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USMLE Step3 Neurology

Subjects : health-sciences, usmle-step-3

Instructions:

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. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
EPV - campylobacter - HSV
Spastic paraparesis
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
MS

2. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
82% specific for dementia
Aphasia - neglect - agnosia - acalculia etc
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

3. How to tx acute exacerbation of MS
High dose IV methyleprednisone;
Despite the term neuroma they arise from schwann cells - schwanoma
Entacapone - COMT inhibitor
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

4. Tx of bells palsy
<20; if patient scores >25 benign forgetfulness
Cerebral palsy; dx mri
Corticosteroid and acyclovir
Autospy gold standard

5. Acute onset of left arm weakness
MS
RBC count >6000
82% specific for dementia
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

6. What mmse score suggest dementia
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

7. best diagnosis for parkinsonim
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Autospy gold standard
Nystagmus on far lateral gaze
Aphasia - neglect - agnosia - acalculia etc

8. labyrinthitis
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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
It patient has electrolyte imbalance and hypothermia

9. impaired perception of complex sounds
Wernicke's encephalopathy; due to thiamine definition; medical emergency
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor
Lesion in nondominant temporal lobe

10. Unable to copy of matchstick - unable to dress up
Antitoxin
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Construction apraxia; lesion in non dominant parietal lobe (right)
MS

11. MMSE score of less than 24
Taper gradually to prevent seizure relapse
82% specific for dementia
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Femoral n lesion

12. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Taper gradually to prevent seizure relapse
Vitamin B12 deficiency

13. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Spastic paraparesis
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Gilberts disease

14. impaired vibration and increased DTR
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Vitamin B12 deficiency
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
Construction apraxia; lesion in non dominant parietal lobe (right)

15. anerior and anteriomedial thigh paresthesia - decreased DTR
Femoral n lesion
Aspirin - control HTN and swallow eval before giving any oral meds
Vitamin B12 deficiency
Difficulty in writing - calculating - distinguishing left and write

16. How to prevent prevent frequency of MS exacerbation
82% specific for dementia
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;
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

17. double vision at the end of day and ptosis
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;
<20; if patient scores >25 benign forgetfulness
Entacapone - COMT inhibitor

18. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
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

19. excessive elevation of legs during walking (toe touch floor earlier than heels)
Despite the term neuroma they arise from schwann cells - schwanoma
Distal lower motor neuron disease
Coronary artery disease
RBC count >6000

20. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Acetylecholinersterase inhibitors
Reduced efficacy of OCP
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

21. Tx of GBS
Lesion in nondominant temporal lobe
Taper gradually to prevent seizure relapse
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Botulism has descending paralysis in contrast othere have ascending paralysis

22. women with unilateral eye pain; neurlogic symptoms here there at different times
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Normal pressure hydrocephalus
Spastic paraparesis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

23. impaired hepatic conjugation of billirubin
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Aspirin - control HTN and swallow eval before giving any oral meds
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Gilberts disease

24. severe headache and high BP
90% of right handed and 60% of left handed persons; speech and language function
Autospy gold standard
20%
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

25. How to differentiate botulism from tick born paralysis - GBS and MG
Tunnel vision - diaphoresis - nausea - pallor
High dose IV methyleprednisone;
Aphasia - neglect - agnosia - acalculia etc
Botulism has descending paralysis in contrast othere have ascending paralysis

26. 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
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis

27. How to differentiate medial and lateral medullary syndrome
Distal lower motor neuron disease
90% of right handed and 60% of left handed persons; speech and language function
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

28. oligoclonal band in CSF
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Corticosteroid and acyclovir
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

29. How to stop antiepileptic drugs
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
Deficit in cranial nerve function
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

30. differentiate picks and huntington
Not within 24 hours; give afte 24-48 hours if patient stable
Cerebellar lesion
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
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

31. How to perform 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
Acetylecholinersterase inhibitors
Myasthenia; due to autoantibodies against acetylecholine receptor;
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.

32. botulism
Upright supine position
Tunnel vision - diaphoresis - nausea - pallor
Construction apraxia; lesion in non dominant parietal lobe (right)
Antitoxin

33. How to tx stroke patient came after 6h
Aspirin - control HTN and swallow eval before giving any oral meds
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

34. When to start fibrinolytic therapy in stroke patient?
Antitoxin
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Coronary artery disease
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

35. differentiate lewy body dementia and vascular dementia
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
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
Propranolol or primidone
High dose IV methyleprednisone;

36. 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
Difficulty in writing - calculating - distinguishing left and write
Despite the term neuroma they arise from schwann cells - schwanoma
Upright supine position

37. acoustic neuroma
Despite the term neuroma they arise from schwann cells - schwanoma
Normal pressure hydrocephalus
High dose IV methyleprednisone;
82% specific for dementia

38. What is pronator drift
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Entacapone - COMT inhibitor
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
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. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
Autospy gold standard
EPV - campylobacter - HSV

40. MG
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
90% of right handed and 60% of left handed persons; speech and language function
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Acetylecholinersterase inhibitors

41. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Cerebral palsy; dx mri
Obturator n lesion
<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

42. indication of plasmapheresis in GBS
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

43. 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
Deficit in cranial nerve function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

44. at first tingling in toes and feet then weakness in extremities
RBC count >6000
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;
Distal lower motor neuron disease
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

45. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebellar lesion
Gilberts disease

46. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
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
Spastic paraparesis
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

47. How to differentiate dementias
Acetylecholinersterase inhibitors
IVIG and plasmapheresis
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Botulism has descending paralysis in contrast othere have ascending paralysis

48. brain stem lesion
Deficit in cranial nerve function
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
RBC count >6000

49. 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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
RBC count >6000
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

50. phenytoin and OCP
Despite the term neuroma they arise from schwann cells - schwanoma
Reduced efficacy of OCP
MS
It patient has electrolyte imbalance and hypothermia

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USMLE Step3 Neurology

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