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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. brain stem lesion
RBC count >6000
Deficit in cranial nerve function
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
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH

2. How to tx lewy body dementia
Cholinesterase inhibitor; and antiparkinsonism drugs
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Distal lower motor neuron disease

3. How to differentiate traumatic LP and SAH
Gilberts disease
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Reduced efficacy of OCP
Tunnel vision - diaphoresis - nausea - pallor

4. impaired vibration and increased DTR
Vitamin B12 deficiency
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
MS
Aspirin - control HTN and swallow eval before giving any oral meds

5. differentiate wenicke and korsakoff
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
Antitoxin
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
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

6. 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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Entacapone - COMT inhibitor

7. MG
Coronary artery disease
Nystagmus on far lateral gaze
Acetylecholinersterase inhibitors
Verapamil

8. How to tx stroke patient came after 6h
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Aspirin - control HTN and swallow eval before giving any oral meds
Verapamil
High dose IV methyleprednisone;

9. earliest sign of phenytoin toxicity
Spastic paraparesis
Get up from chair walk a short distance turn around and sit; screening test for fall
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Nystagmus on far lateral gaze

10. GBS
Verapamil
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
IVIG and plasmapheresis
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

11. dominant parietal lobe on the left side
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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

12. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Spastic paraparesis
Propranolol or primidone
Femoral n lesion
Entacapone - COMT inhibitor

13. Unable to copy of matchstick - unable to dress up
High dose IV methyleprednisone;
RBC count >6000
Distal lower motor neuron disease
Construction apraxia; lesion in non dominant parietal lobe (right)

14. indication of plasmapheresis in GBS
Normal pressure hydrocephalus
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Cerebellar lesion
Diabetes insipidus

15. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
It patient has electrolyte imbalance and hypothermia
Spastic paraparesis
Tunnel vision - diaphoresis - nausea - pallor

16. When to start fibrinolytic therapy in stroke patient?
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Cholinesterase inhibitor; and antiparkinsonism drugs
Reduced efficacy of OCP
Lesion in nondominant temporal lobe

17. How to manage stroke patient came within 4 hours
Obturator n lesion
IVIG and plasmapheresis
Not within 24 hours; give afte 24-48 hours if patient stable
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

18. women with unilateral eye pain; neurlogic symptoms here there at different times
Get up from chair walk a short distance turn around and sit; screening test for fall
Clonidine will take care both high bp and withdrawal
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Myasthenia; due to autoantibodies against acetylecholine receptor;

19. How to confirm braindeath?
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea 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.
Deficit in cranial nerve function

20. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
High dose IV methyleprednisone;
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
20%

21. Patient with carbamazepine; What should be advice?
Gilberts disease
Femoral 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
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

22. How to prevent prevent frequency of MS exacerbation
MS
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
<20; if patient scores >25 benign forgetfulness

23. cortical lesion
Aphasia - neglect - agnosia - acalculia etc
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
82% specific for dementia
High dose IV methyleprednisone;

24. Acute onset of left arm weakness
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Gilberts disease
Verapamil
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. What mmse score suggest dementia
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
<20; if patient scores >25 benign forgetfulness
Gilberts disease
Difficulty in writing - calculating - distinguishing left and write

26. acoustic neuroma
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Get up from chair walk a short distance turn around and sit; screening test for fall
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Despite the term neuroma they arise from schwann cells - schwanoma

27. prodrome of vasovagal syncope
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Tunnel vision - diaphoresis - nausea - pallor
Normal pressure hydrocephalus

28. craniopharyngioma
Propranolol or primidone
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
Diabetes insipidus

29. excessive elevation of legs during walking (toe touch floor earlier than heels)
Get up from chair walk a short distance turn around and sit; screening test for fall
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
Not within 24 hours; give afte 24-48 hours if patient stable

30. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
MS
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position

31. 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
Clonidine will take care both high bp and withdrawal
Diabetes insipidus

32. What is pronator drift
Cholinesterase inhibitor; and antiparkinsonism drugs
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tunnel vision - diaphoresis - nausea - pallor
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

33. How to stop antiepileptic drugs
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
Autospy gold standard
Taper gradually to prevent seizure relapse

34. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
20%

35. differentiate lewy body dementia and vascular dementia
Tunnel vision - diaphoresis - nausea - pallor
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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

36. infections in GBS
EPV - campylobacter - HSV
Acetylecholinersterase inhibitors
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Femoral n lesion

37. How to differentiate medial and lateral pontine syndrome
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
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

38. impaired hepatic conjugation of billirubin
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Gilberts disease

39. lesion in dominant parietal lobe
Vitamin B12 deficiency
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Difficulty in writing - calculating - distinguishing left and write
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

40. contraindication of sumatripta
Wernicke's encephalopathy; due to thiamine definition; medical emergency
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Coronary artery disease

41. dementia plus urinary incontinence
Normal pressure hydrocephalus
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Construction apraxia; lesion in non dominant parietal lobe (right)

42. How to perform apnea test
82% specific for dementia
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Construction apraxia; lesion in non dominant parietal lobe (right)

43. phenytoin and OCP
Reduced efficacy of OCP
High dose IV methyleprednisone;
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
20%

44. What percent of dementia is reversible
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
20%
Nystagmus on far lateral gaze
Reduced efficacy of OCP

45. medial thigh sensory loss and weakness in addcution
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Obturator n lesion
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge

46. 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
Antitoxin
Upright supine position
20%

47. How to tx acute exacerbation of MS
Aphasia - neglect - agnosia - acalculia etc
Get up from chair walk a short distance turn around and sit; screening test for fall
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
High dose IV methyleprednisone;

48. best diagnosis for parkinsonim
Autospy gold standard
Upright supine position
EPV - campylobacter - HSV
Wernicke's encephalopathy; due to thiamine definition; medical emergency

49. impaired perception of complex sounds
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Lesion in nondominant temporal lobe
Clonidine will take care both high bp and withdrawal
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

50. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Cerebellar lesion
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Propranolol or primidone
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.

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USMLE Step3 Neurology

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