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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. When to use brain spect scintigraphy to confirm brain death
82% specific for dementia
It patient has electrolyte imbalance and hypothermia
Antitoxin
90% of right handed and 60% of left handed persons; speech and language function

2. Tx of GBS
Nystagmus on far lateral gaze
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Antitoxin

3. 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
Coronary artery disease
Upright supine position
Distal lower motor neuron disease

4. stroke with lower facial palsy - pronator drift despite on aspirin
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Aspirin - control HTN and swallow eval before giving any oral meds
Get up from chair walk a short distance turn around and sit; screening test for fall
Femoral n lesion

5. How to prevent prevent frequency of MS exacerbation
Entacapone - COMT inhibitor
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Not within 24 hours; give afte 24-48 hours if patient stable

6. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
90% of right handed and 60% of left handed persons; speech and language function
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
High dose IV methyleprednisone;

7. How to tx acute exacerbation of MS
IVIG and plasmapheresis
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
High dose IV methyleprednisone;
<20; if patient scores >25 benign forgetfulness

8. oligoclonal band in CSF
Corticosteroid and acyclovir
MS
82% specific for dementia
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

9. Unable to copy of matchstick - unable to dress up
Construction apraxia; lesion in non dominant parietal lobe (right)
Myasthenia; due to autoantibodies against acetylecholine receptor;
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS

10. GBS
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
IVIG and plasmapheresis
Corticosteroid and acyclovir

11. 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
Get up from chair walk a short distance turn around and sit; screening test for fall
Autospy gold standard
Propranolol or primidone

12. medial thigh sensory loss and weakness in addcution
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Obturator n lesion
90% of right handed and 60% of left handed persons; speech and language function
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

13. phenytoin and OCP
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Cholinesterase inhibitor; and antiparkinsonism drugs
Reduced efficacy of OCP
MS

14. get up and go test
IVIG and plasmapheresis
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
Get up from chair walk a short distance turn around and sit; screening test for fall
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

15. at first tingling in toes and feet then weakness in extremities
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Vitamin B12 deficiency
Clonidine will take care both high bp and withdrawal
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

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

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17. cortical lesion
Lesion in nondominant temporal lobe
Aphasia - neglect - agnosia - acalculia etc
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Obturator n lesion

18. What percent of dementia is reversible
20%
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Cerebellar lesion
Femoral n lesion

19. How to differentiate dementias
82% specific for dementia
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Acetylecholinersterase inhibitors
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

20. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Autospy gold standard
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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

21. How to tx lewy body dementia
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Vitamin B12 deficiency
Taper gradually to prevent seizure relapse
Cholinesterase inhibitor; and antiparkinsonism drugs

22. best diagnosis for parkinsonim
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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;
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Autospy gold standard

23. infections in GBS
20%
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
EPV - campylobacter - HSV
Difficulty in writing - calculating - distinguishing left and write

24. Acute onset of left arm weakness
Follows viral illness; vertigo - tinnitus - nausea. self limiting
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
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
Nystagmus on far lateral gaze

25. double vision at the end of day and ptosis
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Coronary artery disease

26. brain stem lesion
<20; if patient scores >25 benign forgetfulness
Deficit in cranial nerve function
Cholinesterase inhibitor; and antiparkinsonism drugs
Distal lower motor neuron disease

27. How to tx stroke patient came after 6h
Cholinesterase inhibitor; and antiparkinsonism drugs
Entacapone - COMT inhibitor
EPV - campylobacter - HSV
Aspirin - control HTN and swallow eval before giving any oral meds

28. How to confirm braindeath?
Distal lower motor neuron disease
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.
Botulism has descending paralysis in contrast othere have ascending paralysis
Follows viral illness; vertigo - tinnitus - nausea. self limiting

29. MMSE score of less than 24
Verapamil
Acetylecholinersterase inhibitors
82% specific for dementia
Cerebral palsy; dx mri

30. Blood transfusion in hypothermia
Difficulty in writing - calculating - distinguishing left and write
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Deficit in cranial nerve function
Aphasia - neglect - agnosia - acalculia etc

31. korsafoff psychosis
MS: CSF increased IgG -IgM and IgA also increased. not specific to 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
EPV - campylobacter - HSV
Lesion in nondominant temporal lobe

32. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Upright supine position
Cerebral palsy; dx mri
Gilberts disease
Antitoxin

33. Patient with carbamazepine; What should be advice?
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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
90% of right handed and 60% of left handed persons; speech and language function
Tunnel vision - diaphoresis - nausea - pallor

34. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Lesion in nondominant temporal lobe
Normal pressure hydrocephalus
Clonidine will take care both high bp and withdrawal

35. What mmse score suggest dementia
20%
<20; if patient scores >25 benign forgetfulness
Diabetes insipidus
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

36. lesion in dominant tempora lobe
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
<20; if patient scores >25 benign forgetfulness
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

37. impaired hepatic conjugation of billirubin
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
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Verapamil
Gilberts disease

38. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Cerebral palsy; dx mri
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Lesion in nondominant temporal lobe

39. prodrome of vasovagal syncope
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Tunnel vision - diaphoresis - nausea - pallor

40. What is can be used cluster headache prevention
Verapamil
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

41. craniopharyngioma
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Distal lower motor neuron disease
Diabetes insipidus
Gilberts disease

42. excessive elevation of legs during walking (toe touch floor earlier than heels)
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Antitoxin
Distal lower motor neuron disease
Difficulty in writing - calculating - distinguishing left and write

43. 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
Distal lower motor neuron disease
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
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

44. benign essential tremor
Entacapone - COMT inhibitor
Propranolol or primidone
Acetylecholinersterase inhibitors
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

45. 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
EPV - campylobacter - HSV
Coronary artery disease
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

46. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Difficulty in writing - calculating - distinguishing left and write
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Nystagmus on far lateral gaze

47. How to differentiate medial and lateral pontine syndrome
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
Coronary artery disease
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

48. severe headache and high BP
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;
Normal pressure hydrocephalus
Nystagmus on far lateral gaze
Do CT scan at first to r/o SAH - if ct neg lumbar puncture

49. anerior and anteriomedial thigh paresthesia - decreased DTR
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Femoral n lesion
Vitamin B12 deficiency
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;

50. acoustic neuroma
Taper gradually to prevent seizure relapse
It patient has electrolyte imbalance and hypothermia
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma

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USMLE Step3 Neurology

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