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

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2. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

3. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
RBC count >6000
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
Botulism has descending paralysis in contrast othere have ascending paralysis

4. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
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;
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

5. impaired perception of complex sounds
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
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
Lesion in nondominant temporal lobe

6. What is can be used cluster headache prevention
Autospy gold standard
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Botulism has descending paralysis in contrast othere have ascending paralysis

7. Why V12 deficient develop hypokalemia after tx with b12
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Distal lower motor neuron disease
IVIG and plasmapheresis
Autospy gold standard

8. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard
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 glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

9. medial thigh sensory loss and weakness in addcution
Gilberts disease
Obturator n lesion
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
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

10. How to differentiate medial and lateral medullary syndrome
Clonidine will take care both high bp and withdrawal
Normal pressure hydrocephalus
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;

11. differentiate lewy body dementia and vascular dementia
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
Aphasia - neglect - agnosia - acalculia etc
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

12. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Autospy gold standard
Obturator n lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency

13. How to stop antiepileptic drugs
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Autospy gold standard
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse

14. stroke with lower facial palsy - pronator drift despite on aspirin
Lesion in nondominant temporal lobe
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Propranolol or primidone
MS

15. dementia plus urinary incontinence
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Lesion in nondominant temporal lobe
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
Normal pressure hydrocephalus

16. When headache is presenting complaint of brain tumor
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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
Spastic paraparesis
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

17. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Aspirin - control HTN and swallow eval before giving any oral meds
<20; if patient scores >25 benign forgetfulness
Spastic paraparesis

18. How to tx stroke patient came after 6h
Myasthenia; due to autoantibodies against acetylecholine receptor;
Aspirin - control HTN and swallow eval before giving any oral meds
<20; if patient scores >25 benign forgetfulness
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

19. When to suspect traumatic LP
RBC count >6000
Deficit in cranial nerve function
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

20. excessive elevation of legs during walking (toe touch floor earlier than heels)
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Distal lower motor neuron disease
Entacapone - COMT inhibitor

21. When to start fibrinolytic therapy in stroke patient?
Normal pressure hydrocephalus
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Diabetes insipidus

22. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Construction apraxia; lesion in non dominant parietal lobe (right)
Normal pressure hydrocephalus
Spastic paraparesis

23. How to differentiate dementias
Taper gradually to prevent seizure relapse
IVIG and plasmapheresis
90% of right handed and 60% of left handed persons; speech and language function
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

24. 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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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

25. When to use dopamine agonist pramipexol in parkinson
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
Entacapone - COMT inhibitor
Upright supine position

26. korsafoff psychosis
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;
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Deficit in cranial nerve function
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

27. How to differentiate parkinson and benign essential tremor
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
Distal lower motor neuron disease
Diabetes insipidus
Follows viral illness; vertigo - tinnitus - nausea. self limiting

28. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Tunnel vision - diaphoresis - nausea - pallor
Acetylecholinersterase inhibitors
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;

29. differentiate wenicke and korsakoff
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Cerebral palsy; dx mri
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

30. botulism
Antitoxin
Despite the term neuroma they arise from schwann cells - schwanoma
Femoral n lesion
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

31. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
20%
Cerebral palsy; dx mri
MS

32. anerior and anteriomedial thigh paresthesia - decreased DTR
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Femoral n lesion
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
82% specific for dementia

33. oligoclonal band in CSF
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
Get up from chair walk a short distance turn around and sit; screening test for fall
MS
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

34. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

35. Should we tx htn in acute ischemic stroke

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36. When to give aspirin when patient on tPA after stroke
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
20%
Cerebral palsy; dx mri
Not within 24 hours; give afte 24-48 hours if patient stable

37. Patient with carbamazepine; What should be advice?
Obturator n lesion
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
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

38. benign essential tremor
Cholinesterase inhibitor; and antiparkinsonism drugs
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Propranolol or primidone

39. phenytoin and OCP
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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;
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
Reduced efficacy of OCP

40. acoustic neuroma
Acetylecholinersterase inhibitors
Despite the term neuroma they arise from schwann cells - schwanoma
Autospy gold standard
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

41. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Myasthenia; due to autoantibodies against acetylecholine receptor;

42. craniopharyngioma
Diabetes insipidus
Not within 24 hours; give afte 24-48 hours if patient stable
Difficulty in writing - calculating - distinguishing left and write
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

43. GBS
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
IVIG and plasmapheresis

44. contraindication of sumatripta
Coronary artery disease
Distal lower motor neuron disease
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
20%

45. differentiate picks and huntington
IVIG and plasmapheresis
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;
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

46. what drug is used to extend effects of levodopa
EPV - campylobacter - HSV
Obturator n lesion
Entacapone - COMT inhibitor
Verapamil

47. What is pronator drift
MS
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
EPV - campylobacter - HSV
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

48. lesion in dominant parietal lobe
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Difficulty in writing - calculating - distinguishing left and write

49. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Wernicke's encephalopathy; due to thiamine definition; medical emergency
82% specific for dementia

50. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Antitoxin
Normal pressure hydrocephalus
Cerebellar lesion
Difficulty in writing - calculating - distinguishing left and write

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USMLE Step3 Neurology

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