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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. acoustic neuroma
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Despite the term neuroma they arise from schwann cells - schwanoma
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID

2. women with unilateral eye pain; neurlogic symptoms here there at different times
Vitamin B12 deficiency
MS: CSF increased IgG -IgM and IgA also increased. not specific to MS
Entacapone - COMT inhibitor
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa

3. Unable to copy of matchstick - unable to dress up
Taper gradually to prevent seizure relapse
Construction apraxia; lesion in non dominant parietal lobe (right)
Corticosteroid and acyclovir
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

4. medial thigh sensory loss and weakness in addcution
Aspirin - control HTN and swallow eval before giving any oral meds
Obturator n lesion
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
Injury to lateral femoral cutaneous nerve; small sensory nerve direct branch of lumbar plexus; meralgia paresthetica

5. get up and go test
Get up from chair walk a short distance turn around and sit; screening test for fall
Autospy gold standard
MS
Gilberts disease

6. How to prevent prevent frequency of MS exacerbation
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
It patient has electrolyte imbalance and hypothermia
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

7. How to differentiate botulism from tick born paralysis - GBS and MG
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
Botulism has descending paralysis in contrast othere have ascending paralysis
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
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

8. Patient with carbamazepine; What should be advice?
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
Cerebellar lesion
Not within 24 hours; give afte 24-48 hours if patient stable
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

9. How to diffrentiate tick borne paralysis from GBS and spinal cord tumor
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Propranolol or primidone
Get up from chair walk a short distance turn around and sit; screening test for fall
Tick born paralysis fastest manifestation. presents within a day of exposure; no FEVER - csf exam normal

10. When to give aspirin when patient on tPA after stroke
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
Not within 24 hours; give afte 24-48 hours if patient stable
Spastic paraparesis
Propranolol or primidone

11. How to manage stroke patient came within 4 hours
CT scan - if no bleeding tPA - then freq neurocheck - strict BP control with IV beta blocker; bp should be below 180/105;
First 3 to 4.5 hours following symptom onset; CT scan should be done first to r/o intracranial hemorrahge
Lesion in nondominant temporal lobe
Gilberts disease

12. Acute onset of left arm weakness
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
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
Spastic paraparesis

13. anerior and anteriomedial thigh paresthesia - decreased DTR
Cholinesterase inhibitor; and antiparkinsonism drugs
Femoral n lesion
82% specific for dementia
Obturator n lesion

14. botulism
Antitoxin
Coronary artery disease
Nystagmus on far lateral gaze
Not within 24 hours; give afte 24-48 hours if patient stable

15. When to use brain spect scintigraphy to confirm brain death
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
HTN upto 220/120 permitted in patient who did n't receive thrombolytic therapy
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

16. Tx of bells palsy
IVIG and plasmapheresis
Corticosteroid and acyclovir
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.
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel

17. 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
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
EPV - campylobacter - HSV
Cholinesterase inhibitor; and antiparkinsonism drugs

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

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19. what drug is used to extend effects of levodopa
Nystagmus on far lateral gaze
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Entacapone - COMT inhibitor
Verapamil

20. dementia plus urinary incontinence
Normal pressure hydrocephalus
Entacapone - COMT inhibitor
Construction apraxia; lesion in non dominant parietal lobe (right)
Taper gradually to prevent seizure relapse

21. Blood transfusion in hypothermia
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
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
Status epilepticus-clue is twhiching; seizure lasting longer than 5-10 min; tx benzo after ABC - if fails - phenobarbital or phenytoin

22. 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
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
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
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;

23. How to confirm braindeath?
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
Upright supine position
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.
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate

24. How to tx stroke patient came after 6h
Aphasia - neglect - agnosia - acalculia etc
Aspirin - control HTN and swallow eval before giving any oral meds
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

25. differentiate wenicke and korsakoff
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
Upright supine position
Myasthenia; due to autoantibodies against acetylecholine receptor;
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

26. double vision at the end of day and ptosis
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;
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Myasthenia; due to autoantibodies against acetylecholine receptor;
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening

27. Tx of GBS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
<20; if patient scores >25 benign forgetfulness
Bilateral but worse unilateral - morning headache - n/v - headache worsened by bending - night awakening
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

28. stroke with lower facial palsy - pronator drift despite on aspirin
Entacapone - COMT inhibitor
Reduced efficacy of OCP
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
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;

