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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. korsafoff psychosis
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Gilberts disease
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
<20; if patient scores >25 benign forgetfulness

2. When to start fibrinolytic therapy in stroke patient?
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
<20; if patient scores >25 benign forgetfulness
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

3. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
IVIG and plasmapheresis
Cerebellar lesion
Wernicke's encephalopathy; due to thiamine definition; medical emergency

4. MG
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Entacapone - COMT inhibitor
Acetylecholinersterase inhibitors
Deficit in cranial nerve function

5. How to tx acute exacerbation of MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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
High dose IV methyleprednisone;

6. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
High dose IV methyleprednisone;
Tunnel vision - diaphoresis - nausea - pallor
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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;

7. What is can be used cluster headache prevention
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Verapamil

8. differentiate wenicke and korsakoff
<20; if patient scores >25 benign forgetfulness
Entacapone - COMT inhibitor
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
Nystagmus on far lateral gaze

9. cluster headache
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
Femoral n lesion
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

10. Should we tx htn in acute ischemic stroke

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11. Patient with carbamazepine; What should be advice?
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
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
Normal pressure hydrocephalus

12. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in writing - calculating - distinguishing left and write
Spastic paraparesis
Not within 24 hours; give afte 24-48 hours if patient stable

13. Acute onset of left arm weakness
<20; if patient scores >25 benign forgetfulness
Construction apraxia; lesion in non dominant parietal lobe (right)
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

14. cortical lesion
Obturator n lesion
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
Aphasia - neglect - agnosia - acalculia etc
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

15. what drug is used to extend effects of levodopa
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
MS
Distal lower motor neuron disease
Entacapone - COMT inhibitor

16. What is pronator drift
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

17. 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
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;
High dose IV methyleprednisone;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

18. differentiate picks and huntington
<20; if patient scores >25 benign forgetfulness
Femoral n lesion
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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. When to use dopamine agonist pramipexol in parkinson
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

21. How to manage stroke patient came within 4 hours
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Construction apraxia; lesion in non dominant parietal lobe (right)
IVIG and plasmapheresis
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

22. What mmse score suggest dementia
Nystagmus on far lateral gaze
<20; if patient scores >25 benign forgetfulness
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Myasthenia; due to autoantibodies against acetylecholine receptor;

23. How to differentiate medial and lateral pontine syndrome
Femoral n lesion
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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
Aspirin - control HTN and swallow eval before giving any oral meds

24. contraindication of sumatripta
Entacapone - COMT inhibitor
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
Aspirin - control HTN and swallow eval before giving any oral meds
Coronary artery disease

25. How to perform apnea test
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Nystagmus on far lateral gaze

26. dementia plus urinary incontinence
Normal pressure hydrocephalus
Construction apraxia; lesion in non dominant parietal lobe (right)
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;
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

27. excessive elevation of legs during walking (toe touch floor earlier than heels)
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Distal lower motor neuron disease
Aphasia - neglect - agnosia - acalculia etc
Tunnel vision - diaphoresis - nausea - pallor

28. When to use brain spect scintigraphy to confirm brain death
It patient has electrolyte imbalance and hypothermia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

29. impaired hepatic conjugation of billirubin
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebral palsy; dx mri
Cerebellar lesion

30. How to confirm braindeath?
Taper gradually to prevent seizure relapse
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
MS
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.

31. dominant parietal lobe on the left side
Reduced efficacy of OCP
90% of right handed and 60% of left handed persons; speech and language function
Gilberts disease
Cholinesterase inhibitor; and antiparkinsonism drugs

32. How to differentiate medial and lateral medullary syndrome
Reduced efficacy of OCP
Femoral n lesion
High dose IV methyleprednisone;
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;

33. impaired vibration and increased DTR
Vitamin B12 deficiency
Antitoxin
Gilberts disease
Difficulty in writing - calculating - distinguishing left and write

34. benign essential tremor
Propranolol or primidone
Reduced efficacy of OCP
20%
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

35. anerior and anteriomedial thigh paresthesia - decreased DTR
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Femoral n lesion

36. Blood transfusion in hypothermia
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Cerebral palsy; dx mri
Diabetes insipidus
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

37. When headache is presenting complaint of brain tumor
Vitamin B12 deficiency
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

38. impaired perception of complex sounds
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Entacapone - COMT inhibitor
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
Lesion in nondominant temporal lobe

39. acoustic neuroma
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
Reduced efficacy of OCP
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

40. How to prevent prevent frequency of MS exacerbation
Aphasia - neglect - agnosia - acalculia etc
Antitoxin
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

41. How to differentiate botulism from tick born paralysis - GBS and MG
Botulism has descending paralysis in contrast othere have ascending paralysis
Reduced efficacy of OCP
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
It patient has electrolyte imbalance and hypothermia

42. Why V12 deficient develop hypokalemia after tx with b12
Taper gradually to prevent seizure relapse
Cerebellar lesion
IVIG and plasmapheresis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

43. How to stop antiepileptic drugs
Upright supine position
Taper gradually to prevent seizure relapse
Cerebellar lesion
Get up from chair walk a short distance turn around and sit; screening test for fall

44. When to give aspirin when patient on tPA after stroke
Not within 24 hours; give afte 24-48 hours if patient stable
Construction apraxia; lesion in non dominant parietal lobe (right)
Cholinesterase inhibitor; and antiparkinsonism drugs
Propranolol or primidone

45. How to tx stroke patient came after 6h
MS
Vitamin B12 deficiency
Aspirin - control HTN and swallow eval before giving any oral meds
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

46. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Botulism has descending paralysis in contrast othere have ascending paralysis
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

47. earliest sign of phenytoin toxicity
EPV - campylobacter - HSV
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Nystagmus on far lateral gaze
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

48. How to differentiate dementias
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Vitamin B12 deficiency
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

49. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Upright supine position
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Vitamin B12 deficiency

50. MMSE score of less than 24
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
82% specific for dementia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure