12 deficiency
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
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

36. What is pronator drift
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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
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

37. What percent of dementia is reversible
20%
Reduced efficacy of OCP
Tunnel vision - diaphoresis - nausea - pallor
Spastic paraparesis

38. get up and go test
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.
IVIG and plasmapheresis
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Get up from chair walk a short distance turn around and sit; screening test for fall

39. Acute onset of left arm weakness
Acetylecholinersterase inhibitors
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
RBC count >6000
EPV - campylobacter - HSV

40. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Vitamin B12 deficiency
Distal lower motor neuron disease

41. differentiate lewy body dementia and vascular dementia
Myasthenia; due to autoantibodies against acetylecholine receptor;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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. differentiate picks and huntington
Despite the term neuroma they arise from schwann cells - schwanoma
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
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)

43. What mmse score suggest dementia
Get up from chair walk a short distance turn around and sit; screening test for fall
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
<20; if patient scores >25 benign forgetfulness
Cerebral palsy; dx mri

44. botulism
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
EPV - campylobacter - HSV
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Antitoxin

45. infections in GBS
Not within 24 hours; give afte 24-48 hours if patient stable
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
EPV - campylobacter - HSV
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

46. oligoclonal band in CSF
MS
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Difficulty in writing - calculating - distinguishing left and write

47. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
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;
Lesion in nondominant temporal lobe
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

48. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Obturator n lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

49. differentiate wenicke and korsakoff
Wernicke's encephalopathy; due to thiamine definition; medical emergency
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
High dose IV methyleprednisone;
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

50. lesion in dominant tempora lobe
Femoral n lesion
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
Acetylecholinersterase inhibitors

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USMLE Step3 Neurology

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