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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. dementia plus urinary incontinence
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Normal pressure hydrocephalus
Aphasia - neglect - agnosia - acalculia etc
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

2. lesion in dominant parietal lobe
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
Difficulty in writing - calculating - distinguishing left and write
Get up from chair walk a short distance turn around and sit; screening test for fall

3. What percent of dementia is reversible
20%
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
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

4. 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.
Verapamil
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

5. Patient with carbamazepine; What should be advice?
Aspirin - control HTN and swallow eval before giving any oral meds
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

6. How to differentiate parkinson and benign essential tremor
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Antitoxin

7. Acute onset of left arm weakness
Tunnel vision - diaphoresis - nausea - pallor
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Antitoxin
Corticosteroid and acyclovir

8. How to prevent prevent frequency of MS exacerbation
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Obturator n lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

9. differentiate lewy body dementia and vascular dementia
High dose IV methyleprednisone;
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.
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
Nystagmus on far lateral gaze

10. MMSE score of less than 24
Construction apraxia; lesion in non dominant parietal lobe (right)
82% specific for dementia
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Acetylecholinersterase inhibitors

11. excessive elevation of legs during walking (toe touch floor earlier than heels)
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
Taper gradually to prevent seizure relapse
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Distal lower motor neuron disease

12. Tx of GBS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Aspirin - control HTN and swallow eval before giving any oral meds
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Gilberts disease

13. infections in GBS
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Corticosteroid and acyclovir

14. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Femoral n lesion
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Lesion in nondominant temporal lobe
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

15. How to manage stroke patient came within 4 hours
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
RBC count >6000
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

16. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Myasthenia; due to autoantibodies against acetylecholine receptor;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Nystagmus on far lateral gaze

17. When to use dopamine agonist pramipexol in parkinson
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Reduced efficacy of OCP
Lesion in nondominant temporal lobe

18. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Distal lower motor neuron disease
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

19. How to differentiate botulism from tick born paralysis - GBS and MG
Deficit in cranial nerve function
Diabetes insipidus
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;
Botulism has descending paralysis in contrast othere have ascending paralysis

20. cortical lesion
Antitoxin
Gilberts disease
Nystagmus on far lateral gaze
Aphasia - neglect - agnosia - acalculia etc

21. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

22. oligoclonal band in CSF
20%
MS
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Cerebellar lesion

23. MG
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Acetylecholinersterase inhibitors
IVIG and plasmapheresis

24. 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;
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Obturator n lesion

25. What is pronator drift
20%
Corticosteroid and acyclovir
Aphasia - neglect - agnosia - acalculia etc
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

26. labyrinthitis
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
IVIG and plasmapheresis
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Aspirin - control HTN and swallow eval before giving any oral meds

27. brain stem lesion
Tunnel vision - diaphoresis - nausea - pallor
20%
Deficit in cranial nerve function
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised

28. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors
Diabetes insipidus

29. When to start fibrinolytic therapy in stroke patient?
Deficit in cranial nerve function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

30. When to give aspirin when patient on tPA after stroke
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Not within 24 hours; give afte 24-48 hours if patient stable
RBC count >6000
Despite the term neuroma they arise from schwann cells - schwanoma

31. When to suspect traumatic LP
EPV - campylobacter - HSV
Aphasia - neglect - agnosia - acalculia etc
RBC count >6000
Botulism has descending paralysis in contrast othere have ascending paralysis

32. How to stop antiepileptic drugs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Taper gradually to prevent seizure relapse
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

33. How to tx stroke patient came after 6h
Despite the term neuroma they arise from schwann cells - schwanoma
Aspirin - control HTN and swallow eval before giving any oral meds
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

34. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Autospy gold standard
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;
Despite the term neuroma they arise from schwann cells - schwanoma

35. best diagnosis for parkinsonim
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Autospy gold standard
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
IVIG and plasmapheresis

36. differentiate picks and huntington
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Distal lower motor neuron disease

37. Unable to copy of matchstick - unable to dress up
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Corticosteroid and acyclovir
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Construction apraxia; lesion in non dominant parietal lobe (right)

38. earliest sign of phenytoin toxicity
Despite the term neuroma they arise from schwann cells - schwanoma
Propranolol or primidone
Clonidine will take care both high bp and withdrawal
Nystagmus on far lateral gaze

39. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Myasthenia; due to autoantibodies against acetylecholine receptor;
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Reduced efficacy of OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting

40. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Upright supine position

41. Blood transfusion in hypothermia
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Not within 24 hours; give afte 24-48 hours if patient stable

42. medial thigh sensory loss and weakness in addcution
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Obturator n lesion
Construction apraxia; lesion in non dominant parietal lobe (right)
Corticosteroid and acyclovir

43. cluster headache
Construction apraxia; lesion in non dominant parietal lobe (right)
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
Cerebellar lesion
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

44. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Taper gradually to prevent seizure relapse
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;

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

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46. stroke with lower facial palsy - pronator drift despite on aspirin
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
Vitamin B12 deficiency
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

47. what drug is used to extend effects of levodopa
Entacapone - COMT inhibitor
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
MS
Propranolol or primidone

48. craniopharyngioma
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Diabetes insipidus
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency

49. phenytoin and OCP
Reduced efficacy of OCP
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma
Cerebellar lesion

50. double vision at the end of day and ptosis
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Get up from chair walk a short distance turn around and sit; screening test for fall
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Myasthenia; due to autoantibodies against acetylecholine receptor;

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USMLE Step3 Neurology

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