29. headache - non reactive pupil - fall on both sides during walking - impaired upward gaze
Acetylecholinersterase inhibitors
Pineal tumor; parinaud syndrome; some releases hcg which cause precocious puberty
Cholinesterase inhibitor; and antiparkinsonism drugs
Tunnel vision - diaphoresis - nausea - pallor

30. MG
Propranolol or primidone
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
High dose IV methyleprednisone;
Acetylecholinersterase inhibitors

31. impaired vibration and increased DTR
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
Femoral n lesion
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Vitamin B12 deficiency

32. lesion in dominant tempora lobe
Difficulty in understanding spoken or written language; difficulty in expressing thoughts in a meaningful manner
Propranolol or primidone
Acute attack; tx with 100% O2; other options are sumatriptan sq/intranasal; ergot - NSAID
EPV - campylobacter - HSV

33. at first tingling in toes and feet then weakness in extremities
Aspirin - control HTN and swallow eval before giving any oral meds
Verapamil
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure
Spastic paraparesis

34. phenytoin and OCP
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
Reduced efficacy of OCP
Spastic paraparesis
Spontaneous remission; admit if suspected and monitor pulse ox for resp failure

35. excessive elevation of legs during walking (toe touch floor earlier than heels)
Distal lower motor neuron 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
82% specific for dementia
It patient has electrolyte imbalance and hypothermia

36. contraindication of sumatripta
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Cerebellar lesion
Coronary artery disease
High dose IV methyleprednisone;

37. walking like drunken sailor; jerky hesitant and walks in zigzag pattern
Develop hypocalcemia (muscle spasms - diaphoresis - bilateral hand contracture); cannot metabolize citrate to lactate
Upright supine position
Cerebellar lesion
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

38. severe headache and high BP
Do CT scan at first to r/o SAH - if ct neg lumbar puncture
MS
Coronary artery disease
Obturator n lesion

39. How to perform apnea test
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
Preoxygenate and then disconnect ventilator - absence of respiratory drive for 8-10 min with PCO2 >60 pH <7.28 suggest positive apnea test
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

40. oligoclonal band in CSF
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
Wernicke's encephalopathy; due to thiamine definition; medical emergency
Not within 24 hours; give afte 24-48 hours if patient stable
MS

41. MMSE score of less than 24
Verapamil
If glucose is given instead of thiamin in korsakoff psychosis; patient confabulate to fill gaps in memory; mamilary bodies affected; DX mri-increased enhancement
82% specific for dementia
Construction apraxia; lesion in non dominant parietal lobe (right)

42. 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
Clonidine will take care both high bp and withdrawal
Despite the term neuroma they arise from schwann cells - schwanoma
Progressive paralysis in GBS; absent DTR - flaccid paralysis; then resp failure

43. prodrome of vasovagal syncope
Tunnel vision - diaphoresis - nausea - pallor
Beta interferon and glatiramer acetate; they are teratogenic; contraception should be advised
Taper gradually to prevent seizure relapse
Botulism has descending paralysis in contrast othere have ascending paralysis

44. How to differentiate medial and lateral pontine syndrome
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
Younger patients <60yrs due to concerns about long term efficacy and s/e levodopa
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
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;

45. What is pronator drift
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
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
Clonidine will take care both high bp and withdrawal

46. When to suspect traumatic LP
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;
RBC count >6000
Xanthochrmia and discoloration of centrifuged CSF due to Hb breakdown; present in 90% of SAH
Spastic paraparesis

47. How to tx lewy body dementia
Verapamil
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
Cholinesterase inhibitor; and antiparkinsonism drugs
Cerebral palsy; dx mri

48. craniopharyngioma
Diabetes insipidus
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
Entacapone - COMT inhibitor

49. What bp med to be given in a patient with high bp and signs of opioid withdrawal
Clonidine will take care both high bp and withdrawal
Taper gradually to prevent seizure relapse
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
82% specific for dementia

50. indication of plasmapheresis in GBS
Pure motor lacunar stroke; aspirin failure; give more aggressive antiplatelet therapy with clopidogrel
Coronary artery disease
Gilberts disease
Severe flaccid paralysis - patient on mech ventilation; bubar palsy; resp failure

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USMLE Step3 Neurology

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