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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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1. What is can be used cluster headache prevention
Frontotemporal: weird behviors - NPH: incontinence - enlarged ventricls - gait prob; vascular: gradually progressive - mild dementia; Lewy body: l for hallucination +parkinsonism l
Verapamil
Corticosteroid and acyclovir
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level

2. benign essential tremor
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone
Taper gradually to prevent seizure relapse

3. 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
Follows viral illness; vertigo - tinnitus - nausea. self limiting
Normal pressure hydrocephalus
Diabetes insipidus

4. What mmse score suggest dementia
Propranolol or primidone
<20; if patient scores >25 benign forgetfulness
Aspirin - control HTN and swallow eval before giving any oral meds
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement

5. oligoclonal band in CSF
MS
Antitoxin
Deficit in cranial nerve function
High dose IV methyleprednisone;

6. impaired hepatic conjugation of billirubin
Not within 24 hours; give afte 24-48 hours if patient stable
Upright supine position
Gilberts disease
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

7. patient with hx of cluster headache p/w retroorbital pain lacrimation - vomiting suddenly
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Aspirin - control HTN and swallow eval before giving any oral meds
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

8. dementia plus urinary incontinence
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Normal pressure hydrocephalus
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Cerebellar lesion

9. How to tx lewy body dementia
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Clonidine will take care both high bp and withdrawal
MS
Cholinesterase inhibitor; and antiparkinsonism drugs

10. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Femoral n lesion
Clonidine will take care both high bp and withdrawal
It patient has electrolyte imbalance and hypothermia
90% of right handed and 60% of left handed persons; speech and language function

11. best diagnosis for parkinsonim
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;
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
Autospy gold standard

12. 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
Gilberts disease
Upright supine position
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;

13. How to tx stroke patient came after 6h
Myasthenia; due to autoantibodies against acetylecholine receptor;
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
Aspirin - control HTN and swallow eval before giving any oral meds
Aphasia - neglect - agnosia - acalculia etc

14. Why V12 deficient develop hypokalemia after tx with b12
Taper gradually to prevent seizure relapse
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Distal lower motor neuron disease
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

15. drags leg forward in every steps - no knee flexion; hip flexion and straight legs
Autospy gold standard
Spastic paraparesis
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Diabetes insipidus

16. What percent of dementia is reversible
RBC count >6000
20%
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Acetylecholinersterase inhibitors

17. Blood transfusion in hypothermia
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Upright supine position
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

18. dominant parietal lobe on the left side
90% of right handed and 60% of left handed persons; speech and language function
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
Diabetes insipidus
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

19. how donepezil - acetylecholinsterase inhibitor works in Alzheimers
Despite the term neuroma they arise from schwann cells - schwanoma
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
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

20. lesion in dominant tempora lobe
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
90% of right handed and 60% of left handed persons; speech and language function
Cerebral palsy; dx mri
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner

21. 2 yr old child with developmental delay; crawing at 11m; scissoring gait
Distal lower motor neuron disease
Reduced efficacy of OCP
Cerebral palsy; dx mri
Gilberts disease

22. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
<20; if patient scores >25 benign forgetfulness
Upright supine position

23. contraindication of sumatripta
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Coronary artery disease
Aspirin - control HTN and swallow eval before giving any oral meds

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

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25. infections in GBS
EPV - campylobacter - HSV
Not within 24 hours; give afte 24-48 hours if patient stable
RBC count >6000
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

26. GBS
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica
IVIG and plasmapheresis

27. How to differentiate medial and lateral pontine syndrome
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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 writing - calculating - distinguishing left and write
Construction apraxia; lesion in non dominant parietal lobe (right)

28. When to use brain spect scintigraphy to confirm brain death
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin
It patient has electrolyte imbalance and hypothermia
90% of right handed and 60% of left handed persons; speech and language function

29. severe headache and high BP
Vitamin B12 deficiency
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test

30. stroke with lower facial palsy - pronator drift despite on aspirin
Upright supine position
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
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

31. 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
Despite the term neuroma they arise from schwann cells - schwanoma
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
Lesion in nondominant temporal lobe

32. How to differentiate medial and lateral medullary syndrome
Entacapone - COMT inhibitor
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Lesion in nondominant temporal lobe
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. How to stop antiepileptic drugs
Taper gradually to prevent seizure relapse
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Diabetes insipidus
Lesion in nondominant temporal lobe

34. hx of epilepsy - now unresponsive - slight twhiching of mouth and arms
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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%

35. Tx of GBS
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
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
Myasthenia; due to autoantibodies against acetylecholine receptor;
Propranolol or primidone

36. impaired perception of complex sounds
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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
Aspirin - control HTN and swallow eval before giving any oral meds
Lesion in nondominant temporal lobe

37. Acute onset of left arm weakness
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
Taper gradually to prevent seizure relapse
MCA stroke; if comes in < 3-4.5 h - do CT and if neg give tPA
Not within 24 hours; give afte 24-48 hours if patient stable

38. impaired vibration and increased DTR
Spastic paraparesis
MS
Vitamin B12 deficiency
Clonidine will take care both high bp and withdrawal

39. at first tingling in toes and feet then weakness in extremities
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
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Not within 24 hours; give afte 24-48 hours if patient stable

40. Tx of bells palsy
Corticosteroid and acyclovir
Autospy gold standard
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Verapamil

41. When to use dopamine agonist pramipexol in parkinson
Reduced efficacy of OCP
It patient has electrolyte imbalance and hypothermia
Get up from chair walk a short distance turn around and sit; screening test for fall
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

42. How to differentiate traumatic LP and SAH
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure
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

43. phenytoin and OCP
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Reduced efficacy of OCP
82% specific for dementia
90% of right handed and 60% of left handed persons; speech and language function

44. earliest sign of phenytoin toxicity
Nystagmus on far lateral gaze
Aspirin - control HTN and swallow eval before giving any oral meds
Myasthenia; due to autoantibodies against acetylecholine receptor;
EPV - campylobacter - HSV

45. cluster headache
Difficulty in writing - calculating - distinguishing left and write
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
Autospy gold standard

46. craniopharyngioma
Diabetes insipidus
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;
Entacapone - COMT inhibitor
Deficit in cranial nerve function

47. double vision at the end of day and ptosis
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Gilberts disease
Myasthenia; due to autoantibodies against acetylecholine receptor;
Diabetes insipidus

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

49. differentiate wenicke and korsakoff
Corticosteroid and acyclovir
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
Gilberts 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

50. Most effective to reduce aspiration in stroke or patient with swallowing dysfunction
Uptake K by newly formed mature RBC can lead to severe hypokalemia; serum k should be monitor Q48
Alzheimers have decreased level acetylecholine due to degeneration of choline acetyltransferase which synthesize acetylecholine; donepezil inhibits breakdown of aceytylecholine thus increases its level
Upright supine position
Verapamil

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USMLE Step3 Neurology

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