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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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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. differentiate picks and huntington
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
Obturator n lesion
Spastic paraparesis
Wernicke's encephalopathy; due to thiamine definition; medical emergency

2. What percent of dementia is reversible
Clonidine will take care both high bp and withdrawal
Gilberts disease
20%
RBC count >6000

3. at first tingling in toes and feet then weakness in extremities
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Tunnel vision - diaphoresis - nausea - pallor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

4. When to use dopamine agonist pramipexol in parkinson
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
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
Cerebellar lesion
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

5. How to differentiate dementias
Tunnel vision - diaphoresis - nausea - pallor
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
20%
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

6. prodrome of vasovagal syncope
MS
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Tunnel vision - diaphoresis - nausea - pallor

7. How to differentiate traumatic LP and SAH
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Acetylecholinersterase inhibitors
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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

8. construction worker works in squatting position; now develop decreased sensation over anterolateral thigh
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
EPV - campylobacter - HSV
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

9. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Vitamin B12 deficiency
Propranolol or primidone
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty

10. When to suspect traumatic LP
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
Cholinesterase inhibitor; and antiparkinsonism drugs
RBC count >6000

11. botulism
It patient has electrolyte imbalance and hypothermia
Reduced efficacy of OCP
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

12. anerior and anteriomedial thigh paresthesia - decreased DTR
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Femoral n lesion
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

13. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Aphasia - neglect - agnosia - acalculia etc
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

14. MG
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Obturator n lesion
Acetylecholinersterase inhibitors
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

15. Unable to copy of matchstick - unable to dress up
Diabetes insipidus
EPV - campylobacter - HSV
Construction apraxia; lesion in non dominant parietal lobe (right)
High dose IV methyleprednisone;

16. How to stop antiepileptic drugs
It patient has electrolyte imbalance and hypothermia
Taper gradually to prevent seizure relapse
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Upright supine position

17. contraindication of sumatripta
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
Deficit in cranial nerve function
Coronary artery disease
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA

18. dementia plus urinary incontinence
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Tunnel vision - diaphoresis - nausea - pallor
Nystagmus on far lateral gaze
Normal pressure hydrocephalus

19. How to tx acute exacerbation of MS
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Get up from chair walk a short distance turn around and sit; screening test for fall
Deficit in cranial nerve function
High dose IV methyleprednisone;

20. How to confirm braindeath?
Despite the term neuroma they arise from schwann cells - schwanoma
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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.
82% specific for dementia

21. cortical lesion
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Difficulty in writing - calculating - distinguishing left and write
Aphasia - neglect - agnosia - acalculia etc
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

22. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron disease
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Difficulty in writing - calculating - distinguishing left and write
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l

23. GBS
Normal pressure hydrocephalus
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
IVIG and plasmapheresis
Cerebellar lesion

24. Tx of GBS
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Diabetes insipidus
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Cerebral palsy; dx mri

25. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Propranolol or primidone
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Gilberts disease

26. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Coronary artery disease
Clonidine will take care both high bp and withdrawal
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48

27. 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
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

28. impaired perception of complex sounds
Lesion in nondominant temporal lobe
Spastic paraparesis
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

29. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
Clonidine will take care both high bp and withdrawal
Distal lower motor neuron disease
Femoral n lesion
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

30. 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
Entacapone - COMT inhibitor
Aphasia - neglect - agnosia - acalculia etc
Myasthenia; due to autoantibodies against acetylecholine receptor;

31. What is can be used cluster headache prevention
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
Verapamil
Taper gradually to prevent seizure relapse
Cerebral palsy; dx mri

32. lesion in dominant tempora lobe
Aspirin - control HTN and swallow eval before giving any oral meds
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

33. phenytoin and 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
Reduced efficacy of OCP
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
Upright supine position

34. korsafoff psychosis
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy

35. MMSE score of less than 24
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
82% specific for dementia
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
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

36. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Acetylecholinersterase inhibitors
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

37. How to manage stroke patient came within 4 hours
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
Cerebral palsy; dx mri
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;

38. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
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
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Cerebellar lesion

39. medial thigh sensory loss and weakness in addcution
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;
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
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
Obturator n lesion

40. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Spastic paraparesis
Reduced efficacy of OCP
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

41. indication of plasmapheresis in GBS
MS
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
IVIG and plasmapheresis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

42. differentiate wenicke and korsakoff
Taper gradually to prevent seizure relapse
Spastic paraparesis
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
<20; if patient scores >25 benign forgetfulness

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

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44. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
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
Normal pressure hydrocephalus

45. When to give aspirin when patient on tPA after stroke
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
Not within 24 hours; give afte 24-48 hours if patient stable
Botulism has descending paralysis in contrast othere have ascending paralysis

46. lesion in dominant parietal lobe
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Gilberts disease
Difficulty in writing - calculating - distinguishing left and write

47. When headache is presenting complaint of brain tumor
Reduced efficacy of OCP
Verapamil
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Normal pressure hydrocephalus

48. benign essential tremor
Propranolol or primidone
High dose IV methyleprednisone;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Tunnel vision - diaphoresis - nausea - pallor

49. 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
90% of right handed and 60% of left handed persons; speech and language function
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Spastic paraparesis

50. best diagnosis for parkinsonim
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; if patient scores >25 benign forgetfulness
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Autospy gold standard

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USMLE Step3 Neurology

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